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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Penn State Erie. USA Paul Gemmel Professor. Hawaii
International Journal of Health Care Quality Assurance Vol. Healthcare and Services Management. UK
Dr Syed Saad Andaleeb Professor and Program Chair. Spain Dr Keng Boon Harold Tan Ministry of Health. St Vincent’s Hospital. School of Healthcare. King Saud Health Sciences University. Faculty of Health Sciences. UK Ales Bourek National Board of Medical Standards. 1. Salisbury NHS Foundation Trust. Guo Associate Professor.1
EDITORIAL ADVISORY BOARD
Dr Waleed Albedaiwi Quality Management Advisor and Director. Faculty of Medicine. UK Dr Udo Nabitz JellinekMentrum. Centre for Clinical Governance Research. 21 No. Ireland Ellen J. University of New South Wales. Wellmark Blue Cross Blue Shield of Iowa and South Dakota. Allied Health Administration.IJHCQA 21. Gaucher Group Vice President Operations. Sheffield Hallam University. 2008 p. Faculty of Economics and Business Administration. Universidad Complutense de Madrid. Australia Ian Callanan Clinical Audit Co-ordinator. Czech Republic Professor Jeffrey Braithwaite Director. AIAR. UK Professor Abdul Raouf Institute of Leadership and Management. Quality Management and Performance Measurement Research Unit. Singapore Peter Wilcock Visiting Professor in Healthcare Improvement. USA Professor Jiju Antony Strathclyde Institute for Operations Management. The Netherlands Professor John Øvretveit The Nordic School of Public Health. Marketing Black School of Business. Germany Max Moullin Director. University of Strathclyde. Pakistan Ulises Ruiz Faculdad de Medicina. 4 # Emerald Group Publishing Limited 0952-6862
. Hamburg. Gibraltar Professor Dr Johannes Moeller University of Applied Sciences. Quality and Customer Satisfaction. Bournemouth University and Director of Service Improvement. Belgium Dr Kristina L. Ghent University. Department of DMEM. School of Public Health. Sweden Helen Quinn Senior Lecturer/Academic Lead for Internationalism. Saudi Arabia
Dr Karen Norman Director of Nursing and Patient Servcies. St Bernards Hospital. University of Leeds. University of Hawaii’i-West O’ahu.
dissects and develops SERVQUAL. the eight manuscripts and 50 K words amount to a themed book containing novel elements on clearly what is an important and enduring quality assurance subject.Editorial
Patient satisfaction structures. They also spend time carefully explaining methods for modifying existing. It is harder. He or she needs to stop smoking to preserve the remaining limb. patient satisfaction remains a popular author and reader topic. which usefully extends and develops Arasli et al. First. and recruiting new ones. Arasli and his colleagues offer fascinating insights into Cypriot patient expectation and satisfaction. Second. 21 No. The second private patient oriented manuscript emerges from Ramsaran-Fowdar’s Mauritian study. That is. We wanted to address private and public patient satisfaction. and introduce a middle “process” segment. 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. Her detailed psychometric explorations relate to both general and private healthcare. The authors remind us that service quality is one of the most important drivers behind customer attraction. 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. retention and loyalty. Wicks and Chin also concentrate on SERVQUAL but in USA outpatient surgery contexts. and her ﬁndings reveal that seven not ﬁve SERVQUAL quality dimensions are needed for Mauritian private health services. fascinating patient satisfaction issues emerge that are important for health service managers and practitioners. 2008 pp. Long-in-the-tooth patient satisfaction researchers know this mineﬁeld well. One particular sobering analysis for insurance-based healthcare managers and practitioners is the cost difference between: losing loyal patients. They used SERVQUAL – notably the instruments’ ﬁve dimension – to compare and contrast private and state hospital patient satisfaction. Consequently. Ramsaran-Fowdar too unpicks. In short. processes and outcomes Two things prompted us to produce our second special issue this year. to satisfy the patient because he or she does not want this course of action. 1. The resulting Cypriot health service strengths and weakness ﬁndings are likely to make managers and practitioners worried or proud. learned from their explorations into SERVQUAL’s psychometric properties. manuscript submissions and author downloads steadily increased in 2006-2007. A unique feature in Ramsaran-Fowdar’s article is her needs and wants’ section. Unexpected ﬁndings also materialise such as staff social skills’ importance in patient satisfaction. They concentrate on two existing SERVQUAL segments: expectations (or pre-process) and perceptions (or post process). valid and reliable patient satisfaction measures for use in different settings. although it might not be thought possible that new patient satisfaction insights can emerge. Readers also will beneﬁt from the lessons Arasli et al. and we are fortunate to publish two private patient satisfaction-oriented studies. 5-7 q Emerald Group Publishing Limited 0952-6862
.’s commentary. First. a patient needs a lower limb amputation owing to smoking-related peripheral vascular disease. this issue’s authors not only revisit stalwart patient satisfaction debates but also explore new topics not often encountered in the literature. readers will be surprised how
International Journal of Health Care Quality Assurance Vol. therefore. Similarly.
Discussion around SERVQUAL’s history and development reinforces discussion elsewhere. government accreditation agencies’) and bottom-up (e. Readers familiar with customer satisfaction literature know that health service researchers usually borrow from industry and commerce. patient satisfaction is a complex and multi-factorial healthcare outcome. Speciﬁcally. Vinagre and Neves’ related project connects. Readers should ﬁnd their method explanation and discussion educational. Clearly.g. the authors ﬁnish with arguments for modifying their patient satisfaction measure for non-health use. the Mayo team are following-up this study with a separate analysis about which patient types are likely to respond to patient satisfaction questionnaires. process and outcomes. 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.. satisfaction and emotions. Because some patients completed the patient satisfaction questionnaire ten years after answering the MMPI. they are just as likely to recommend a provider to family and friends. Readers may not be surprised to learn that pessimistic and hostile patients are less likely to rate care higher. their warnings about adopting of-the-shelf patient satisfaction studies without adjusting them to suit local culture are salutary. However.g. Leventhal’s bitter-sweet article is a lesson to service providers. a secondary analysis of archived information. combines Minnesota Multiphasic Personality Inventory (MMPI) and patient satisfaction data. the top-down (e. other stakeholder pressures cannot be ignored. Moreover.. and readers will emphasise with the case study family. Moreover. 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. Leventhal uses a case study to illustrate his arguments. their starting point is SERVQUAL.
. Might it be possible that patient behavioural and emotional characteristics are equally if not more important satisfaction drivers? The Mayo study. In short. Unusually. processes and outcomes when statutory healthcare services are not up to the mark. However.1
relatively unimportant empathy seems to be in the patients’ rankings. Portuguese patient service expectation. among other things. they argue that these two behaviours are more tangible during patient-physician contact – another reason for concentrating on these two personalities. Their customer-provider framework and the way they dissect patient expectation and satisfaction are also useful. The authors extracted almost 1. In common with other authors in our special issue. Intriguingly. which is often used in consumer research but infrequently if hardly ever used in patient satisfaction studies. elderly patients’ children) inﬂuences on face-to-face care become clear. It showcases poor service structures. the authors concentrate on two enduring and stable personality characteristics – pessimism and hostility. despite lower satisfaction scores.300 patients that answered both questionnaires. a study we hope to publish later. which they modify to ﬁt local culture. the authors tie SERVQUAL data with a range of patient emotion scores from the Differential Emotional Scale II. 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.IJHCQA 21. 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.
completed an intriguing study and report.e. However. Referrer behaviour is tangibly observable but variations remain unexplained.Jonnson and Øvretveit’s article could just as easily sit in our Patient Safety special issue (Vol. 21 No. Jeffrey Braithwaite. 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. Plainly. Unperturbed. In short. Comparing referring physician (i. Finally. Vol. Westbrook. Like other articles here. the paper “Promoting safety: longer-term responses of three health professional groups to a safety improvement programme”. the stakeholders and gatekeepers) with provider clinician (hospital core staff) service quality perceptions proved fascinating. Travaglia. readers will beneﬁt from the authors’ thorough and clear method section. For example. Stakeholder analyses are paramount therefore. Another feature readers will notice in this issue is the range of countries included. They concentrate on “internal customers” (fellow health service professionals) rather than “external customers” (patients). the picture is complex since patient complaints in another database levelled in comparison. Mary T. Nevertheless. Westbrook. is worrying. Merely benchmarking within and between countries and feeding back results. is educational if not instrumental for improving service quality. Jonnson and Øvretveit’s work is groundbreaking in several ways. Hensen and his German co-authors. Rowena Forsyth. What is known. In common with other articles in this special issue. Nadine A. Travaglia. one dataset shows incidents tripling in 25 years. 20 No. important ﬁndings emerge. for example. while referrers’ perceptions are less upbeat. however. provider clinicians have a strong positive image about their services. comparing complaints and claims information shows that the true adverse event frequency may be underestimated. clinician response rates are notoriously poor and unfortunately the authors were victims. 7) and it would pay to read their work in a patient safety context. for example. Christine Jorm and Rick A. The authors revisit information stored in three complaints and claims databases. the implications for practitioners and managers are clear. the eight articles include helpful reference lists that should arm patient satisfaction researchers and writers with a valuable resource. Joanne F. Speciﬁcally. Joanne F. Iedema. For example. was authored by Mary T. 20 No. 1 materials’ range and depth makes it an essential text for the library shelf. 7 was authored by Jeffrey Braithwaite. Peter Nugus. and despite the low “turn-out”. they offer explanations and solutions to poor response rates. attitudes and practice” published in Vol. Christine Jorm and Marjorie Pawsey. published in the same issue. Debbi Long. questionnaire surveys in this context are always on thin ice. Mallock. Keith Hurst
We would like to point out that the paper “Are health systems changing in support of patient safety? A multi-methods evaluation of education. Patient commendations are a strong theme in the article and interestingly. geographically remote patients are less likely to recommend a service to family and friends. Rick Iedema. For example. Also. Debbi Long.
2008 pp. who have recently beneﬁted from hospital services in Famagusta. Cyprus.The current issue and full text archive of this journal is available at www. Public sector organizations Paper type Research paper
International Journal of Health Care Quality Assurance Vol. including other dimensions such as hospital processes and discharge management and co-ordination may provide further insights into understanding inpatients’ perceptions and intentions.1
Gearing service quality into public and private hospitals in small islands
Empirical evidence from Cyprus
School of Tourism and Hospitality Management. relationships between staff and patients. These are: empathy. hospital administrations need to gather systematic feedback from their inpatients. Hong Kong. professionalism of staff. Private hospitals. Turkey
Received 21 December 2005 Revised 13 April 2006 Accepted 1 June 2006
Erdogan Haktan Ekiz
School of Hotel and Tourism Management. 21 No. Additionally.htm
IJHCQA 21.emeraldinsight. giving priority to the inpatients needs. Eastern Mediterranean University. 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. Patients. Hospitals. food and the physical environment. 8-23 q Emerald Group Publishing Limited 0952-6862 DOI 10. establish visible and transparent complaint procedures so that inpatients’ complaints can be addressed effectively and efﬁciently. There is considerable lack of literature with respect to service quality in public and private hospitals. 1. were selected to answer a modiﬁed version of the SERVQUAL Instrument. Findings – This study identiﬁes six factors regarding the service quality as perceived in both public and private Northern Cyprus hospitals.com/0952-6862. since job satisfaction leads to customer satisfaction and loyalty. Keywords Customer services quality. Famagusta – (North) Cyprus. Faculty of Business and Economics. New East Ocean Center. 454 respondents. Design/method/approach – Randomly. The instrument contained both service expectations and perceptions questions. 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. Additionally. Hospital managers should also satisfy their employees.1108/09526860810841129
Salih Turan Katircioglu
Department of Banking and Finance. Future studies should include the remaining regions in Cyprus in order to increase research ﬁndings’ generalizability. Eastern Mediterranean University. Turkey
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. The Hong Kong Polytechnic University. 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. Gazimagusa – (North) Cyprus. Kowloon.
on the other hand. inpatient satisfaction and practitioner loyalty (Pakdil and Harwood. Moreover. However. 2002). i. like their counterparts. Cronin and Taylor.. high risks exist for the private hospitals whilst offering their services in a highly competitive environment dealing with human health. Uzun. require a sustainable.3 percent (Public 5.3 percent of the world Gross Domestic Product (GDP) in the year 2000. the number of satisﬁed inpatients and. a hospital. Labarere et al. understanding inpatients’ evaluations of their hospital service quality performance can help to improve existing health care system output in general and. Reichheld and Sasser. have to deal with several service product characteristics such as intangibility. 1996. Yi. It has also been claimed that. simultaneously. consequently. hospitals.. It is currently acknowledged that service quality measurement can be used to understand how well a service organization.4 and Private 3. It is also assumed that those inpatients. may enhance service quality of speciﬁc healthcare processes (Meehan et al.. far superior to other organizations. However. Service quality. which have experienced services from both hospitals over a speciﬁc period. 1990). 1995. There is a generalization that service organizations. there is no scientiﬁc empirical evidence to indicate that public hospital staff attitude is the same as their private counterparts. therefore.Introduction The share of services such as tourism. since their structure and functioning are different..9 percent) in the world GNP (World Development Indicators. The health care expenditures equated to 9. the authors could not come to any common conclusion on a conceptualization of service quality and customer satisfaction issues. There has been a great deal of service quality assessment research conducted on different industries. 1990. including those in health care. A strong link has been found in the literature between service quality. Contrary to the above stereotyping in the literature. 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. Although several scales have been developed and tested to measure service quality (Parasuraman et al.. many government hospitals are blamed and
Service quality in public and private hospitals 9
. which involves sensitive decision making and extensive service provision in comparison to other services. as hospital service quality improves. and the situational factors in different industries. such as a clear ¨ deﬁnition of quality service or dimensionality (Gronroos. 2001. This might be true for the private institutions. Deﬁning service quality is complex and necessary for any measurement effort. 2004. has functioned in terms of outcomes like service quality over several years (Labarere et al.e. Hasin et al. since the competition is unavoidable for them within the free market economic system.. has become the focus of considerable attention in respect of satisfying and retaining customers in the service industry (Spreng and MacKoy. heterogeneity. less attention has been paid to the comparative assessment of service quality in public and private hospitals. 1993. 2003).. more attention should be given to the service quality improvement issues. Therefore. 1992. health and so forth contributed 66. Vandamme and Leunis. This feedback could also be used in their overall service quality improvement effort in the industry. 1999). Lim et al. Within the fast developing health care industry. at the same time. 2005. therefore. inseparability and perishability. Tomes and Ng. competitive advantage and. State hospitals. 2005. 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. 1997) in the USA and European healthcare sectors. could provide valuable feedback that serves to identify the variations in both types of organizations in terms of their service provision. 1990). 1985. 2004). Kara et al. Valdivia and Crowe. 2001. education. however.
1995. Just one year later. 2005). Gulle.. Anderson. kitchen and service sections (Kibris Newspaper. and inpatient complaints. medicine and facilities. is to assess and compare service quality in the Northern Cyprus public and private hospital sector. less is known about service quality differences between public and private hospitals (Jabnoun and Chaker. Study context Healthcare services are carried out by both public and private institutions in Northern Cyprus. The majority (626 beds. The remaining institutions are also controlled by the government. The foremost aim of this study. poor service quality and of low priority given to the inpatients’ needs. therefore. The authors primarily stated that both the public and private hospital administrations have little or no concept of systematic data collection about inpatient needs. For example. 1993). Poor service quality has been identiﬁed as a problem for many years. no empirical research exists to our knowledge on service quality. 2004.
In other words. 2004). 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. we can conclude from our personal observations. Caluda. Withanachchi et al. disinterested staff and limited opportunities for patients to choose the doctors they want (Kibris Newspaper.1
criticized today for their lack of speed owing to the inﬂexibility of their traditional hierarchal structures in respect of their quality improvement (Tountas et al. 2004. for the ﬁrst time. is two fold. Camilleri and O’Callaghan. Arasli and Ahmadeva. predominantly in legislation. 2004. This introductory section provides a brief description of the service. He also stated that changing circumstances require an urgent major change. Second. then. the health care challenges. 2005. 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. which has examined the service quality differences by collecting data from users of both types of hospital within a speciﬁed time period. Franck et al. Speciﬁcally. long waiting lists. claimed that the sector’s quality and standard are suffering from a lack of structure as well as from employing poorly qualiﬁed. Arasli and Ahmadeva (2004) empirically measured. the Public Personnel Association Head. The current Minister of Health and Social Affairs. as well as the conceptual relationship between
. 2005).IJHCQA 21. 1998.. the former Minister of Health and Social Affairs. Furthermore. First. there are nine public and 52 private hospitals. Cyprus hospitals’ service quality using a public opinion survey. Arasli and Ahmadeva. highlighted additional problems such as institutions’ ﬁnancial incapability. complained about the inadequate number of personnel in the hospitals’ cleaning. with which to develop some future strategies for the promotion of a quality health care service. They found that. unprofessional personnel.9 percent) belong to public hospitals (Arikan. 2002). 67. Jack and Phillips. that several ongoing quality problems exist in Northern Cyprus healthcare.. the Doctors’ Coalition Minister. In a recent study. Whilst pinpointing service-quality problems. 2003. 2005). The contribution of this study to the relevant literature. their proposed model also provided indicators for overcoming these problems by employing a total quality management (TQM) approach. Arabacioglu. corroborated by the above statement. Celal. service quality. although private hospitals conditions are better than those of their public counterparts. lack of medical equipment and instruments.
Gabbie and Neill. Half were aimed at measuring service user expectations and the remaining half measured perceptions.. 1993. (3) responsiveness – willingness to provide help and a prompt service to customers. Asubonteng et al. courtesy. responsiveness. 1991. 2005. Lam et al. credit card services and car maintenance (Arasli et al. (1985) initially developed the SERVQUAL scale. 1997. 1992). (1988). Originally. for example. 2005. and (5) empathy – caring and understanding. 1990).. which enjoy greater government patronage and funding. Carman. After Parasuraman et al. 1993. communications. 1992.service quality. Fick and Ritchie. At a later stage. (4) assurance – the knowledge and courtesy of employees and their ability to inspire trust and conﬁdence. Lim and Tang (2000) attempted to determine the expectations
Service quality in public and private hospitals 11
. competence. Coyle and Dale. there are ﬁve common characteristics. access. reliability. Parasuraman et al. such as tangibles. credibility. Nelson and Nelson. They found that the public hospital inpatients were more satisﬁed with service quality than their private hospital counterparts. The seven-point Likert scale is used by some researchers while others use the ﬁve-point format. 1994. Mehta et al. 1988). Uzun. equipment and the presence of personnel. 2004. Sultan and Simpson. 1999. (2) reliability – ability to perform the promised service responsibly and accurately.. 2001.. inpatient satisfaction and recommendations and some background information about Northern Cyprus public and private hospitals. which used the SERVQUAL scale speciﬁcally in the public and private health care industry. which included twenty-three items representing six dimensions (empathy. 1996. developed an instrument and validated it across various service environments. which could be applicable to service organizations: (1) tangibility – facilities. 1996. The main aim at that time was to develop general criteria for measuring service quality in various service organizations in different sectors. the SERVQUAL scale contained 22 pairs of items.... Babakus and Boller. security. They originally identiﬁed ten service quality factors generic to the service industry. such as higher education. 1999. (1988) replaced the former version of the service quality measurement. Literature review Parasuraman et al. compared service quality practices between the private and public hospitals in the United Arab Emirates. Lam and Zhang. Through the use of a modiﬁed SERVQUAL scale. Parasuraman et al. insurance. Babakus and Mangold. which a company provides and/or offers its customers in terms of its individualized and personalized attention (Parasuraman et al. dentistry. Sohail. Boulding et al.. Thus there are a limited number of studies. tangibles. 2000. Kilbourne et al. health care. reliability. level of administrative response and support skills). communication and a willingness to understand the customer. developed and integrated these reformed scales into the various service industry sectors (Pakdil and Harwood. Jabnoun and Chaker (2003). banks. 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. many researchers and practitioners replicated. 1995. The scale’s founders contended that whilst each service-producing industry is unique. Moreover. 2003. tourism.
communication. 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. empathy. Private Hospitals are no more successful than public hospitals in providing health care services for inpatients. (1991. a total of 650 questionnaires were printed and distributed to respondents. A modiﬁed SERVQUAL scale. H1b. Both public and private hospitals meet inpatients’ expectations. We also aim to compare both types of hospitals’ service quality. 454 four usable responses were obtained for a response rate of 69. reliability. In order to collect quantitative data for the study. H2b. There is a difference between public and private hospitals concerning their service quality. Judd et al.
. Improvements were required across all six dimensions. assurance. 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. we hypothesize that: H1a.8 percent – a percentage we deemed acceptable. H3a. There is no difference between public and private hospitals concerning their service quality. Results also indicated that both groups have room for improvement. In total. An analysis covering 216 inpatients revealed that private hospitals provide better services than public hospitals in respect of service quality. assurance. 2005).1
and perceptions of inpatients in Singaporean hospitals through the use of a modiﬁed SERVQUAL scale that included twenty-ﬁve components representing the tangibles. Method We primarily develop and test a modiﬁed SERVQUAL scale for public and private hospitals in Northern Cyprus. Sample There is one public and 12 private hospitals that include large-scale clinics in which surgery is carried out. responsiveness. The total bed capacity in these hospitals is 294 of which 180 are public and 114 are private (Kobat. H3b.IJHCQA 21. 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. accessibility and affordability dimensions. with 25 items representing ﬁve aspects of service quality (responsiveness. p. Andaleeb (2000) compared the quality of services provided by private and public hospitals in urban Bangladesh. Both public and private hospitals do not meet inpatients’ expectations. H2a. Analysis covering 252 inpatients revealed that there was an overall service quality gap between in-patients’ expectations and their perceptions. assuming that errors of judgment in the selection will tend to counterbalance one another”. discipline and baksheesh (devotion or dedication)). Private hospitals are more successful than public hospitals in providing health care services for inpatients. Finally. Based on the above discussion and arguments.
2 percent) were married and although occupations were widely dispersed. (5) food (six items).1 percent). and ﬁnally. which I had asked for was given to me” (mean 3. The lowest public hospital expectation score was obtained from question 44: “the food. the results of explanatory factor analysis showed that all factor loadings were above the recommended cut-off value of 0. It is important to note. Results Table I demonstrates respondents’ demographic breakdown. Responses to all items were elicited on a seven-point Likert scale ranging from 1 ¼ strongly disagree to 7 ¼ strongly agree. Approximately 71 percent had either high school or vocational school education. housewives (15.Measures A questionnaire was developed based on the studies of Parasuraman et al. A high alpha value of 0. Expectation scores The mean expectation scores were high when compared to the perception scores – ranging from 3.5 (Nunnally.46 for the private hospitals. which showed that dimensions like food and the physical environment were often studied. (3) giving priority to inpatient’s needs (eight items). (2) relationships (nine items). Moreover.1 percent). The majority (57. 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. The quantitative survey was produced based on a synthesis of the literature we studied.2 to 5. There were six dimensions in the present study: (1) empathy (ten items). that these dimensions may not represent all service quality aspects. A survey instrument of 48 components was used in order to measure Famagusta hospital service quality. This low expectation level may be the result of previous experience or negative word of mouth
Service quality in public and private hospitals 13
. the popular ones were: agriculture/animal related (27. (4) professionalism of staff (ﬁve items). Lim and Tang (2000) and Andaleeb (2000). if required.2). 1978). This was individually distributed to 15 families in the Famagusta district.0 for Windows was used to analyze our data. other dimensions may be added and adopted.19 to 6. Analysis The SPSS 12. (6) physical environment (nine items). More than 64 percent of the respondents were between the ages of 38-57 who were almost equally distributed in terms of their gender. The reliability of the scale was tested using Cronbach’s alpha. 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).914 was achieved indicating a good internal consistency for the forty-eight item scale. (1998). Jabnoun and Chaker (2003).6 percent) and professionals (14.32 for the public hospitals and from 4. However. Arasli and Ahmadeva. 2004. in the future studies. however.
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 49 102.0 9.0 50. this is not signiﬁcantly lower than other items in the questionnaire.IJHCQA 21.5 3.2 100.9 5.3 34. This high
. Inpatients’ families sometimes cook or they purchase food from restaurants for their relatives.0 14.1 13.6 2.4 10.5.0 57.4 3.2 39. had disappointing experiences with the quality of food or the limited choice of food.4 100.7 28.4 13.0 2.2 454 260 179 15 454 64 27 45 23 25 5 123 61 71 10 454
% 10.4 9.9 37. Sample demographics
communication from family members or friends who.5 1.1 5. Although question 5 has the lowest expectation score.8 100.0
Table I. perhaps.7 100.1 6. thus it can be evaluated as a high expectation score.4 49.4 15. The highest public hospital expectation score was statement 12: “doctors were capable of performing tests and procedures on me” (5.0 13.7 33. However.1 27.6 100. it is slightly above 3.32). 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” (4.19).
expectations.40 5. Doctors were capable of performing tests and procedures on me 24.89 3. perception and gap scores in public and private hospitals
.27 0.779 0.768 5. Doctors worked hard to prevent me from worrying 29.68 6.704 0.77 Variance exp: ¼ 40:7%/a ¼ 0:89 0.05 3.13 0.87 5.748 4.12 3.56 5.762 5.74 0.77 3.74 0. I had enough conﬁdence in my doctor to discuss my very personal matters
0.17 0. Nurses were polite while speaking with me and my family 27.782 5.23 4.700 4.21 4. Doctors were courteous while speaking with me and my family 26.97 5.95 3.74 5.23 5.19 0.780 0. Doctors spent enough time examining me 28.790 4.727 5. Doctors discussed after discharge medical issues with me
Giving priority to inpatient’s needs 21.24 0.36 0.32 4.41 0. In hospital. Nurses talked to me in order to get to know me better in their “spare” time 32.70 5.81 5. Doctors spent extra time with me to discuss my fears and concerns 18.04 5.
Empathy 15. Gap FL Gap
Private hospital Exp.708 0.34 5.776 0.44 0.15 0.74 0.08 0.11 0.24 0.89 5.21 0.76 3.07 Variance exp: ¼ 21:9%/a ¼ 0:87 0.92 0.91 4.08 0.17 0.11 0.43 -0.12 -0.73 3.15 0.14 0. My personal concerns were of utmost importance for the hospital 23.00 3. Doctors made me feel comfortable even when they were not really successful in treating me 3. Factor loadings.08 0.92 5.819 4.12 5.56 0.786 0.91 3.32 4.79 0.821 4.16 3.723 5. the nurses did not pay attention (R) 16.08 0.774 0. I was treated with respect 19.17 0.09 0.12 0.748 0.32 5.48 0.27 5.70 5.787 3.795 4.28 0.75 3.59 0.81 5.21 3.19 0.05
Public hospital Exp.34 0.15 5. I had complete trust in my doctor 30.737 Variance exp: ¼ 12:0%/a ¼ 0:89 0.41 5.86 4.841 4.779 0.773 4. In hospital. I was taken care of as an individual not like a customer 12.16 4.824 3.809 5.06 0.89 3. Doctors took care of me as soon as I arrived on the ward 4.15 5.82 3.70 3.763 0.04 0.93 4. Whenever I asked for help.769 0.82 0.67 4.17 0.80 0. I was presented with choices when doctors were deciding about my medical treatment 33.17 0.21 4.77 3.26 0. Per.80 0.48 5.02 0.64 0.09 (continued)
Service quality in public and private hospitals
Table II. I was involved in the planning of medical treatment 25.69 4.04 0. Doctors did their best to make me emotionally comfortable 14.752 5.89 5.790 0.11 4.10 0.783 4.57 0.741 0.95 3.34 5.20 0.Statements Variance exp: ¼ 22:0%/a ¼ 0:92 0.23 -0.771 5.07 0.22 0.747 0.55 0.27 0.780 3.33 0.802 3.21 5.792 5. Per.727 0.
The use of each procedure and test was explained to me before they were done 17.87 4.03 4. Doctors spent extra effort to make sure that I understaood my condition and its treatment
Table II.06 3.24 4.29 0.69 4.83 3.89 5.86 3.60 3.66 0. I had a clear understanding of my condition during my stay in hospital 2.94 4.714 0.769 0.17 4.12 0.745 0.12 5.14 5. The nurses asked my permission before performing any test on me 20.90 5.819 0.10 6.20 0.97 0.13 0.731 0.824 4.06 0.819 4.17 (continued)
IJHCQA 21.58 5.90 4.821 4.25 5. The nurses were kind. Doctors gave me medical advise in a simple way that I can understand 11.87 5.11 0.02 4.13 0.16 -0. FL Public hospital Exp.82 0.48 0.02 5.34 -0.831 0.750 0.90 5.12 0.784 0. Gap Variance exp: ¼ 15:3%/a ¼ 0:84 5.65 0.21 4.46 5.19 0.09 0.783 0.73 3.03 0. Per.815 0. I was treated with dignity and had adequate privacy during my treatment 1.14 5.745 0. Per. a ¼ 0:91 0.45 4. Gap FL Private hospital Exp.820 0.98 5.12 4.803 5.810
Relationships 13.785 0. Doctors asked my permission before performing any test on me 31. Doctors explained frankly to me the reasons for tests and procedures Variance exp: ¼ 20:7%/a ¼ 0:87 0.774 0.01 3. gentle and sympathetic at all times 6.28
Professionalism of staff 9.16
Statements Variance exp: ¼ 9:3%. Doctors talked to me frankly and politely 8.745 0.13 0.721 3. My doctor was interested in not only my illness but also me as a person 7. The nurses spent time with me to discuss my concerns about my condition 5.03 0.23 0.11 0.19 0.09 6.15 0.16 0.776 0.94 4.22 3.19 5.38 0. The ward rules and regulations were explained to me 22.09 3.99 3.01 3.71 3. Doctors carried out my tests completely and carefully 10.25 0.776 0.02 5.07 0.79 4.12 0.775 0.20 0.29 0.39 0.71 4.98 5.818 0.21 5.841 6.04 4.58 3.763 0.767 5.97 5.34 5.1
.90 0.07 Variance exp: ¼ 8:2%/a ¼ 0:93 0.79 4.
17 5.44 0.64 3.87 5.21 3.84 0.09 0.77 0. The screens were drawn around my bed.782 4. The ward was well furnished and decorated 39.37 0. 44.738 5.35 0.45 0.805 3. The bathrooms and toilets were always clean and pleasant to use 38.14 0.51 0. The beds.23 0.03 0.87 4.94 0.749 6.724 0.76 4. 43.58 3.824 4.20 3.19 0.831 4.72 6.21 0. The ward was clean at all times 37.818 0.69 0.68 0.815 5.
Food 45.32 0. all factor loadings (FL) and co-efﬁcient alpha scores (a) are above the cut-off value recommended by Nunnally (1978) and Tabachnick and Fidell (1996)
Service quality in public and private hospitals
Table II.37 0.
.19 3.67 0.12 3.33 0.98 0.29 0.39 4.05 0. Per. pillows and mattresses were comfortable enough 35.84 0.807 4. noises were kept at minimum level during night times 36.20 0.15 0.47 3.01 3.850 3.91 4. Outside noises were kept to a minimum 42.15 0. 46.25 3.14 0.16 3.34 5.46 0.861 4. There was adequate number of bathrooms and toilets in the ward 41.02 5.869 4.861 4.52 0.843 3.12 4.796 6.14
Public hospital Exp.37 0.761 5. Per.784 6.45 0.52 3.66 0.64 0.98 0. 47.22 4.64 3.23 0.849 4.43 6.Statements Variance exp: ¼ 15:9%/a ¼ 0:90 0.28 0.719 5.712 4.08
Physical environment 40.24 0. Inside the ward.865 4.732 0.717 5.49 Variance exp: ¼ 18:8%/a ¼ 0:94 0.09 3.856 3. while medical procedures and examinations were carried out
Notes: Each item is measured on a seven point Likert scale.88 5.76 0.46 6. The ward was well ventilated 34.
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 0.03 0.82 4.25 0.14 0.10 0.768 5. Gap FL
Private hospital Exp.41 0. 48.91 6.788 4.13 Variance exp: ¼ 29:4%/a ¼ 0:93 0.817 0.17 0.34 0.16 3.18 0.772 6.50 0.61 5.754 4.09 3.44 0.21 0.89 0.04 5.22 5.18 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” (4.8 percent). both the lowest and the highest perceptions occurred in the same question.12). giving priority to patient needs (12 percent).IJHCQA 21.28) and portion size (0. therefore. Hence food becomes an important factor. However. interestingly. p. are rejected. Gap scores Table II shows that although overall expectation levels were low.3 percent). therefore. Therefore. Giving priority to patience needs (21. the inpatients consider professionalism (20. All these gaps came under the physical environment construct. while H3a is accepted.66) and bathrooms/toilets (0. The highest perception score in public hospitals was obtained from the statement 12 “doctors were capable of performing tests and procedures on me” (5. physical environment (18.7 percent variance in the private.37 for the private hospitals.34) was observed in statement 44: “the food. physical environment (29. it seems that people are dissatisﬁed with public hospital doctors’ competency level.
.03 to 5. The hypotheses H1a and H2a. private investment encourages high expectations even on a simple.12 to 6. none was met in public hospitals.9 percent).68) was observed in statement 38: “the beds.1 percent). It seems that respondents are not satisﬁed with the public hospital food menu since both their expectation and perception mean scores were low. It was followed by gaps in ward cleanliness (0. Tomes and Ng (1995. Table II also shows that although the overall expectation levels were comparatively higher than public hospitals. The highest expectation score in private hospitals was obtained from statement 41 “the bathrooms and toilets were always clean and pleasant to use” (6. This conﬁrms that private hospitals do not meet expectations about food. Interestingly. about the only thing the inpatient can look forward to are meals to break the monotony. The largest gap (0. still most expectations were not met in private hospitals. there are differences between the two types of hospital services. The largest quality gaps.1
expectation level may be the result of a lack of trust in the doctors. but vital issue like the number of ward bathrooms and toilets. inpatients put their priorities differently in public hospitals as: food (33. occurred in the food construct statements.7 percent). Of course. ranging from 3.9 percent). especially those in the public hospitals.37). The lowest perception score in public hospitals was obtained from statement 44: “the food which I had asked for was given to me” (3.64). and relationship (15. pillows and mattresses were comfortable enough”. in which the lowest and the highest expectations are reported. food (15. This item’s expectation score was again highest in public hospitals. When we compared public and private hospital inpatients (Table II).46). showing that public hospitals are suffering from a lack of cleanliness and comfort.” Like public hospitals all these gaps come under the physical environment construct.4 percent).24).12 for the public hospitals and from 4. which are the tangible quality factors.12). which I had asked for was given to me”. which is a tangible quality factor. Signiﬁcantly. The highest private hospital expectation score was related to: “the bathrooms and toilets were always clean and pleasant to users” (6. and relationships (9 percent) important in the public hospitals. Perception scores The mean perception scores were lower compared to the expectation scores. It was followed by the gaps related to food service (0. 27) explain: “Apart from the visits. The largest gap (0. The empathy dimension had the highest priority in both types of hospitals with 22 percent variance in public hospitals and 40.
doctors took care of me as soon as I arrived in the ward (Q. 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. Jabnoun and Chaker. hospital managers should ﬁrst be committed to delivering superior service quality and the achievement of inpatient satisfaction (Arasli and Ahmadeva. While comparing public and private hospitals. 15). it is interesting that there were variances in inpatients priorities. and facility-related activities. Results show that expectations in both hospital types were not met. This result is consistent with the previous empirical investigations (Withanachchi et al. who found that public hospital inpatients were more satisﬁed with service quality than their counterparts in United Emirate private hospitals. the instrument has been found to have face and convergent validity as well as acceptable reliability coefﬁcients. our results contradict Jabnoun and Chaker (2003). mentioned by the previous researchers such as Hariharan et al.. which brings us to the important assumption that privatization would offer higher performance in Northern Cyprus’ health services sector. Please note that the expectation for an empathetic response of both hospitals’ inpatients got the highest priority in rank. Our ﬁndings have important implications for private hospital owners. 2005.Discussion and conclusions Our empirical ﬁndings reveal that the study instrument provided sound psychometric properties. Northern Cyprus hospitals suffer from a number of quality problems. The biggest service quality gap occurred in the “physical environment” dimension.. Therefore.) were perceived to be better in private hospitals. 2000). managers. such as the quality of the service provided by doctors and nurses. 2003. Moreover. 1996). Speciﬁcally. 43). 2004. academics and other related parties in the Northern Cyprus health services. which is aligned with the majority of recent study ﬁndings (Pakdil and Harwood. However. and doctors did their best to make me emotionally comfortable (Q. 2004). professionalism. Kara et al. patients’ expectations were not met in the private hospitals regarding the physical environment and the food quality served to them. Our ﬁndings also revealed that there are signiﬁcant quality differences in employee related hospital activities. relationships between staff and patients. Healthcare services were found to be better in the private hospitals with the exception of choice of food on the menu (Q. hospital administrations need to gather systematic feedback from their inpatients and to establish visible and transparent
Service quality in public and private hospitals 19
. However. 25). etc. since job satisfaction leads to customer satisfaction and loyalty (Rust et al. Our study has identiﬁed six service quality factors as perceived in both Northern Cyprus public and private hospitals: empathy. giving priority to the inpatients’ needs. inpatients seem to have preconditioned themselves to expect different health care service in both types of hospitals. etc. Broadly. Results derived from this study should be carefully considered by healthcare managers in both the Northern Cyprus public and private hospitals. Additionally. Hoel and Saether (2003) and Angelopoulou et al.. Regarding the other dimensions. (2004). such as building infrastructure and new equipment. 2005. Possible reasons for this gap. Interestingly.. At the micro level. showers. government ofﬁcials. wards 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. Kibris Newspaper. private hospitals were found to provide a better service than their public counterparts. 2005). who examined SERVQUAL in both public and private hospitals. food and the physical environment. (1998). Hospital managers should also satisfy their employees. Lim and Tang. North Cypriot inpatients perceived public hospitals to be inferior in the quality of their service provision. it may be difﬁcult for inpatients to accurately evaluate quality. the physical quality of equipment and facilities (toilets. except for the empathy dimension.
Most customers are reluctant (Ekiz. p.
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T. pp.Sultan. and Souliotis. and Crowe. World Bank Publications. pp.J. Karnaki. Tabachnick. Further reading McGorry. pp. Yi. pp. 68-123. 25-33. and Ng. 2. 5. 74-81. 361-9. International Journal of Services Industry Management. “The ‘unexpected’ growth of the private health sector in Greece”. Vol. Y. Health Policy. Washington. S. pp. 3rd ed. New York. 14 No. America Marketing Association. J. and Simpson. Withanachchi. 4 No. 2. Corresponding author Huseyin Arasli can be contacted at: huseyin. A. (2001). O. Vol. Vol. N. (1996). Using Multivariate Statistics. and Handa. Review of Marketing. M. Vol. (2000).edu. 188-216. 208-12.C. pp. IL. V. and Leunis. K. International Journal of Health Care Quality Assurance. (1997). (2004). in Zeithaml. Y. L. Qualitative Market Research: an International Journal.. Vandamme. 18 No. International Journal of Health Care Quality Assurance.com Or visit our web site for further details: www. E.P.emeraldinsight. T. B. 30-49. Uzun.S. Journal of Health Organization and Management. and Fidell. Journal of Nursing Care Quality. pp. “Service quality in hospital care: the development of an in-inpatient questionnaire”. 5. W. S.. Vol. “Inpatient satisfaction with nursing care at a university hospital in Turkey”. Valdivia. R. 74 No. 8 No. Vol. 24-33. 3. “A performance improvement programme at a public hospital in Sri Lanka: an introduction”. “International service variants: airline passenger expectations and perceptions of service quality”. NY. 3. Vol. “A critical review of consumer satisfaction”. 16 No.E.A. pp. “Achieving hospital operating objectives in the light of inpatient preferences”. Journal of Services Marketing.Y. 1. Pavi. (1990).).G. M. (1995). (2005).com/reprints
. Tountas. World Development Indicators (2003). 3. Vol. (1993).tr
Service quality in public and private hospitals 23
To purchase reprints of this article please e-mail: reprints@emeraldinsight. 167-80. Karandagoda.R.. DC. World Development Indicators Indicators in CD Database. Tomes. (2000). “Measurement in a cross-cultural environment: survey translation issues”. Harper Collins College Publishers. 10 No. “Development of a multiple-item scale for measuring hospital service quality”. 3 No.arasli@emu. Vol. P. 4. pp.. Y. F. Chicago. (Ed.
Practical implications – Results indicate what is important to patients in each service process segment that focus where ambulatory surgery centers should allocate resources. Originality/value – This study is the ﬁrst to evaluate patient satisfaction with all three process segments.The current issue and full text archive of this journal is available at www. 1985.emeraldinsight. 1991. 1.1
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
IJHCQA 21. The service quality Gap Model is operationalized by the SERVQUAL instrument (Parasuraman et al. Texas. United States of America. It draws on the disconﬁrmation paradigm from the psychology and consumer behavior literature and the Gap Model (Parasuraman et al. Chin
University of Houston. 2000). and
Wynne W. The Gap Model operationalized by SERVQUAL is widely used to measure service quality. 1990. Keywords Patients. 21 No. The lack of proper segmentation and methodological criticisms in the literature motivated this study. 1996) and has been adopted for health care operations as well (for example. process.com/0952-6862. Shelton.1108/09526860810841138
Introduction The operations management and marketing literature focus on measuring service quality as the gap between expectations and perceptions. Patient satisfaction criteria speciﬁc to hospital selection are not included in this study. see Carman. All three segments should be measured. Rhode Island. 2008 pp. a form of structural equation modeling. Houston. USA. USA
Purpose – The purpose of this research is to develop an alternative method of measuring out-patient satisfaction where satisfaction is the central construct. 24-38 q Emerald Group Publishing Limited 0952-6862 DOI 10. Smithﬁeld. 1988. Research limitations/implications – Only one out-patient surgery center was evaluated. Oliver.. Reidenbach and Sandifer-Smallwood. Findings – Results indicate that each process stage mediates subsequent stages. Outpatients Paper type Research paper
International Journal of Health Care Quality Assurance Vol. is used to develop a framework to evaluate patient satisfaction in three service process segments: pre-process. 1988). Customer services quality.. 1990. and post-process service experiences. 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. Performance levels. the SERVQUAL instrument only measures expectations (resulting from the pre-process segment of the service experience) and perceptions (resulting from the post-process segment). Shewchuk et al. However. Bitner.. Although SERVQUAL is a good base for measuring service quality and
. 1996. Wicks
Bryant University. 1990). an approach widely used in service operations (Spreng and Page. Design/methodology/approach – A partial least squares (PLS) approach.
the possible trade-offs between functional areas. An out-patient surgery center was selected for this study. 1992. see Cronin and Taylor. 1993. Additionally. process. The R 2 values for the perception scores are often higher than the overall gap scores (Cronin and Taylor. Peter et al. 1990). 1988).. 1993).. and post-process (Babin and Grifﬁn.. Overall satisfaction model
. 1992. spurious correlations and variance restriction problems make gap measure a poor choice as a measure of psychological constructs (Peter et al. Low reliability. poor discriminant validity. 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.. customer satisfaction. 1993).
Measuring the three process segments 25
Figure 1. 1993). 1994. several problems exist owing to the nature of the creation of the gap measurement (for example. 1993. higher than the gap scores (Parasuraman et al. Vandamme and Leunis. service operations. Babakus and Boller. 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. 1960). marketing. Few patient satisfaction studies have been performed on out-patient surgical experiences even though many traditional in-patient procedures have been converted to out-patient procedures (Peyrot et al. Rosen and Karwan. SERVQUAL only measures the pre-process segment (expectations) and the post-process segment (perceptions). 1993).. 1990. psychology and health care operations literature and by a series of focus group discussion.. Service process measurement should include all three consumption experience segments: pre-process. or higher than expectations scores (Brown et al. Our framework was developed from operations management. 1994). not quality. 1992. our study develops an alternative method for measuring patient satisfaction in a larger retention framework where satisfaction. Peter et al. 1998. Teas. Therefore. 1993). Singh.
the post-process transactions primarily relate to errors in insurance submission. However. That is. the patient satisfaction deﬁnition antecedents are listed in Table II (see Wicks et al.e. The sample size requirement in PLS is typically determined by locating the dependent construct in the model with the largest number of predictors (i. The degree of loyalty depends on the patient’s overall satisfaction. 1999). independent variables) and applying procedures used in multiple regression (Chin and Newsted. tangibles are not applicable for the post-process segment.1
Method Our pilot survey consists of 100 questions related to the survey constructs. six demographic questions. two insurance questions and one open-ended question. The relevant constructs were determined for each service process segment from the literature and focus groups. A total of 631 usable surveys were completed and returned (17 percent response rate). a sample size of 631 far exceeds the minimum required to provide sufﬁcient analytical power (Cohen. the sample size is sufﬁcient for our regression-based PLS analyses. In our study the constraining construct involved twelve predictors. The patient satisfaction deﬁnitions for each segment and for overall satisfaction are listed in Table I. Therefore. Overall Satisfaction in the model leads directly to loyalty and loyalty leads directly to retention. Retention model
. therefore. There were few missing data in the survey results. 2004b) for a complete discussion of the
Figure 2. The expectations minimization algorithm was used to substitute missing data in both the pilot and ﬁnal surveys. which patients were expected to return to the doctor at a post-operative appointment. The dotted lines leading into and out of overall satisfaction indicate how satisfaction ﬁts within the larger retention framework (Figure 2). These types of processes are primarily phone transactions. Some doctors did not forward the surveys to the hospital resulting in a lower than expected response rate. The dotted lines indicate where the exogenous variable for cognitive and behavioral antecedents relates to overall satisfaction. The Overall Satisfaction Model is presented in Figure 1. The same patient satisfaction antecedents were used for each segment except for tangibles. 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. See Witten and Frank (2001) for a detailed discussion of the algorithm’s use.IJHCQA 21. The questionnaire was included with the patient’s discharge papers. Therefore. (2004a. Pilot survey data were drawn from 112 usable responses. 1988).
. The validity of several other constructs outside the satisfaction portion of the PLS model is logically connected to this study in Figure 2. and personnel appear neat and clean Table II. Loyalty is deﬁned as the attitude toward reuse of the center. Retention is deﬁned as the actual reuse of the center by the patient. Patient satisfaction antecedents’ deﬁnitions
framework’s development.e. 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. 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. equipment. the satisfaction deﬁnitions and the patient satisfaction deﬁnition antecedents used in this study). for example. Cognition. is deﬁned as the mental process by which knowledge is acquired about the out-patient surgery center. rigorously correct) The degree to which the health care provider promptly responds to the needs of the patient The degree to which the risk in the health care environment is reduced for the patient The degree to which the health care facilities.Latent variable Overall satisfaction Pre-process satisfaction Process satisfaction Post-process satisfaction
Deﬁnition The degree of positive affective orientation toward the patient’s outpatient surgery experience The degree of positive affective orientation toward the patient’s pre-admission experiences The degree of positive affective orientation toward the patient’s outpatient stay experiences The degree of positive affective orientation toward the patient’s post-discharge experiences
Measuring the three process segments 27
Table I. Behavior is deﬁned as the mental process linked to speciﬁc directed action toward the out-patient surgery center.
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
794 0.884 0.988 respectively. The item loadings are provided in Table VI also resulting in high composite reliabilities for the three stage constructs of 0. we replaced “out-patient surgery” with “pre-admission experiences” for OAPR_1 and OAPR_2.778 0.891 0. two indicators were used.840 0. Table VII presents the correlations among construct scores with the AVE results on the diagonal.900 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 0.923 0.998 0.902 0.885 0.997 0. The results of both analyses indicate that the model’s psychometric properties are sufﬁciently strong to enable structural model estimate interpretation.965 0.998 0.773 0.865 0.969 0. are all larger than the correlations. and “post-discharge experiences” for OAP_1 and OAP_2.760 0.757 0.843
OA Stage 1 0.997.961 0. 0.919 0.884.837
OA Stage 2 0. The cross-loadings provide similar results.861 0.846 0.989
Table VI.998 0.812 0.941 0.887 0.875
Stage 1 0.887 0. “surgery stay experiences” for OAS_1 and OAP_S.846 0.892 0.856 0.832 0.921 0. Overall satisfaction model – loadings/cross loadings of items
Overall Overall Stage 1 Stage 2 Stage 3 0. and OA Stage 3).900 0. The AVE value square roots.808 0.837 0.787 0. all item cross loadings are higher for the construct on which the item should load than on any other construct.789 0.869 0. OA Stage 2.889 0.954 0.954 0.835 0.852 0.898 0.842
OA Stage 3 0. indicates strong item convergence towards a highly reliable scale. Using the same wording for items OAA_1 and OAA_2.998 and 0.796 0.935 0.932 0.867 0.746 0.988 0.926 0.809 0.843 0. 0.895 0.902 0.900 0.980.824 0.815 0.950 0.895 0.988
Table VII.841 0. All the loadings are signiﬁcant at an alpha of 0.902 0.863
0.0.882 0. The composite reliability.920 0.889 0.955 0.834 0.01.872 0.831 0.944 0.997 0.934 0.996 0.924 0.837 0.793 0.869 0.809 0. represent a strong relationship.810 0.802 0.866 0. For each of the three process stages (OA Stage 1.932 0.836 0. as required. Overall satisfaction – Survey: Correlation among construct scores (square root of the AVE extracted in diagonals)
.835 0.869 0.826 0.
These results indicate that models based on
. whether paths minimally impact or larger).6 percent of the variance in overall patient satisfaction with out-patient surgery experience. the global set of 15 items for overall satisfaction provides an operationally discriminant difference to those used for the three stages. as just noted.666. In terms of satisfaction at the start of the process in Stage 1 impact.0676 respectively. using the cross-validated redundancy option.148 effect on overall satisfaction. indicating a small effect for both segments on overall patient satisfaction.18 and the post-process stage has only a 0. Speciﬁcally. Overall satisfaction model results indicate that the patient’s satisfaction with the actual surgical stay.7511 for the Stage 3 and 0. This implies that the model constructs have high predictive ability. 0.1
Structural model assessment Bootstrapping results indicate that all path coefﬁcients are signiﬁcant at an 0.67.01 alpha and estimates are presented in bold in Figure 3. The highest impact is the path coefﬁcient value of 0.788 for Stage 2. The strength of the relationships between patient satisfaction and the three service experience process segments is also tested. Moreover. Typical for path analytic/structural equation techniques. 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.e.0811 and 0. As found when assessing the measurement model.973. The f 2 for Stage 1 and Stage 3 are 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.18 and the post-process segment (Stage 3) has only a 0. we noted the construct discrimination among the stages as well. As such.IJHCQA 21.18 from Stage 1 to Overall Satisfaction.891 from Overall Stage 1 to Overall Stage 2. In terms of substantive effects and predictive relevance. Stage 2 has a large impact on overall patient satisfaction with an f 2 of 0.36 from Stage 1 to Stage 3 and an even lower value of 0. satisfaction towards the out-patient stay (i. The pre-process segment (Stage 1) has a signiﬁcantly lower impact of 0. with a lower value of 0. 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. The pre-process stage has a signiﬁcantly lower path coefﬁcient of 0. the relative strength of each stage’s impact on overall satisfaction as well as among each other is consistent. While this is high for predictive models. The model is an excellent overall patient satisfaction predictor. 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.e.790 for overall satisfaction. Stage 2) has the most impact on overall satisfaction with the pre and post stage satisfactions being much less inﬂuential and approximately equivalent. In particular. we see that the model explains 92. it should not be surprising to ﬁnd signiﬁcance for all paths owing to the relatively large sample size independent of the effect size (i.148 path coefﬁcient. are 0. The Q2 predictive relevance values. Furthermore. what is also important is whether paths estimated are also substantive with high R-squares. Stage 2’s impact (path coefﬁcient) on overall satisfaction is 0. Conclusions and recommendations Our study establishes and tests the relationships between three service process segments and overall patient satisfaction.
However.expectations. empathy. conﬁdentiality. security. Our analysis also found that. This indicates that pre-process segment impact. reliability. equivalent to the Stage 1 service experience pre-process segment. courtesy is most important. patients pay attention to the facility’s neatness and cleanliness. the highest impact is represented by the path coefﬁcient of 0. The results of the Process Satisfaction model indicate that convenience has the most impact on the formation of overall process satisfaction. Overall Stage 1 has a dramatically lower effect on Stage 3 (0. The remaining antecedents were ranked as competence. For this service process segment. The remaining antecedents are ranked as conﬁdentiality. ranked second in the process segment. 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. responsiveness. Assurance has the greatest impact on the formation of Post-Process satisfaction. empathy.e. The remaining antecedents are ranked in order of impact on pre-process satisfaction as follows: reliability. Assurance at this stage can impact how comfortable the patient feels about the surgical process.180). have signiﬁcantly less impact on overall satisfaction. For example. but this may be true since process satisfaction had such a large effect on overall satisfaction.891 from Overall Stage 1 to Overall Stage 2. If the health care provider can handle the pre-registration process well then it can probably handle the surgery to a good standard. responsiveness. Tangibles may be important in this case because of the correlation between cleanliness and a good surgical outcome (i. communication. communication. responsiveness. conﬁdentiality. competence. These results cannot be generalized to all segments since process satisfaction impacts overall satisfaction more than the post-process segment. security and then convenience. Assurance. competence. no infection following surgery). each process stage mediates subsequent stages. reliability. each process stage inﬂuences the development of overall patient satisfaction and all three stages should be included in the model. assurance had the highest rankings across all process segments. in fact. and security. 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. communication.
Measuring the three process segments 33
. however. The tangibles antecedent was not included for Post-Process Satisfaction. The greatest impact on overall satisfaction is the actual surgical experience. assurance and tangibles. Our research establishes and tests the relationships between patient satisfaction antecedents and overall satisfaction for each service process stage. however. the path coefﬁcient for courtesy is almost twice that of the next highest path coefﬁcients: reliability. The same 11 antecedents were evaluated for Pre-Process Satisfaction and for Process Satisfaction. or expectations. The number one ranking for convenience in the process satisfaction segment was unexpected. empathy. for this model. and empathy. One possible explanation could be that the process segment convenience aspects act to reduce stress over the actual surgical process. tangibles. When the Overall Satisfaction model was evaluated. courtesy. Convenience is closely followed by assurance and courtesy. closely followed by courtesy. diminishes as the patient moves away from the pre-process segment. The results of the Pre-Process Satisfaction model indicate that courtesy has the most impact on customer satisfaction for this segment.
The remaining surgical procedures should be designed to be as stress-free as possible. assurance for the post-process segment and for overall satisfaction. empathy. How well the patient feels that the surgery will be performed may be much more important. The results of the different satisfaction models indicate the antecedents have differing impacts on satisfaction depending on where the antecedent is measured. 2000). responsiveness. Conﬁdentiality and convenience had the lowest impact. competence. 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. Patients may consider assurance more important in the out-patient surgical setting than how empathetic the health care providers appear to be. 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. so tangibles were not included in the rankings. 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. Patients are pre-registered for out-patient surgery. reliability. transportation to the facility exit should be ready and waiting so the patient can easily leave the facility. Empathy ranked ninth out of ten antecedents consistently evaluated in all three process-segment models and ranked last in the process segment.1
followed closely by courtesy. When the patient is discharged. The low ranking for empathy may have occurred because approachability and sense of security were omitted from the newly-developed deﬁnition. Directional assistance should be available so patients can easily arrive at the proper location within the facility. The most important pre-process segment antecedent for the patient was courtesy. convenience for the process segment. The organization should focus on making the center easy to ﬁnd by providing good directions and appropriate signage for example. Conﬁdentiality ranked low in all aspects of the out-patient surgery experience. but the organization should focus on these aspects during the registration process to alleviate anxiety about the impending surgery. 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. Designing the out-patient surgery process to be convenient for the patient on the day of surgery can have the greatest
. 2000). communication. assistance could be in the form of clear and adequate directions possibly from an information desk at the out-patient entry. The health care literature stresses the importance of communication in evaluating patient satisfaction (Shelton. 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. speciﬁc entry and departure areas for the patients and perhaps valet parking. The results of some rankings were unexpected. which may have occurred since a communication aspect was included in the assurance deﬁnition. However. staff should design parking facilities and procedures to be as convenient as possible by providing adequate signage. communication was eighth in the overall rankings. and security. Tangibles were not evaluated in the Post-Process Satisfaction model. 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. so paperwork should be in place when he or she arrives at the surgery center.IJHCQA 21.
2000. 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. (2001). 1993) and the satisfaction model might prove valuable in this area as well. These factors have been included in quality studies in non-health-care services (see Anton. Satisfaction antecedents developed for this study should be modiﬁed and applied to on-line services. value and image should be included as well. Shi and Singh. the major determination would need to be about selecting satisfaction antecedents for industry-speciﬁc applications in the service sector. more work is needed to determine if satisfaction antecedents vary in impact among service industries. Patients also need to feel that any ﬁnancial information will be kept strictly conﬁdential. Assurance needs to be the focus in any post-process interactions with the patient. Access. Good results were obtained from these models in an out-patient surgical setting. Naumann and Giel (1995) and John (1992) found image an important quality determinant. 1993. while access. Value has been determined to be important in health care (Donabedian. Our study only evaluated patient satisfaction antecedents for an out-patient surgery center located in a large USA city. however. 1993. Training programs for administrative personnel in billing and insurance to properly address these issues can also have a great impact on post-process satisfaction. 2001). 1995) included value in their studies. 1995. He or she needs to feel that any billing or insurance problems are going to be taken care of appropriately. Barsky. Access has been included in numerous health care studies as a construct for determining health care quality and/or patient satisfaction (Ware et al. The model also appears generalizable.. 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. Waldbridge and Delene. Therefore. The generalized model could also be applied to public service and not-for-proﬁt service areas. Kristensen et al. Service models have been applied to service segments within manufacturing organizations (O’Hara and Frodey. Shelton. and focuses on an insurance-based healthcare system. Naumann and Giel (1995) and Rust et al. The assumption was made that the health care provider and the extent of health care coverage had already been determined. 1978. Bolton and Lemon (1999). Sale. 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. image and value as satisfaction antecedents. Shi and Singh. 2000. 1988. Archer and Wesolowsky (1994). the distributor and other entities along the supply chain is extremely important (Preis. this study does not include access. image and value should be included in the generalized model. A more generalized model should be developed to evaluate satisfaction in other types of services. 2000) for a review of access). Supply chain management is a particularly rich area where retailer satisfaction. Technology has had an enormous impact on how organizations do business (Harvey et al. (1994. Waldbridge and Delene (1993) determined that image was an important health care quality determinant. The
Measuring the three process segments 35
. 2001). The literature reviews and focus groups determined general patient satisfaction antecedents. 2001). 2003). The generalized model could be easily modiﬁed for supply chain applications. Barsky (1995). Shi and Singh.
Vol. (Ed. 66 No. (1999). Vol. 2nd ed.W. J. NJ.W. present.P. 155 No. 14 No.W. 33-55. “A partial least squares latent variable modeling approach for measuring interaction effects: results from a Monte Carlo simulation study and an electronic-mail emotion/adoption study”. M. pp. and Newsted. 54 No. “The clinical course of palpitations in medical out-patients”. Vol. Thousand Oaks. (1995). “Consumer perceptions of service quality: an assessment of the SERVQUAL dimensions”. “A dynamic service quality cost model with word-of-mouth advertising”. “The partial least squares approach for structural equation modeling”. pp. Journal of Retailing. L. E. pp. K. (Ed. Barsky. J. B. pp. 69-82. J. “An empirical assessment of the SERVQUAL scale”.W. Vol. Babakus. pp. and Peter. M. (1998). Harvey. and Boller. Bitner. Cronin. diversity of means”. 36 No. Hillsdale. 24 No. Vol. (1993). Journal of Retailing. Cohen. Vol. 127-39. (1998). 25 No. Journal of Marketing Research. CA.IJHCQA 21. Technovation. Again. Vol. International Journal of Service Industry Management. 5. 189-217.. Chin. Jr. Vol. and Newsted. Chin. W. 18.
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18 No. Singh. Gaithersburg. Vol. Vol. G. R. T. 18-34. Journal of Marketing. R. Bryant University. (2004a). A. RI. “Development of a multiple-item scale for measuring hospital service quality”. Journal of Health Care Marketing. “Reﬁnement and reassessment of the SERVQUAL scale”. Witten. and Gale. pp. J. 1. 420-51. pp. pp. 1-54. A. Journal of Marketing. and Wold. pp. evaluation. “Expectations as a comparison standard in measuring service quality: an assessment of a reassessment”.IJHCQA 21. 6-16. “In search of service quality measures: some questions regarding psychometric properties”. “The strategic management of service quality”. RI. (1993). S. 58 No. Spreng. Health Services Management Research. W. J. 19 No. 18 No. 4.. Wicks. S. “Measuring physician attitudes of service quality”. P. Systems under Indirect Observations: Causality. (1982). K. S. 1. DeSouza.. Vol. (Eds). in Joreskog. pp. V. (1991). MD. D. working paper. pp. (1996). (2001). (1991). Wicks can be contacted at: email@example.com. Vol. (1993). Data Mining – Practical Machine Learning Tools and Techniques with Java Implementations. and Leunis. H. and Singh. (1985). L. Wicks. (1993).G. R. pp. International Journal of Service Industry Management. 13 No.. Fletcher. Teas. and Page. 12. J. “A multifacet typology of patient satisfaction with hospital stay”. and Chin. and consumers’ perceptions of quality”. Vol. 1. and Frank. B. L. O’Connor. Vandamme. Further reading Parasuraman. Davies-Avery. Structure. CA.1
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Personality. Rochester. rather than in multi-specialty groups or health maintenance organizations. 1. Among the hostile patients. while 72 percent with scores in the optimistic range rated it as excellent (p ¼ 0:003). 59 percent rated overall care by their physicians as excellent. USA
Purpose – The purpose of this research is to determine whether a pessimistic or hostile personality style adversely affects satisfaction with out-patient medical visits. Thomas G. including interactional style and the physician’s age (Kirsner and Federman. 21 No. McLeod and G. 1. The Medical Outcomes Study (MOS) evaluated patient satisfaction based on practice type and payment method (Rubin et al.The current issue and full text archive of this journal is available at www. Mayo Clinic. while 66 percent of the least hostile patients rated it as excellent (p ¼ 0:002). Colligan
Department of Psychiatry and Psychology. Mayo Clinic. USA.. nor how polished the physician’s interpersonal skills. The MOS included more than 17. Originality/value – Pessimistic or hostile patients were signiﬁcantly less likely to rate their overall care as excellent than optimistic or non-hostile patients. 1993). Costello. Patient satisfaction has been widely studied. United States of America. and
Robert C. Rochester. Patients seen in a solo or single-specialty practice. Minnesota. Design/methodology/approach – An eight-item patient satisfaction survey was completed by 11. Richard Locke III
Division of General Internal Medicine.636 randomly selected medical out-patients two to three months after their episode of care. efﬁcient and expert their care.
International Journal of Health Care Quality Assurance Vol. no matter how comprehensive. 39-49 q Emerald Group Publishing Limited 0952-6862 DOI 10. Dierkhising and Kenneth P. Keywords Patients. The association of pessimism and hostility scores with patient satisfaction ratings was assessed. Minnesota.1108/09526860810841147
Pessimism and hostility scores
Received 6 May 2006 Revised 13 September 2006 Accepted 23 September 2006
Ross A. Mayo Clinic. 1997). but little has been written about the association between patients’ personality characteristics and their satisfaction ratings. Offord
Division of Biostatistics.emeraldinsight. Many patient and health care provider demographic characteristics have been related to patient satisfaction with a health care encounter. to physician characteristics.htm
Pessimism and hostility scores as predictors of patient satisfaction ratings by medical out-patients
Brian A. inconsolable and personally challenging. Satisfaction determinants range from structurally-based ones such as the type of health care delivery system.259 had previously completed a Minnesota Multiphasic Personality Inventory (MMPI). Minnesota. Of these. Health services Paper type Research paper
Introduction Practicing clinicians know that certain patients are difﬁcult to satisfy. 2008 pp.000 patients who had ﬁlled out a nine-item questionnaire after an out-patient visit. 57 percent rated their overall care by physicians as excellent. Findings – Among patients who scored high on the pessimism scale. Rochester. were most likely to rate the overall visit as excellent.com/0952-6862.
Physician age and gender have also been correlated with patient satisfaction.. in a study of patient characteristics among out-patients at our center.IJHCQA 21. When the two data sets were merged we found that 1.000 Minnesota Multiphasic Personality Inventories (MMPIs) archived at our institution since 1959. 1980. and all study subjects gave research authorization. Effective communication skills and particular physician behaviors. including the patients’ personality characteristics. patients’ reports of satisfaction with care. particularly patient waiting time. We then assessed the degree of association between: . have been associated with higher patient satisfaction ratings (DiMatteo et al. patients with depression or anxiety disorders are more likely to express dissatisfaction from unmet expectations (Kroenke et al. This study investigated the personality characteristics of pessimism and hostility as they relate to patient satisfaction ratings. is important. Therefore. For example. G. 1993). 1993). structural. Furthermore. as assessed by the MMPI. longer waiting times result in lower patient satisfaction (Probst et al. 1984. personality traits of pessimism and hostility. female physicians (Hall et al. as expected. 1997).. lower satisfaction ratings were reported by patients who were young. understanding factors associated with patient satisfaction.. an MMPI.R. Methods Two archival data sets were abstracted. The study was approved by our institutional review board. general satisfaction with the visit and willingness to recommend our center to others. before that survey was completed. surprisingly little has been written about patient characteristics and their relationship to medical care satisfaction ratings. Of the MMPI and the patient satisfaction responses.. Patient satisfaction is associated with compliance and willingness to continue receiving care from a particular physician (Rubin et al. interactions with physicians and allied health staff. patients who believe their health status is good are more satisﬁed with their care (Probst et al.. The survey response rate was 60 percent. Conversely. speciﬁcally. We hypothesized that pessimistic or hostile patients would report less satisfaction with their care. All MMPIs had been obtained before the satisfaction survey. The topic of the eighth item was the completion of all scheduled tests and consultations (yes/no). Bartlett et al. such as performing a physical examination. Organizational factors. and who lived locally (Locke. A ﬁve-point scale was used to rate seven items pertaining to satisfaction with access. not satisfaction. who were employees of the center. lower satisfaction is reported by patients after seeing younger.259 out-patients formed the basis for our study. 1. Robbins et al.636 medical out-patients who completed a patient satisfaction survey for the Department of Internal Medicine from March 1998 through March 1999.. Pessimism and hostility were chosen for study because these
. The ﬁrst data set consisted of information from 11. and .259 medical out-patients had completed both the patient satisfaction survey and. personal communication. The second data set comprised scores from approximately 335.. and physician-speciﬁc factors related to patient satisfaction. An eight-item questionnaire was mailed to randomly selected medical out-patients two to three months after their care episode. Although much has been written about organizational. 1994).. 1997). have been studied and. 1997). September 2002).
The MMPI consists of 550 unique true/false items about thoughts. 1990). and previous life experiences (Swenson et al. we also adjusted for previously identiﬁed predictive covariates. For the question about recommending the medical center to others. from experience with previous internal analyses. emotional symptoms. being a medical center employee or a dependent of an employee (“employee/dependent”. unsocial. these qualities come closest to deﬁning the intangible characteristics that physicians sense in patients who are difﬁcult to satisfy. 1995). in our experience. scoring high on the Ho scale) as:
. 1993. 5-32). . 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.. Hostility was measured by the MMPI hostility (Ho) scale (Cook and Medley. but signiﬁcant. High scores on the pessimism (PSM) scale reﬂect a pessimistic explanatory style. 1994). 1989. stable (rather than transient) and global (rather than speciﬁc) possess a pessimistic personality trait.. The scale’s developers describe a “hostile person” (i. relationships that might not otherwise be uncovered in smaller or more highly selected samples. low scores. Furthermore. age. which are standardized to a mean of 50 and an SD of 10. feelings. are considered relatively stable (Maruta et al. responses were coded “1” for “deﬁnitely would recommend” or “0” for any other response. This procedure for collapsing and dichotomizing the ﬁve-point scale is in keeping with the convention from marketing literature (Jones and Sasser. .personality traits. These included patient’s residence distance from our medical center. Additionally.Hostility amounts to chronic hate and anger. which suggests that people who believe that the cause of an adverse event is internal and personal (rather than external). Maruta et al.e. .
Pessimism and hostility scores
The MMPI scales are reported as T-scores. The PSM scale for the MMPI is based on Seligman’s explanatory style theory (Colligan et al.. 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. 1 ¼ yes. Finally. as assessed by the MMPI. attitudes. immoral. poorer physical health. optimistic. For six questions. 1954).. These are known and important explanatory variables when modeling patient satisfaction at our center. lower levels of achievement and increased use of medical and mental health services (Seligman. . 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). . We considered this variable because many of our patients travel long distances to our center for intensive out-patient
. [and] sees people as dishonest. 0 ¼ no) and receiving primary care. lone who has little conﬁdence in his fellowman. pp. . Research shows that a pessimistic explanatory style is predictive of an increased likelihood of depression. ugly and mean. 2000). responses were coded “1” for “excellent” or “0” for all other response categories to that item.
Statistical methods Logistic regression models were used to assess the association between patient satisfaction ratings and the PSM and Ho scores. physical symptoms. Our large sample size allowed us to detect small. The dependent variables were seven patient satisfaction responses from the eight-item survey.
1 to 5 years after the MMPI. and .e.1 to 10 years after the MMPI. Travel distance varied considerably: . and . 199 (16 percent) lived 121 to 250 miles away. we modeled the interaction of time and the MMPI scale score within the context of two models.259 out-patient participants: . 388 patients (31 percent) lived within 20 miles. Three sets of explanatory variables were used in the modeling. 219 (17 percent). either PSM or Ho) and the interaction between time and the MMPI scale of interest as explanatory variables. . the adjusting variables described above and the interaction between time and the MMPI scale as explanatory variables. and complete appointment itinerary could affect ratings of patient satisfaction. . 286 (23 percent) lived more than 250 miles away. 5.039 patients (83 percent) had their tests and consultations completed (85 [7 percent] had missing data). The ﬁrst model was done univariately. and . The third included both MMPI scales of interest and the adjusting variables already mentioned. 386 (31 percent) lived 21 to 120 miles away. 1. 222 (18 percent) 1. One included the MMPI scale of interest (i. . 277 (22 percent) were seeking primary care. we believed that scheduling a timely. The second model included only one of the MMPI scales of interest and the adjusting variables described above. including only the MMPI scale of interest (i. . Wald x2 statistic p values were calculated from these logistic regression models. 515 (41 percent) were 66 years or older. 632 (50 percent). During the visit studied.e. Since the MMPI and the patient satisfaction survey were not completed concurrently. efﬁcient. Results Patient characteristics At the time the satisfaction survey was completed by the 1. more than 10 years after the MMPI. 1 had missing time data.1
evaluations during a single episode of care.IJHCQA 21. 27 (10 percent) were 18 to 40 years old. The survey was completed as follows: . The other model consisted of the MMPI scale of interest. . Therefore. 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. Among these patients: . . Therefore. 719 (57 percent) were female. 201 (16 percent) were medical center employees or dependents. and . .
. either PSM or Ho). 617 (49 percent) were 41 to 65 years old.
Pessimism and hostility scores
. The same patterns were present among the “excellent” ratings in relation to patient hostility (i. 64 percent. the percentage of patients giving “excellent” ratings was signiﬁcantly lower. 63 percent. 71 percent. and . . p . p ¼ 0:008). . willingness of physicians to listen to the patient and family (60 percent v. p . 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). the association weakened when adjusting for the Ho T-score. p ¼ 0:001). The results from the models were also similar. p ¼ 0:001). In general. reﬂecting an increasing pessimistic explanatory style. 66 percent. Speciﬁcally. 63 percent. The exception is the question pertaining to the patient’s willingness to recommend the center. the odds of a patient giving the center an “excellent” rating were signiﬁcantly lower. . higher Ho T-scores) as for the PSM scale. This is evident in their responses on individual items: . 66 percent. This can be explained by the relatively large positive correlation between the PSM and Ho T-scores (r ¼ 0:61.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. physicians responding to questions about the patient’s medical condition and treatment (57 percent v. respect shown by physicians (57 percent v.001). .001). This pattern was fairly consistent for all survey questions. overall care received (52 percent v. 89 percent of optimists.001). 72 percent of the optimistic patients rated it excellent (p ¼ 0:003). p ¼ 0:282). even after adjusting for completion of tests/consultations and for all the previously identiﬁed predictors of satisfaction. a signiﬁcantly smaller proportion of pessimists than optimists rated other aspects of their care as excellent: . With higher PSM T-scores. p ¼ 0:002). helpfulness of allied health staff (53 percent v. and . Table II displays the percentage of “excellent” ratings by Ho T-score groupings and the p values from the logistic regression models. overall care provided by their physicians (57 percent v. 0.e. overall care received (55 percent v. . respect shown by physicians (64 percent v. 75 percent. . p ¼ 0:003). However. 70 percent. p ¼ 0:002). p ¼ 0:047). for which the ratings were not associated with these MMPI scale scores. 67 percent. p ¼ 0:002). 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). However. 0. 67 percent. while 59 percent of the pessimistic patients rated the overall care provided by their physicians as excellent. the PSM scale scores were not associated with willingness to recommend the center (86 percent of pessimists v. . physicians responding to questions about the patient’s medical condition and treatment (53 percent v. willingness of physicians to listen to patient and family (54 percent v. p ¼ 0:008). helpfulness of allied health staff (47 percent v. 0. Furthermore. 65 percent. with higher PSM T-scores. p .
and patient age by center employee/dependent status interaction).841
.221 0.002 0.075 0.219 0.1
Questionnaire item 83 83 83 83 100 83 100 88 89 86 86 62 62 62 64 61 59 57 56 43 51 88 70 64 61 59 52 71 65 63 89 71 75 66 65 68 64 64 67 62 61 65 60 55 61 59 72 75 67
Overall care by physician Respect by physician Listening by physician Physician addressing questions Helpfulness of allied health staff Overall care Willingness to recommend centerd
Notes: PSM ¼ pessimism scale of the Minnesota Multiphasic Personality Inventory.002 0. patients with high scores ($60). distance from the center by center employee/dependent status interaction. Within PSM groupings. center employee/dependent [1 ¼ yes.282 0. pessimistic.229 0.011 0. b p2 is the p value from the test of the coefﬁcient of the PSM T-score variable from the logistic regression model with the dependent variable being the rating (1 ¼ excellent. patient age [in years]. 0 ¼ not excellent) and the independent variables as for p2 but with both the PSM and hostility scale T-scores included in the model.774 0. seen in primary care area [1 ¼ yes.843 0. and variables previously identiﬁed from the analysis of the patient satisfaction survey (distance of residence from the center [in miles]. * Entries are the percentages of patients rating that aspect of care as excellent.002 0.003 0.005 0.002 0. Patients with low scores (#39) were classiﬁed as optimistic.003 0. Relationship between patient satisfaction rating of “Excellent” and the PSM T-score PSM T-score groups * Subtotals . sample sizes are ranges because the number of respondents varied among questions. 0 ¼ not excellent) and the independent variables being completion of tests and consultations during the initial visit (1 ¼ yes. d Entries are the percentages of patients who “deﬁnitely would recommend” the center
IJHCQA 21. 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. 0 ¼ not excellent) and the independent variable being the PSM T-score.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 0.056 0. 0 ¼ no). 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. 0 ¼ no].133 0.047 0. 0 ¼ no]. PSM T-score.002 0.008 0.
008 0.Questionnaire item 47 65 65 53 59 53 71 89 87 89 84 82 88 65 64 57 59 58 56 50 54 35 43 64 63 68 61 58 56 39 67 53 47 52 83 67 70 66 63 66 60 61 69 63 59 60 57 48 48 39 66 70 66 57 57 54
Ho T-score groups * Subtotals .097 0.001 0. Within Ho groupings.002 0.001 0.048 0.947 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. hostile. Relationship between patient satisfaction rating of “Excellent” and the Ho T-score
.002 0. 0 ¼ not excellent) and the independent variables being completion of tests and consultations during the initial visit (1 ¼ yes.328 0.011 0. 30 30-39 40-49 50-59 60-69 $70 Nonhostile Hostile (n ¼ 6) (n ¼ 92-95) (n ¼ 307-311) (n ¼ 393-401) (n ¼ 323-329) (n ¼ 102-106) (# 39) ($60) p1 a p1 b
0.001 0. * Entries are the percentages of patients rating that aspect of care as
excellent.006 0.068 .026 0. and patient age by center employee/dependent status interaction). 0 ¼ not excellent) and the independent variables as for p2 but with both the optimism-pessimism scale and Ho T-scale scores included in the model. and variables previously identiﬁed from the analysis of the patient satisfaction survey (distance of residence from the center [in miles]. 0 ¼ not excellent) and the independent variable being the Ho T-score. seen in primary care area [1 ¼ yes. 0 ¼ no]. a p1 is the p value from the test of the coefﬁcient of the Ho T-score variable from the logistic regression model with the dependent variable being the rating (1 ¼ excellent.046 . b p2 is the p value from the test of the coefﬁcient of the Ho T-score variable from the logistic regression model with the dependent variable being the rating (1 ¼ excellent.403 0. Patients with low scores (#39) were classiﬁed as nonhostile.001 0.001 0. c p3 is the p value from the test of the coefﬁcient of the Ho T-score variable from the logistic regression model with the dependent variable being the rating (1 ¼ excellent.0. patients with high scores ($ 60). patient age [in years].434 0. d Entries are the percentages of patients who “deﬁnitely would recommend” the center
Pessimism and hostility scores
Table II. center employee/dependent [1 ¼ yes. distance from the center by center employee/dependent status interaction. 0 ¼ no].001 0.0. Ho T-score. sample sizes are ranges because the number of respondents varied among questions. 0 ¼ no).
depression) at the time of the survey or episode of care. Table III displays the odds ratios for “excellent” ratings corresponding to 10-unit (1 SD) increases in MMPI scale scores for PSM and Ho. 83 percent) and non-hostile patients (Ho T score # 39. However.g. 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. or certain patient expectations. regardless of their opinion about some aspects of their experience during a particular care episode. Previously.02 to 0. However. having a pessimistic explanatory style as theorized by Seligman) or hostile patients (i. except for the question about willingness to recommend the center. the exception to this trend was the question pertaining to a patient’s willingness to recommend the medical center to others. Our results are a ﬁrst step towards understanding that certain aspects of the patient’s personality affect ratings of their satisfaction with care. unknown to the physician. the estimated odds ratios that corresponded to a 10-unit (1 SD) increase in the MMPI T-scores increased with the interval. these patients would still recommend the center because of other factors such as the center’s reputation.IJHCQA 21. these aspects of patient personality were experienced subjectively and understood solely through physician’s intuition and judgment. before the encounter. Adverse encounters were believed to result from the physician’s characteristics and behaviors or from organizational and structural factors surrounding the care episode. our ﬁndings indicate that important data about the factors contributing to patient satisfaction ratings are missing if patient personality characteristics are not considered.e. 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. our approach to studying the contributions of patient personality has not been previously taken. Among patients who would deﬁnitely recommend the center. The odds ratios were estimated for each of the three models. We included all patients who had completed both a patient
. It is notable that willingness to recommend our center to family and friends was not associated with hostility or pessimism. There was no signiﬁcant difference in the percentages of hostile patients (Ho T score $ 60. Now it is evident that some aspects of the patient’s personality affect ratings of satisfaction with care.03 for every 5-year interval increase..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. Our analysis shows that pessimistic patients (i. Discussion Patient satisfaction has been studied from various vantage points. high scores on the Ho scale) are signiﬁcantly less likely to rate satisfaction with their care as excellent. Additionally. these odds ratios increased by about 0. Clearly there are likely to be other patient-related characteristics that affect patient satisfaction ratings. This may result from feelings that. These may include emotional states (e. In general. When signiﬁcant associations existed.1
Again. patient satisfaction ratings for particular physicians and health care organizations are tacitly assumed to be a reﬂection of physicians or health care system. 88 percent) who reported “deﬁnitely would recommend the center” (p ¼ 0:434). These occur independently of other factors already known to contribute to variations in ratings of patient satisfaction.
00) (0. 0 ¼ not excellent) and the independent variables as in model 2 but including both PSM and Ho T-scores. 0 ¼ no].01) (0. for the PSM scale and the overall care by the physician.83 0.85-1.90 0. OR ¼ odds ratio. the OR was not signiﬁcantly different from 1 at the a ¼ 0:05 level.06) (0.00) (0. c Model 3 is a logistic regression model with the dependent variable being the rating (1 ¼ excellent. 0 ¼ no).90 0.95) (0.75-0.97) (0.76-0. Ho ¼ MMPI hostility scale.77-0.81-1.80-1. a Model 1 is a logistic regression model with the dependent variable being the rating (1 ¼ excellent.77-0.90 0.03) (0. Odds ratios (95 percent CI) for percentage of “Excellent” ratings for a 10-unit (1 SD) increase in the MMPI T-scores *
.86 0.21) 0.86 0.94) (0.95) (0.85 0.83-1.95) (0.81 0.85d 0.93 0.79 0. * See Tables I and II for the p values of the ORs that were signiﬁcantly different from 1 (associated coefﬁcient was different from 0).01) (0.94 (0.94) (0.93) (0. MMPI ¼ Minnesota Multiphasic Personality Inventory.19)
PSM scale Model 2b Model 3c Model 1a 0.02) (0. b Model 2 is a logistic regression model with the dependent variable being the rating (1 ¼ excellent.87 0.85 0.96) (0.10) (0.92) (0.91) (0.92 (0.76-0.01
Ho scale Model 2b
Model 3c (0.11) 0.08) (0.79-1.86 0.87 0.Questionnaire item 0.91) (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
Table III.91) (0. 0 ¼ not excellent) and the independent variable being the PSM or Ho T-score.84 0.71-0.80-1.82 0.99 (0.76-0.74-0.83 0.70-0.98 (0.84 0.00) (0.77-0.86 0.80-1.92 0. 0 ¼ not excellent) and the independent variables being completion of tests and consultations during the initial visit (1 ¼ yes.79-1.94) (0.98) (0.88 1.81-1. patient age [in years].72-0.76-0.85 0.76-0. and variables previously identiﬁed from the analysis of the patient satisfaction survey (distance of residence from the center [in miles].05) (0.98 0.73-0.07) 0.75-0.06) (0.00) (0.94 0.92 0.75-1.79-1.72-0.84-1.94) (0. PSM ¼ MMPI pessimism scale.81 0.92 0.83 0. d For example. PSM or Ho T-score.85 0. * * ORs are for the percentage of patients who “deﬁnitely would recommend” the center. center employee/dependent [1 ¼ yes.81 0.93) (0.74-0.13) (0.96) (0.94) (0.75-1.86 0.74-1.76-0.73-1.83 0. distance from center by center employee/dependent status interaction.74-1. 0 ¼ no].95) (0.80-1.87 0.78-1.74-0.28)
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.94) (0.73-0. In addition.84 0. and patient age by center employee/dependent status interaction).98 (0.80-1. if the 95 percent CI for the OR contained 1.97) (0.80-1.76-0.77-0. seen in primary care area [1 ¼ yes.89) (0.16) 0.85 0.
. Vol. Patient mix may temper an individual doctor’s satisfaction ratings. D.C. and Prince. A. since astute physicians are attuned to the personal qualities of their patients.. L.. Cook. and Medley. Vol.. Finally.
. Levine. J.M.1
satisfaction survey and an MMPI and did not exclude cases in which there was a long interval between the survey and the MMPI. K. and Libber.H. Nonetheless. 12.S. pp. Grayson. Conclusions and recommendations This research clearly demonstrates that patient personality characteristics play an important role in the results derived from patient satisfaction surveys. 38. and communication in medical visits”..P. Schulman. D. J. Irish. (1984). R. 4.W. signiﬁcant differences were noted in satisfaction on the basis of levels of hostility or pessimism. and adherence”. Ehrlich. (1954).. Colligan.. institutional policy makers need to be aware of the potentially signiﬁcant contribution of patient personality factors in adversely affecting the patient satisfaction ratings of individual physicians. 71-95.
References Bartlett. Physicians are much less likely to obtain excellent ratings from pessimistic or hostile patients. E. D. Malinchoc. 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. M.R. Journal of Applied Psychology. gender. “Satisfaction..E. Medical Care. Vol. 414-8. recall. (1980). M. including status as employee/dependent.. pp. distance traveled for care. Patient satisfaction ratings may be decreased if these patients are also characterized by traits of pessimism or hostility.. A.IJHCQA 21. pp. the possibility exists that physician care or manner may be modiﬁed by patient personality factors. Hall. C. P. 1216-31. 376-87. We included these independent variables in the models as adjusting variables. pp. M. who had also been asked to complete an MMPI. Golden. (1994). pp. S. Friedman. 32 No.M. M.M. Offord. Medical Care. Roter. 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. Therefore. Taranta. and type of care received.T. R. as deﬁned in this article. W. This inﬂuence is independent of physician or practice characteristics. Journal of Chronic Diseases. while contributing little to the practical management of hostile or pessimistic patients. 37 Nos 9-10. “Proposed hostility and pharisaic-virtue scales for the MMPPI”. Vol.L. 755-64. had a combination of medical and psychological issues requiring multidisciplinary investigation. H. Barker. “CAVEing the MMPI for an optimism-pessimism scale: Seligman’s attributional model and the assessment of explanatory style”. Although these ﬁndings are intriguing. 50 No. 1. Patient satisfaction at our center is associated with several variables. Time limits were not imposed because we were studying two personality traits that are relatively stable. one might speculate that patients coming to a tertiary care medical center for evaluation. and Seligman. and Miller.E.M. Such patients are diagnostically and personally challenging for physicians. “The effects of physician communications skills on patient satisfaction.. “Predicting patient satisfaction from physicians’ nonverbal communication skills”.. age of patient. (1994). Vol. Journal of Clinical Psychology.A. L. 18 No. Furthermore. DiMatteo.
pp. 68 No. Journal of the American Medical Association. (1990). “Optimists vs pessimists: survival rate among medical patients over a 30-year period”..P.R. 318). 1. (2000).. Jackson. Azari. 88-99. K. S.L.edu
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To purchase reprints of this article please e-mail: reprints@emeraldinsight.. p. Mayo Clinic Proceedings. Vol.H. “Patient and physician satisfaction with an out-patient care visit”.S. T. M. “Patient satisfaction: quality of care from the patients’ perspective”. 5. and Selassie. (1997). Swenson. (1997). K. Helms. 17-20. pp. T.brian@mayo.E..Jones. Bertakis. Rochester. pp.emeraldinsight. 11. 7.C... pp. J. R. Harvard Business Review. H. New York. Jr. 140-3 (“Erratum”.. Probst. R. Mayo Foundation. (1995). Callahan. “Why satisﬁed customers defect”. and health”. B. “The identiﬁcation and measurement of the psychoneuroses in medical practice”. pp. Journal of the American Medical Association. C. 122.com Or visit our web site for further details: www. 109-14.E.. Robbins. Seligman.G. W. 25 No.W. L.. Vol. Corresponding author Brian A. 75 No. Vol.C. R. Jr. 75 No. 1427-31. Vol. 736. Gandek. (1989).com/reprints
. Kosinski. Archives of Dermatology.. Vol. Kroenke.. 339-47. Osborne. in Mayo Clinic Proceedings. M. C. and Hathaway.O. (1993). “Depressive and anxiety disorders in patients presenting with physical complaints: clinical predictors and outcome”. and Offord. R. “Patients’ ratings of out-patient visits in different practice settings: results from the Medical Outcomes Study”. M. Maruta. (1993). D. D. and Colligan.L.. Offord. W. (1997). McKinley. (1943). 103 No. Vol. and Sasser. Brief Therapy Approaches to Treating Anxiety and Depression. E..C.A. D.. J. Colligan.L. Journal of Family Practice. American Journal of Medicine.C.E. Malinchoc.A. 3. Rogers.P. 270 No.D. Vol. pp. Maruta.J. 835-40. and Ware. K.C.. Family Medicine.E. Colligan. and Federman. R. (2000).J. 133 No. “The inﬂuence of physician practice behaviors on patient satisfaction”. pp. Rubin. A. achievement. J. J.. Vol. 418-25. Mayo Clinic Proceedings. pp. 2.A. and Creten. Brunner/Mazel. J. D. 45 No. Kirsner. Jennings. McHorney.A..P. “Keeping hostility in perspective: coronary heart disease and the Hostility Scale on the Minnesota Multiphasic Personality Inventory”.M. 2. Costello can be contacted at: costello. pp. Vol. Vol. R. T. 5.. and Chamberlin. M. W. K.R. J. and Malinchoc. Frye. M. “Explanatory style: predicting depression. 3rd ed. (1993). Hamburgen. Greenhouse. A User’s Guide to the Mayo Clinic Computerized Scoring and Interpretative System for the Minnesota Multiphasic Personality Inventory (MMPI). 161-7.. NY.
Section three continues to build the argument by further differentiating between customer expectations in intangible services and then health care services. Australia
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. developing and implementing effective complaints handling systems to assist the industry as it grows in demand. Section two builds the argument that aged care services involve a unique and complex form of customer expectations. School of Law.1
The role of understanding customer expectations in aged care
Conﬂict Management Systems Designer. Customer satisfaction Paper type Case study
Received 21 June 2006 Revised 10 July 2006 Accepted 15 July 2006
International Journal of Health Care Quality Assurance Vol. with the onset of the baby-boomer generation entering into aged care.The current issue and full text archive of this journal is available at www. Additionally. Keywords Elder care. Findings – The author builds an argument that aged care service providers must understand consumer needs and expectations so that customer satisfaction is generated. 1. 2008 pp.emeraldinsight. 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. It begins by differentiating between customer expectations in tangible products and intangible services. 21 No. understanding customer expectations at the outset of providing services can reduce the incidence of complaints that may occur after the services have been rendered. 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. Australia. Design/method/approach – The author ﬁrst explores expectation theory and how it links to customer behaviour and then discusses conﬁrmation/disconﬁrmation theory.
IJHCQA 21. is critical. 50-59 q Emerald Group Publishing Limited 0952-6862 DOI 10. Caulﬁeld North. Patients.com/0952-6862. Additionally. both owing to the ageing population and to the social nature of baby boomers to complain when their expectations are not met. Originality/value – Exploring patient and relative expectation and satisfaction in different theoretical contexts. Understanding the role of expectations in aged care is important because it can increase customer satisfaction.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.
p. 2001). strategies for understanding customer expectations and implications for the aged care sector in the wake of its baby-boomer growth stage are discussed. These post-purchase affective states range from delight. Additionally. 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. satisfaction and dissatisfaction – all relative to the original customer expectation. which therefore. word of mouth or customer needs. As Gilbert et al. implicit or explicit.staff must adopt unique approaches to understanding customer expectations. (2) expected needs – those which customers are able to articulate when asked about what they want. 47) put it:
Expectations provide the yardstick people use to evaluate the attractiveness and desirability of outcomes. Expectations can be based on market communication. . unrealistic or realistic (Ojasalo. increasing in intensity as more dissatisfaction is felt (Santos and Boote. events. 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. Affective behaviours stemming from satisfaction and delight are compliments. people. customer pre-attitudes or even the traditional marketing mix can inﬂuence what the consumer will expect from a product or service. an ideal standard or subjective norm. an industry standard or objective norm relating to the marketplace. Expectations have also been described as standards: . They have also been identiﬁed as being fuzzy or focused. (1992. and . Those emerging from dissatisfaction are complaints. and (3) exciting requirements – those unexpected needs that produce great satisfaction. A review of customer expectation theory Customer expectations are related to complaints through post-purchase affective states that cause affective behaviour such as complaining. image. while “should expectations” are those that the consumer thinks should happen in the next encounter. but will only be missed if not provided for. Prior experiences with organisations also form the basis of consumer expectations. Predictive or “will expectations” are those that the consumer thinks will happen in the next service encounter. In the ﬁnal section. a relationship standard based on the overall experience a customer has had in the past with a particular product or service. 2003). products. services and the like. customers “expected needs” can become “must be needs”. places responsibility on the provider of goods or services to continually improve
Understanding customer expectations 51
How expectations form What forms the basis of expectations has been discussed extensively in the literature. along with organisational and structural attributes. Over time.
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
2001). privacy (advocating for patient privacy) and appearance (all tangible aspects of care) (Perucca.
Loyalty comes from satisfaction. . in addition to intangible and process elements of service quality. attitude.. 2001). which is expected to maximise an inclusive measure of patient welfare. they will be satisﬁed and the health care service provider will retain customers (Bendall and Powers. non-verbal gestures. Consequently. 50). if expectations are negatively disconﬁrmed. 1992 as cited by Lim et al. being able to tune out the world and tune in the patient. body language and facial expressions (Perucca. Like other products and services. 1995). which make it harder to understand customer expectations in general services. Of course. a plethora of other stakeholders often become involved with service delivery.. In short. 1999. quality of care:
. . 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. [is] fully meeting the needs of those who need the service most. are unable to articulate their concerns because of a lack of self conﬁdence and fear of retribution (ACAA. . ﬁve common interpersonal expectations in health care – important to patients’ wellbeing – are staff attitudes (sincerity and trust). 1999. . 2005). Aside from involving care recipients’ physical wellbeing. which turns into customers’ intention to return to the service provider. and . and ability to break preoccupations. sensitivity (open ended questioning). . Finally. deﬁned as:
A process by which health care providers inﬂuence loyalty and maintain existing patients. p. customer dissatisfaction will occur and the possibility of complaints opens (Bendall and Powers. cited by Lim et al. aged care services have additional layers of customer expectations that make providing these services far more complex than general health care. 1995. An important health industry feature is that meeting customer expectations is not enough to guarantee customer loyalty and retention. 424). In addition. . Interpersonal elements that inﬂuence health care customer impressions include: . in a majority of cases. after one has taken into account the balance of gains and losses that attend the process of care in all its parts (Donabedian. . aged care residential services are permanent residential arrangements and with that comes more extreme intimate issues such as
. responsiveness (recognising needs and responding). aged care service customers are frail and elderly who. each with his or her own set of interests and concerns (ACAA.
Understanding customer expectations 55
Quality of care impacts on the patient’s intention to return to the health care provider.and courtesy and warmth received). if patients’ quality of care expectations have been exceeded. 424). p. unlike health care services. Customer expectations in aged care services In addition to the interpersonal skills and caring attitudes needed to meet customer expectations in health care. eye contact. In summary. at the lowest cost to the organisation within limits and directives set by higher authority and purchasers (Ovretveit. 1980. 2005). becomes that kind of care.
she became an expert at knowing every aspect of her mother’s needs. the mother was independently able to go to
. customer expectations in aged care will broaden to include updated information technology processes. feeding. It also involves deeply personal issues such as customer residency and security and family guilt. Quality of Care Principles 1997 and User Rights Principles 1997 deﬁne what aged care service customers should expect from their service and service provider. walking. dressing and bathing. Different family fragments give an additional complexity as multiple sets of expectations are involved. Moreover. 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. when she could no longer bear the burden of being a full-time carer. likes and dislikes. the importance of process delivery and the necessity of having a quality caring environment. was placed in the care of a nursing home. at the age of 92. the daughter’s heartbreak and guilt feeling for breaking her vow to her mother could at least be minimised by making sure her mother received the same treatment in the aged care facility. 2006). she was expert at administering medication. The daughter and mother had lived together all their lives. the purpose of which is to analyse the model of disconﬁrmation of expectations theory in a real case scenario. when her mother began to suffer dementia. including immediate family members. The case solely represents the views of the complainant.1
home. hearing and anxiety. it would be the best thing to place her mother in the hands of professional carers. concerns. The daughter cared for her mother from 1994. Upon admission to the home. This way. aged care services have the additional complexities of understanding and meeting the expectations of other stakeholders aside from the direct customer. During the course of their lifelong companionship. wants. During the nine and a half years of care that the daughter experienced. 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. these rules and principles may not be made clear to residents’ relatives. 2006). with the onset of baby-boomer generation retirement and the aging population. The daughter agreed to this oath and was faithfully fulﬁlling her carer’s role until 2003. the Aged Care Act 1997. in addition to the intangible nature of services. until 2003. other stakeholders. However. fears. The mother’s dementia worsened to the point of not knowing her daughter by face most of the time. security and emotional support (Thomas. Additionally.IJHCQA 21. all of which the daughter expected to be done in the same manner in the aged-care facility. owing to the intangibility of the nature of service and lack of communication that exists within aged care facilities. Case study This case study is the basis of a complaint lodged against a nursing home. 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. In no means is the following case meant to be treated as a judgement of the circumstances that surrounded the complaint. In summary. A good example of this scenario is illustrated in the following case study. when. the mother asked her daughter to swear to her that she would never put her into a hospital or nursing home. To assist in meeting the aged care residents’ and their families’ expectations. Finally.
One-to-one interviewing could be used as an additional method for strengthening customer satisfaction and managing customer expectations (Halliday and Hogarth-Scott. Her mother died ten weeks after entering the home. This case illustrates that both levels of expectations were not met. feed herself with minimal assistance and walk with a walking frame. according to the daughter. providers need to create cultures for better practices in complaints handling (Thomas. having kidney failure and pneumonia. 2001) or “desired” (Santos and Boote. As stated above. The second expectations’ group not met in this case were those relating to the alleged poor quality of care. not fed according to her visual impairment needs.the toilet at night time. those that must be delivered no matter what. allegedly owing to illnesses that were not detected because her mother was. At this stage. this service was at the level of the “worst imaginable”. In line with the Santos and Boote (2003) model of positive/negative disconﬁrmation. These expectations. as deﬁned above. One basic strategy already in place in many aged care facilities is to understand customer expectations through resident and family meetings or discussions. the daughter communicated these expectations and expected and them to be fulﬁlled. anxiety instructions not being listed to. She felt that her mother’s life was taken away from her owing to what she witnessed and described as horriﬁc care conditions. 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. these expectations refer to quality of care standards and principles set out in the Aged Care Act 1997. Now. are those that the customer can articulate when asked about what he or she wants. 2006). 2003) expectations. This model goes through phases:
Understanding customer expectations 57
. they were the expectations that were listed on the care plan that the care recipient’s daughter handed to the nursing home. The daughter naturally then lodged a complaint via the external complaints resolution scheme and is still pursuing a satisfactory settlement. Strategies for positively disconﬁrming customer expectations in aged care The onset of the baby boomer generation entering aged care is increasing demand for services. These expectations are deﬁned as “must be needs” (Ojasalo. according to the daughter. the mother not being warmly dressed. 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. Unfortunately. This case can be divided into two components for analysis of expectations. hearing aid not being attended to. 2006). In aged care. which led to the affective state of dissatisfaction. medicated to the point of being unconscious. Hence. converse. over the next few weeks. not walked. not taken to the toilet at night. understanding the future customers’ needs and expectations will minimise the amount of time and money spent on complaints handling. As a mismatch of customer expectations and experiences are the beginning of the complaints process (Thomas. according to the daughter. 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”. (1999) discussed a method of increasing customer satisfaction called quality deployment function. In this case. Lim et al. issuing medication without authority and with misleading information. 2000). 2001) or “minimum tolerable” (Santos and Boote. 2003) expectations. The ﬁrst group of expectations that were not met were those deﬁned above as “expected” (Ojasalo. These included. wash herself after toileting.
Lim. or given the daughter the choice of seeking a different provider that would have better suited her needs. “Cultivating loyal patients”. Journal of Applied Management Studies. 11 No.. H. providers should do pre-admission assessments to determine whether a potential resident is suited to that facility (Phillips. 3.L.). (2001). Conclusion This article discussed expectation theory and how meeting customer expectations can lead to either conﬁrmation or positive/negative disconﬁrmation.M. Journal of Health Care Marketing.IJHCQA 21. it is vital to understand all stakeholders’ quality aged care expectations. Bendall. “Managing customer expectations in professional services”. Adaptation Level Theory. F. (1964). there are multiple parties that includes families. 9 No. “Handling complaints in Australia’s residential aged care facilities – a report”. Halliday. (1999). (3) ranking customers expectations. Vol. concerns and expectations to be met. Tang. Sydney. and (4) identifying quality management systems that address meeting those expectations. Vol. As a result of not going through this process. (1992). Helson. J. 55-69. S. Harper & Row. etc. pp. 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.
References ACAA (Aged Care Association of Australia) (2005). Finally. the events described above occurred. and Dant. Lumpkin. Different types of expectations were identiﬁed. pp. 1. Listening Post. 6.P. Managing Service Quality. A case study of negative disconﬁrmation in aged care illustrated how it is the expectations of other stakeholders that are critical in understanding. 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. and Jackson. care recipient. “Adaptation and customer expectations of health care options”. J. and Hogarth-Scott. 46-55.K.V. “New customers to be managed: pregnant women’s views as consumers of healthcare”. Journal of Health Care Management. D. T. “An innovative framework for health care performance measurement”. Gordon. 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. N. 15 No. 2005). (1995). pp. P. government. resulting in the daughter taking action through the external complaint resolution scheme.1
(1) understanding who the customer is (in aged care. (2000). Gilbert.C. 50-2. Vol. Ojasalo. and that to avoid complaints to the external complaint resolution scheme.W. Services were highlighted as being distinct from products owing to their intangibility and delivery process requirements. Vol. R. (2) understanding their expectations through interviews. NY.R. and Powers. 12 No. pp. Vol. 9 No.
. Managing Services Quality. S. 4. 3..H. 423-34. New York. P. in aged care. 200-12. pp.
(2001). and Berry..W. 3 No.com Or visit our web site for further details: www. Phillips. pp. Journal of Consumer Satisfaction. National Health Care Journal. “A conceptual model of service quality and its implications for future research”. (2003). 2. 142-56. L. 9. A. 49 No. S. (2001). “One size does not ﬁt all. Summer. A. pp. pp. Vol. Does your facility ﬁt your residents?”. “A theoretical exploration and model of consumer expectations. and Kumar. Russell Kennedy. Perucca. post-purchase affective states and affective behaviour”. pp. and Boote. (1985).L. 24-5.Olshavsky. 32 No. pp. 14. Vol. “Complaints: the right culture hears the message”. (2006). Zeithaml.com
Understanding customer expectations 59
To purchase reprints of this article please e-mail: reprints@emeraldinsight. Santos. Journal of Consumer Behaviour. Vol. R. 60-73. V. J. Vol. Corresponding author Leib Leventhal can be contacted at: LeibLeventhal@bigpond.com/reprints
. (2005). “Customers with options”. Dissatisfaction and Complaining Behavior.emeraldinsight. April-May. Parasuraman. Journal of Marketing. “Revealing the actual role of expectations in consumer satisfaction with experience and credence goods”. 20-4. Thomas. Melbourne. 41-50.A. L. R. Health and Aged Care Brief. Nursing Management. 4. J.
Thomas and Petersen. MMC. 2004a). Adjustment for confounders not present in the databases. 2000. The National Board of Health and Welfare.
Introduction Research shows signiﬁcant safety problems in health care in Sweden and abroad (Kohn et al. 2000. This means knowing more about the different systems’ advantages and disadvantages for reporting adverse events and for gathering safety data (Zhan and Miller. their strengths and weaknesses. Measurement. e. Better patient safety depends on better data about incidence and causes.g. Stockholm. Complaints Paper type Research paper
Received 14 August 2006 Revised 29 December 2006 Accepted 6 February 2007
International Journal of Health Care Quality Assurance Vol. Design/methodology/approach – The article ﬁrst describes previous research into patient claims and similar schemes. Phillips et al. Findings – The databases’ value is problems related to spontaneous reporting. 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.htm
IJHCQA 21. It then presents three types of data on patient claims and complaints in Sweden: data generated by the Patient Insurance Fund.g. 2003. empirical evidence about the causes of and conditions inﬂuencing adverse events varies according to the investigation method. 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. Patients. Sweden
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. data collection method and their limitations as a source of data about the true incidence and prevalence of injuries and safety problems. 21 No.emeraldinsight. Another issue is the balance between the size of study materials and the timeliness. 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. Similarly. 60-74 q Emerald Group Publishing Limited 0952-6862 DOI 10.com/0952-6862. data on hospital case-mix. and (3) Patients’ Advisory Committees respectively... the Medical Responsibility Board and the Patients’ Advisory Committees and considers methodological issues in using the data.1
Patient claims and complaints data for improving patient safety
Pia Maria Jonsson and John Øvretveit
Medical Management Centre. 2008 pp. but little is known about the data. e.. Empirical evidence about the number of adverse events for patients varies according to data collection methods. Karolinska Institutet. (2) Medical Responsibility Board. 2003). 2004). Keywords Quality improvement. 1.The current issue and full text archive of this journal is available at www. We describe three main types of Swedish patient claims and complaints’ data: (1) data generated by Patient Insurance Fund activities. Safety. when diagnosis-speciﬁc analysis requires data pooling over several years in order to reach adequate case numbers. how they can be used. which makes it difﬁcult to know how much the data correspond to general injury rates and health care patterns. Sweden.
1991).000 men and 243 per 100.9 per cent and death in 20. 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.. The high proportion of patient management errors. In Denmark.8 per cent. This organisation is ﬁnanced from tax revenue raised by the local government counties. the hospital admissions with adverse events prevalence was estimated at 9 per cent of admissions and 40.5 per cent (Baker et al. outline the databases’ development and the information available. 1991). and . all healthcare providers are obliged to have a medical malpractice insurance policy to cover indemnity for patient injuries.4 per cent of the adverse events were judged to be preventable (Schioler 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. was regarded to suggest that many of the events would be preventable. which we describe later. The committees also host databases with complaints’ information. 2001). which may have resulted from a healthcare episode without having to ¨ ¨ prove negligence (Patienforsakringen.000 women in the general population were hospitalised owing to care complications in 2002 (The National Board of Health and Welfare. Among these cases. 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.. Patients can apply for injury compensation. the Medical Responsibility Board and the Patients’ Advisory Committees? Our purpose. present previous and current data analyses.7 per cent of hospitalisations and that 28 percent of these events were due to negligence (Brennan et al.. Based on various databases and studies. The National Board of Health and Welfare (2004 a) estimated that adverse events contribute to
Patient claims and complaints data 61
. is to: . .d. Patients using private providers in the county can also apply for compensation to this publicly funded patient insurance fund. Can these data be used to monitor care safety and to highlight safety issues? What can we learn about patient safety from the experience of the Patient Insurance. The Canadian Adverse Event Study estimated that the incidence of adverse events among hospital patients was 7.). therefore. 2004b). 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. 2004). n. Drug complications were the most common type of adverse event amounting to 19 per cent of all cases (Leape et al.In Sweden. statistics compiled by the National Board of Health and Welfare show that approximately 203 per 100. 1996). The county councils’ Patients Advisory Committees handle all types of patient complaints concerning health services ¨ (Patientnamnden. events judged to be preventable occurred in 36. 2000). and holds extensive claims’ data. 1995). discuss the value of patient complaints and claims data for research and practical improvement work. 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. n..d. 58 per cent of all adverse events.). The Quality in Australia Health Care Study reported that 16.
Under a no-fault system. although there is no clear evidence. This study identiﬁed 906 claims from patients with diabetes where the total indemnity paid was almost $27 million. New Zealand and the Nordic countries). One of the few empirical studies that contrasted the two systems considered preventable in-hospital medical injury under the no fault system in New Zealand (Davis et al.g.1
around 1. Although comparisons are difﬁcult.. 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. which found rates associated with both physician performance and specialty (Taragin et al. which allows patients to seek redress from a doctor for perceived negligence (e. diabetes patients were older and predominantly male.. 1990). 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. How has data from both types of malpractice claims systems been used for research. 1994). 2000). USA.800 deaths per year. The Physician Insurers Association of America (PIAA) database has been used as a surveillance tool for diabetes-related malpractice claims (Meredith et al.. Under a tort system. There are thought to be advantages and disadvantages to each. insurance costs are lower.. where patients do not have to prove negligence in a court of law (although they can use this route). and (2) a no-fault system. but can have their claim assessed and compensation awarded through another system. Research also considered whether physician performance and type of speciality is related to malpractice claims. seeking compensation may be easier and less expensive. 1998). 1986). An unpublished UK study found standardised incidence ratio of error highest in the specialties. Legal redress may act as a deterrent against lower practice standards (Hiatt et al.. Weycker and Jensen.. Patient claims and complaints systems provide different types of data about health care adverse events.. which traditionally produce the most claims – accident and emergency. 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. 2003). 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.IJHCQA 21.g. obstetrics and trauma and orthopaedics (Davy et al.. 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. systematic research into the epidemiology and aetiology of adverse events in the Swedish healthcare system has only just begun. It also may be more likely that health care personnel report “errors” or “near misses”. which is thought to be important for effective safety reporting systems. This was one of the ﬁrst studies showing how these data help to predict and understand adverse events. 2004). compensation awards can be high. The proportion of diabetes claims was highest in
. and the total costs to society less. When compared to all claimants. Data suggested problem areas for attention that included supervision and foetal heart monitoring. 1989). However. 1998). 2000. UK). usually administered by a government agency and tax funded (e.. Insurance against claims is also high and medicine is practiced more defensively (Bovbjerg and Sloan.
070 3. Nurse negligence has been reported to be associated with 27 per cent of all USA claims and with 26 per cent in one Taiwan study (Beckman. Levinson et al. Moles et al.546 19. 2000.003 9. for example. A greater proportion of diabetes claims. 16. Annual reports from the Medical Responsibility Board and The National Board of Health and Welfare
Table I.. Medical Responsibility Board and Patients’ Advisory Committees. 2005).. was associated with the highest level of injury severity. 2001. Lester and Smith.ophthalmology. internal medicine. as compared to all claims. The Swedish databases In Sweden the Patient Insurance Scheme. Since the databases were developed at different times and for different purposes. Malpractice claims research has been used for ﬁnancial risk management and quality improvement. (2004) reported that medical experts considered that 83 per cent of 371 malpractice cases reviewed could be “improved by quality management”. In 1989. Table I displays the number of complaints and claims made to each body (1997-2004). Little research has considered the role of nursing or paramedic professions in patient claims.377 3..119 3. Goebel and Goebel (1999)..938
Medical Responsibility Board 2.860 3. Tsai et al. 2004).871 9.
Patient claims and complaints data 63
Year 1997 1998 1999 2000 2001 2002 2003 2004
Patient insurance 8. 1997).. they differ in the numbers of complaints as well as in the amount and character of information they contain.500
Sources: Statistics from the Patient Insurance Fund. found evidence that malpractice lawsuits could be prevented by quality interventions such as clinical guidelines. Number of complaints to the Patient Insurance Fund. Adamson et al. Prevention programs designed to reduce liability among high-risk specialties could also lead to improved care quality for patients with diabetes.552 8. Persson and Svensson. 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.064 3.227 3.250 3.239 18. 1996.174 8. The study concluded that the PIAA database can be a useful resource to monitor trends in diabetes-related malpractice. general and family practice.572 m. 1989). 1989). 1993.995 22.395 8. one study reported a dramatic rise in the incidence of nurses as defendants in malpractice claims (McDonough and Rioux. 1998. Claims databases have also been used to assess economic costs (Fenn et al. 1994.664
Patients’ Advisory Committees m.129 8. 22.. 1997-2004
.. m. More studies are examining which type of patients ﬁle claims and why (Hickson et al.717 8. or that health care has not met their expectations. 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. Tsai et al.
Figure 1. Indemnity for personal injury can be paid. Number of claims to the Swedish Patient Insurance Fund. There is no indemnity in cases where the treatment simply has not led to the desired result or where (predictable) complications arise. 5. 9. Claims applications have increased to: . when a treatment injury as described in the insurance conditions occurred. In January 1997 the voluntary insurance scheme was replaced by The Patient Injury Act (1996). and . .1
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.IJHCQA 21. Figure 1 shows the annual numbers of both applications for claims and compensated cases from the Patient Insurance Fund (1975-2003). 1975-2004
. 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.000 in 1993. both public and private care providers are obliged to have a medical malpractice injury policy that covers patient indemnity.400 claims in 2003. irrespective of fault or negligence.000 in 1983. in the event of accidents in connection with medical or dental care and in connection with incorrect prescribing. if the injury concerned could have been avoided. 3. . Indemnity for patient injury could be paid on objective grounds.300 in the ﬁrst year of operation in 1975. The conditions in the Act on Injury to Patients largely correspond to the conditions of the previous voluntary scheme. if infection has been transmitted in the course of treatment. 7. if it was caused by faulty medical or dental equipment or by incorrect diagnosis. Under the act.
and . injuries related to certain clinical ﬁelds. 2006). 1996).. . there were previously also complaints about poor service or care quality. Specialties with many cases registered in the database include orthopaedics. patient consequences. 1998. Previous studies addressed a range of clinical topics – e. injury year. Raf and Claes. Over the years about 60 per cent of cases have concerned female patients (Pukk et al. After 1994. data include: . which investigates complaints against all registered health care professionals to examine whether there is cause for disciplinary action (Instruction to The Medical Responsibility Board. 1997).. . cases solely concerning services a patient has received are referred to the Patients’ Advisory Committees. gynaecology and ¨ ˚ obstetrics (Jonsson and Wahlberg. surgery. 2003b). Anyone who is or has been a patient can ﬁle a complaint to the Medical Responsibility Board. since 1998. breast implant etc. The complaints are reviewed by medical experts. Regarding such injuries. Gender-speciﬁc analyses have indicated differences between women’s and men’s injury patterns ¨ (Jonsson and Raf. Apart from complaints about errors in medical treatment. injury effects.g. 1996. to speciﬁc types of medical error or to the use of selected medical technologies ¨ ¨ ¨ (Cronstrom et al. Certain cases are examined by the chairman alone.. after which the Board examines the case and decides.Overall 40-45 per cent led to a compensation payment. basic diagnosis. the complaint may be submitted by a close relative. Medical responsibility board The Medical Responsibility Board is an independent national authority. . Consequently. If the patient him/herself is incapable. . data about possible surgical interventions. . and . Diagnosis and operation codes are used to analyse injuries to patient groups (diabetes. The numbers of complaints to the Medical Responsibility Board and the numbers of disciplinary
Patient claims and complaints data 65
.) or patients undergoing a particular treatment (hip joint replacement. although a small proportion of cases involve withdrawing registration following notiﬁcation from the National Board of Health and Welfare. there is a higher risk of women injured by radiological examinations. Ohrn et al. When taken. injury cause and effect. e. . operation for short-sightedness. Johansson and Raf.). 1997. this action is usually an admonition or a warning. care giver type. . cataract etc.. county council. but a generally higher risk of lethal patient injury among men. 1999). data can be analysed by: . medical specialty.g. care level. injury cause. cardiovascular disease.
e.064 3.070 3.664 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. Data from the Medical Responsibility Board have been used in regional comparisons (The National Board of Health and Welfare. Hence. The study identiﬁed second-hand information as an aggravating circumstance when assessing the urgency of care needs. Number of complaints received and disciplinary actions taken by the Medical Responsibility Board..860 3. Patients’ advisory committees The ﬁrst Swedish law about the Patients’ Advisory Committees was created in 1980.. The high claims rate in the Stockholm region applied to all types of activity. 1995-2004
Source: Annual reports from The Medical Responsibility Board
. the survey identiﬁed two areas that educational programs could improve patient safety. but was most prominent in dental care and general medicine. have few direct sanctions and do not have disciplinary powers. 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.659 2. The most common reason for a nurse receiving a warning or an admonition was negligent handling of drugs. a new law came into force.250 3. Kalmar and Kronoberg counties. 2002). 1998). Analysis showed large differences in Sweden between counties in number of claims per inhabitant in 1999/2000.1
actions in 1995-2004 are presented in Table II. 2004).119 3. in contrast to sparsely populated area rates.521 2. Cases from the Medical Responsibility Board have been presented in the Swedish Medical Association Journal. 2003). They give advice to patients and provide a quasi-independent body for investigating dissatisfaction and mediating disputes
Complaints n 2. Claims rates were ¨ appreciably higher in Stockholm. Recently.IJHCQA 21. Nearly all disciplinary actions against physicians concerned misdiagnoses (subarachnoid haemorrhage in particular).g. The Patients’ Advisory Committees do not make medical judgements. Another study analysed all available complaints about stroke management made to the Medical Responsibility Board over a ﬁve-year period (Johansson et al. Uppsala. which shows that a steady increase in the number of cases appears to be levelling off.377 3.227 3. The Stockholm region also showed the highest number of disciplinary actions per inhabitant. but there have been few scientiﬁc analyses of the material. an exploratory study analysed factors and circumstances related to complaints in emergency medical dispatching. Goteborg and Bohus counties. partly based on complaints to the Medical Responsibility Board (Wahlberg et al. In January 1999.
Complaints are often questions or criticisms that patients or relatives have tried to take up with healthcare personnel. communication. The Committee’s aim is to solve problems quickly and in a non-bureaucratic way. 53 per cent concerned inpatient care. This analysis and the studies noted earlier show how each database provides a different picture. because. Analysis also considered data from patient questionnaires in the same hospitals. The rates per specialty. they feel they may suffer in the future as a result. Little research has used data from the Patients’ Advisory Committees. but feel they have not been heard or respected. 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 previously mentioned study on emergency medical patching (Wahlberg et al. feed-back sessions at local hospitals have been a popular way of sharing experience.000 complaints were ﬁled in 2002 (The National Board of Health and Welfare. while applications and claims in specialities such as obstetrics and gynaecology were higher. Reports to the National Board of Health and Welfare show that more than 22. for example. 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. the reverse was true. 2005
Source: Stockholm County Patients’ Advisory Board.255 298 2.000 discharges. by gender..951
Women % 33 15 43 10 100 Table III.743 % 32 12 45 11 100 n 967 431 1.
Patient claims and complaints data 67
Men Type of complaint Medical treatment Interaction. hospitals. It is also their task to refer patients to other agencies. Sometimes. information Organisation. 24 per cent primary health care and 8 per cent mental health services. According to Committee representatives. 2003). for example. 2003) drew some data from one of the committees.between patients and health services or personnel. the importance of knowing the strengths and weaknesses of each and often the need to use multiple data sources. resources Other complaints All n 555 204 787 197 1. Table III shows the complaints’ distribution by one county’s Patients’ Advisory Committee about different issues (Stockholm County Patients’ Advisory Committee. but the effectiveness of using data in the prevention of patient injuries has not been studied systematically. were compared with corresponding rates for the Medical Responsibility Board and the Patient Insurance Scheme. 2006). for example in the ﬁelds of neurology and geriatrics. Results showed that. it is problems patients do not want to raise directly with personnel. Annual Report 2005
. 2002). Distribution of complaints to the Stockholm County Patients’ Advisory Committee. to ﬁle a malpractice claim. whereas complaints about care and treatment were more likely to be registered in the complaints to the Patients’ Advisory Committee. In 2001. public health care districts and other involved authorities. The conclusion was that dissatisfaction about lack of information and patient participation was more likely to be detected by surveys. Of these. calculated per 100.
let alone make a claim (Øvretveit.000 inhabitants. researchers and quality improvement practitioners should use these data with caution and awareness of their limitations. number of complaints per 1. Hence. The ICD 10 classiﬁcation Y-codes. is important. not for the purpose of assessing quality and its determinants. A critical question is how far matters reported to different instances correspond to general dissatisfaction or injury patterns. It was noted that neither reporting nor compensation rates were constant. Most patients experiencing problems do not complain. The problem of spontaneous reporting One special methodological problem analysing and interpreting data from the databases is that they are based on spontaneous reporting. Analysing patient injury rates in the general population also permits comparisons of the safety problem magnitude across different society sectors. and by healthcare providers’ attitudes and approach to informing. 1992). 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 to lodge a complaint may be affected by patients’ knowledge regarding the possibilities of applying to the various instances for support or compensation. e. If we challenge the self-evident healthcare utilisation rates rather than focusing on how much harm the healthcare system does in the general population then rates calculated per inhabitant rather than per patient/discharge may need to be studied. 2004b). In 1992. Similar differences may exist between various clinical specialities.IJHCQA 21. 1993). have been the basis for the production of this kind of statistic from the National Patient Register (The National Board of Health and Welfare. trafﬁc safety. the Patient Insurance etc. it may be advisable to relate the numbers of claims to the healthcare utilization rates. This may interest researchers when societal resources are allocated to prevent accidents. in comparative studies. and only give a partial picture. However. they seem to have a potential to help both quantitative and qualitative quality and safety of care analyses. Cases are registered in order to assess liability and damages or to solve patients’ problems. insurance practice over the years also affects material composition.1
Methodological concerns As the complaints and claims’ databases are so voluminous and the information in them relatively detailed. One way of dealing with problems related to spontaneous reporting is to follow long-term
.000 hospital discharges and number of injuries for which compensation was paid in relation to number of complaints. While this is possible for hospital inpatient care through links to the National Patient Register. but there were variations regarding complaints per 1. used in Sweden since 1998. The data might not be collected consistently over time. but there may be cut-off points where the beneﬁt-harm ratio gets too low and the level of healthcare utilisation should be questioned. county councils were compared regarding claims’ numbers and ´ compensated cases from the Patient Insurance Scheme (Rosen and Jonsson. different age groups and between women and men.g. The tendency in various patient groups to report shortcomings in service and treatment to The Medical Responsibility Board. Increased healthcare utilisation is likely to increase the magnitude of harm. Regarding Patient Insurance.. encouraging and assisting the complaints process. Some may make false claims. there are great difﬁculties in calculating rates in outpatient care owing to the lack of outpatient services national registrations.
Here. however. The Patients’ Advisory Committees data. e. sex and severity of illness is important when comparing clinical outcomes. Although the study gives an indication of an important phenomenon that should be analysed further. This. 2003). claims rates from departments of general medicine. Unfortunately. Owing to medical and technological development. Size of materials and timeliness of study Although three databases contain large numbers of complaints regarding different medical specialties. Responsiveness inherently means that service is adjusted to patients’ needs and expectations. lack of information and patient participation. 2003a). 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 variations between hospital case-mix that occur. Size becomes even more critical if analysis is to deal with several confounders. 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. e.g. The size of the study material is mainly a problem in quantitative research. the practice of medicine and safety of care may be different today compared to the early 1990s. In the claims data. however. owing to few previous studies on risks and safety. different specialties or patient groups. Hence. 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. there seems to be a weak case for comparing hypothetical standard populations instead of real-life patient ones. this procedure does not deal with the differences in reporting tendency that may exist between men and women and different age groups. may be additionally aggravated by differences in reporting tendency. orthopaedics and general surgery were compared with hospital managers perceptions care quality in their departments (Pukk et al.g. we cannot exclude that results may be somewhat biased by lack of adjustment for confounders when comparing the claims rates from different departments.. However. it is difﬁcult to know how much of a change is happening in different ﬁelds over time. e. While adjustment for confounders such as age. owing to organisational factors. High patient satisfaction should be one care target at all healthcare units. the same logic does not necessarily apply to complaints about. 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. No correlation was found between managers’ adverse events’ perceptions and the actual claims frequency from patients’ associated with the department.g. gynaecology/obstetrics. selection by diagnosis and type of medical or surgical intervention easily reduces the volume of study materials.
Patient claims and complaints data 69
. could also be used in qualitative analysis of problems that patients experience in health care. A solution may be to pool data over several years to attain enough observations.trends that reveal themselves in the proportions of total materials represented by. needs to be balanced against the rapidity of change in medical practice. regardless of patient population composition. In a recent study involving data from the Patient Insurance Scheme.
400 cases. 2006). Australia and UK (Danzon. which contains information on cases since January 1992.g. McLoughlin et al. the risk of serious patient injury has not changed over time. when a number of patients died owing to malpractice). The obligation to report rests upon the person nominated by the health care principal. the healthcare professionals’ reporting tendency has not been subjected to study. e. under certain circumstances. As opposed to patient claims and complaints. Hence. at what type of institution and in what medical service an injury or an incident occurred. There is a case. In 2002. the numbers of claims to the Medical Responsibility Board – 3.IJHCQA 21. is not possible to judge today. Canadian Institute for Health Information. approximately 9. but knowledge of risks gives care providers more opportunities for improving quality and helps care consumers choose care and treatment. Patient Insurance Fund claims. 2006. Following analysis. Changes are also possible to these databases and collection systems to make them even more valuable for quality improvement.g.500 cases in 2002). Such analyses could also shed light on the extent patients’ claims and complaints reﬂect safety problems grasped by purely medical-technical safety indicators. and what consequences repeated events can have for the patients affected. the annual numbers of Lex Maria cases have not changed much since the mid 1990s.000. in practice. This and other studies show the value of data on claims and complaints for providing information for researchers and practitioners. however. therefore. Conclusions The risk of adverse medical events and medical errors can never be entirely eliminated. Correspondingly. 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 material can show.. In comparison. To what extent this is due to patients underreporting problems. “Lex Maria” (named after an incident at Maria Hospital in Stockholm in the 1930s. 2006. It should. while the Patient Register only covers hospital inpatient care.200 claims in 2002 – can be compared to the numbers of injuries coded as mishaps (approximately 3. However.
. Statistics regarding “Lex Maria cases” are collected in the Board’s RiskDataBase. The number of registered complications in 2002 was approximately 22.000 cases were reported according to Lex Maria. often the senior physician or the nurse with medical responsibility. 2004b). Serious injuries. are relatively few. 1. The Swedish Patient Register is in many ways comparable to hospital data sources in other countries. or that not all complications lead to injury entitled to compensation. which is related to quality and is driven by patient and user perceptions. including ICD 10 codes for medical and surgical treatment complications (The National Board of Health and Welfare. patient safety indicators constructed from administrative data and developed in. Tentatively. e. diseases and risks in health care must.1
Relationship to other sources of safety information As illustrated earlier the National Patient Register includes information about all hospital discharges in Sweden. be reported to the National Board of Health and Welfare – according to a special law. Canada. Analysis of existing data at a local and national level can provide valuable insights for quality interventions as well as for research. be noted that claims data include all levels of care. 1990). 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.
Patient claims and complaints data 71
. Lawthers. pp. R. 187-95. M. “Preventable in-hospital medical injury under the no fault system in New Zealand”. C. 2. S.A. “No-fault for medical injury: theory and evidence”. L. Lay-Yee. University of Cincinnati Law Review. the United Kingdom and Australia”.M. Brown. for using data from a number of sources to provide different perspectives on the rate and causes of safety and quality problems. pp. and Rene. The Western Journal of Medicine.E. cihi. New England Journal of Medicine. N. (2003). J. 370-6.R. Canadian Medical Association Journal.M.O. CA. V. Davis.. R. Patient Safety Indicators Overview. pp. Vol. and Tamblyn.A. Beckman. 330-8. Vol.. V. Hogeras. Canadian Institute for Health Information.ahrq. N.H. A. pp.qualityindicators.. A. pp.. L. P.therefore.jsp?cw_page ¼ patient_safety_e ¨ ¨ Cronstrom. British Medical Journal. 99-105.J. Briant.. D. Agency for Health Care Research and Quality.htm ¨ ˚ Appelros. pp.. 11. and Arnetz. and Scott. A. Laird. and Hiatt. Stockholm... B. available at: www. “Nursing negligence”. Acta Neurologica Scandinavica. 1678-86. 324 No. pp. P. pp. unpublished report to the UK National Patient Safety Authority and Department of Health.. M. Sweden’s Health Care Report 2001. A. F. (1989). Leape. Vol. 145-9. available at: http://secure....M. Vol.S. A complex relationship”.. “Incidence of adverse events and negligence in hospitalized patients.P. Vol. H. The epidemiology of error: an analysis of databases of clinical negligence litigation”. A. Majumdar.R. Sheps.L. Vol. P. A. pp. (2000). and Vincent.G. J. CIHI (2006). Etchells.ca/cihiweb/dispPage. 48-58. Law. (1991). The National Board of Health and Welfare. Bovbjerg.G. J. Blais. Esmail.A.. Danzon. Vol. Norton. 12 No. and Oppenberg. Davy.
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International Journal of Health Care Quality Assurance Vol. 1990). Clinicians tended to rate their services and offerings higher than referring physicians (p ¼ 0:019). A comparative questionnaire survey was established to identify improvement areas and factors that drive referral rates using descriptive and inferential statistics. Germany
Purpose – The purpose of this research is to show that referring physicians play a strategic role in health care management. 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. Hospitals. Munster. 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.1108/09526860810841174
. 2008 pp. 2006). is of growing importance in the rapid changing health care market.emeraldinsight. The number of referred patients was correlated with medical reports’ informational value (p ¼ 0:042).com/0952-6862. Although Germany has a health care system that allows patients direct access to specialized care (Coulter.and after-care treatments (Braun and Nissen. This study aims to evaluate the perception of hospital services by referring physicians and clinicians for quality improvement. 2005). They inﬂuence the patient’s choice of where to be admitted and organize most of the pre.The current issue and full text archive of this journal is available at www. Findings – Referring physicians’ (n ¼ 53) and clinicians’ (n ¼ 22) survey results concordantly revealed that timely and signiﬁcant information about hospital stay as well as accessibility to hospital staff are major points for improvement. Doctors. Hospitals should pay careful attention to their communication tools. Customer services quality. Meinhard Schiller. 1. Munster University. Geographic range was correlated with the frequency of patient commendation (p ¼ 0:005) and the perception of friendliness (p ¼ 0:039).. Originality/value – Survey results should be useful for continuous quality improvement by regular measuring and reporting to executive boards. 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. Rosemann et al. 75-86 q Emerald Group Publishing Limited 0952-6862 DOI 10. In the German health care system. Since referring physicians play a strategic role ensuring the survival of institutions providing health care services. 1998.htm
Evaluating hospital service quality from a physician viewpoint
Peter Hensen. well established in industrial markets. particularly medical reports. Dieter Metze and Thomas Luger
Dermatology Department. referring physicians act as de facto gatekeepers to hospitalization. 21 No. 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. Signiﬁcant differences between both samples were found with respect to inpatient services and patient commendation. Keywords Questionnaires.
To accomplish our objectives. and to reveal associations between quality-related variables and physician-speciﬁc aspects. A questionnaire study using measurement and feedback was conducted to identify improvement areas from referring physicians’ perspectives. 4 ¼ “sufﬁcient”. controversial results. Starﬁeld et al. Understanding factors that drive referral rates can help identify improvement areas and to anticipate future demands for hospital services. 1992) and validated in internal audits among attending physicians. 2 ¼ “good”. The questionnaire items enabled respondents to rate their perceptions in respect to each speciﬁed quality aspect. A six-point ordinal scale was used: 1 ¼ “very good”.1
partnerships between medical professionals in hospital and external physicians are essential and should be sought. Nevertheless.. patient questionnaires and customer complaint systems are widely applied for user orientation in health care systems and hospitals respectively (Castle et al. the questionnaire size was limited to a one-page-only design and the number of items was restricted to a reasonable quantity. to some extent.IJHCQA 21. surveying referral physician perspectives is not yet extensively established in the hospital care sector. 1999. such as socioeconomic status (Carr-Hill et al. To increase feasibility and respond-rates.
. The term “clinician” used in this study encompasses physicians at the clinical department including residents and attendings (i.. such as disease severity (Chan and Austin. In a large German dermatologic centre providing outpatient and inpatient care at a secondary and tertiary care level.. 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. and community-speciﬁc characteristics. 2003) or individual insurance coverage (Shea et al. but most remains unexplained (Franks et al..e. 1996) or urban location (Chan and Austin. senior and junior doctors). Variability in physician referral decisions is observable. 1999).. Method We used a quantitative survey research design. 2005). Moreover. In contrast. Each item was carefully worded in a clear and precise manner. Overall. a questionnaire was developed containing 14 items suggested by previous research on physician referrals (Beltramini and Sirsi. were shown to predetermine referrals from primary care physicians to specialists. and 6 ¼ “insufﬁcient”. 2002). Several patient-speciﬁc characteristics. Data collection ¨ We conducted our study at the University of Munster dermatology department. but with a lack of consensus and with. hospital clinicians should know exactly how the services they provide are perceived by referring physicians. 3 ¼ “satisfactory”. 2003). 2005). a quality improvement process was initiated that focused on relationships between clinicians and referring physicians. 5 ¼ “faulty”. suggesting that referral patterns are related more strongly to the type of community than the supply of specialists (Chan and Austin. Our main approach was to compare our results with a corresponding survey regarding the same items from the clinicians’ point of view. physician-speciﬁc inﬂuences on the referral process were investigated equally. Presently. 2003).
cooperation with physicians in private practice. Our survey was performed anonymously – respondent’s personal data were recorded on the questionnaire. . San Diego. Over the years. . were continuously stored in a database. To avoid personal cost. . and . supplied medical reports’ signiﬁcance and informational value. 2 ¼ regional area. A chi-square test (Fisher’s exact test) was used to analyse signiﬁcance differences between deﬁciency frequencies. and 3 ¼ supra – regional area. an unmodiﬁed questionnaire was sent to all dermatology department residents and attending physicians. . Referring physicians were asked for their medical specialty. Bivariate correlation analysis was performed to study the association between descriptive variables. clinical departments’ perceived reputation. such as geographic range or annual number of referred patients. Data analysis Statistical analysis was conducted using SPSS. 20 km. commendations from recurring patients. and the rated questionnaire items (Spearman correlation). regular newsletter. therefore. . respondents were free to use an accompanying stamped and pre-addressed envelope. . . CA). names and addresses of miscellaneous specialists and general practitioners. the number of referred patients per year. . Pearson’s
Evaluating hospital service quality 77
. Factor analysis was used to examine the relationships among the items to identify components that summarize evaluation questions. outpatient consultation availability. hospital staff friendliness. . education and training for external doctors. outpatient services. 20-50 km. was difﬁcult. . time interval in which medical reports are supplied. . 50 km. questionnaires were sent by mail to a total number of 304 external physicians in private practice including general practitioners and specialists. available hospital bed quantity and capacity. 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. The geographic range between private practice and the hospital were coded using: 1 ¼ city area. release 13. clinicians’ medical expertise. . who frequently referred patients to the dermatology department. Equally. and the practice’s postal zip code. Using these data.. inpatient services. . hospital services and staff accessibility in urgent cases. Reminding non-respondents.0 (SPSS Inc. 20 patients. To get an image from hospital medical professionals. 2 ¼ 6 2 20 patients. the annual number of referred patients was scaled (Table I) as follows: 1 ¼ 0 2 5 patients.Our evaluation questions covered the following quality aspects: . No incentives for completion were offered. and 3 ¼ . .
a deﬁciency frequency of 80 per cent and higher can be considered to indicate urgent improvement areas. the proportions of referring physicians’ ratings of each questionnaire item were displayed (Figure 1). The alternative hypothesis would be accepted at a p . The calculated deﬁciency frequencies and a ranking of priority are shown in Table III. 0. Nearly all respondents declared to be dermatologists (n ¼ 51. Identifying improvement areas Means and standard deviations were calculated to obtain an average rating for items 1-14. Regarding the referring dermatologist subgroup. 50 km) Not speciﬁed
Table I.05 statistical signiﬁcance level. 17.8 17. these values were combined to a conjoint deﬁciency variable that represents poorer quality needing action.0 17. Response rates and the average ratings divided into referring physicians and clinicians along with the comparative statistical results (Table II).3 60. 20 km) Regional area (20-50 km) Supra-regional area (. representing nearly the complete physician staff in the clinical department. see Table I) but two respondents did not answer this question.2 3.845. The overall Cronbach’s alpha for the questionnaire was 0. The length of
. A total of 22 useable questionnaires. The absolute deﬁciency frequencies in our study were used to show areas of improvement. In contrast. a frequency of 60 per cent to 79 per cent is suitable for detecting areas of improvement with lower priority. Physician medical expertise was highly ranked by referring specialists.IJHCQA 21. 5. external physicians’ estimations of patient commendations were low.4 per cent).1
Characteristic Specialist status of respondents Dermatologist Not speciﬁed
n 51 2 9 9 32 3 9 6 32 6
% 96. In short. a 21 per cent response rate was obtained. Results A total of 53 usable questionnaires were returned by referring physicians (response rate.3
Number of referred patients per year 0-5 patients 6-20 patients .0 60.20 patients Not speciﬁed Geographic range between clinic and respondents City area (. Moreover. Value 1 “very good” and 2 “good” frequencies were summed to a conjoint variable indicating an acceptable quality level without need for action.7 17 11. were returned from the subsequent internal survey. Data overview and characteristics of referring physicians who responded
correlation tested association among questionnaire items.4 11. Absolute frequencies also containing missing values are more predictive for the given population in small samples than relative ones. Under the assumption that a potential quality problem is indicated by lower ratings from 3 to 6.
002 .4 100.014 0.29 ^ 0.00 ^ 0.6 96.3 96.9
Referring physicians n ¼ 53 % Mean (^ SD) n 2.81 2.81 19 22 20
51 49 49 45 46 47 51
0.49 ^ 0.10 1.84 2. 50 51 52 51 94.03 1.78 3.7 96.55 ^ 0.27 ^ 0.41 ^ 1.77 ^ 1.86 2.73 1.69 1.2
2.2 2.43 ^ 0.80
. * Mann-Whitney U test.81 2.92 2.032
13.4 100 100 100 100 100 100 86. 12.1 96.80 ^ 1.2 77.2 92. Questionnaire items.9
Clinicians n ¼ 22 % Mean (^ SD)
1.0 90. 14.No. 7.76 ^ 0.86
19 22 22 22 22 22 22
86.23 ^ 0. 8.5 84. 48 51 41 90.8 88.64 ^ 0. 0.03 3.15 2.93 2.87 2.98 ^ 0. 9.60 2.72 ^ 1. 2.001
6.90 2.63 3.46 ^ 0.42 ^ 0.001 0.98 2. mean values. and comparative statistics
.26 ^ 0.96 ^ 1.28 ^ 0. 3.10 2.84 ^ 1.95 ^ 1. item response rates.4 3.95 ^ 0.05 ^ 0.53 ^ 0.5 90.73 ^ 0.84 2.22 22 22 21 20 100 100 95.77 ^ 0.00 ^ 0. 10.05 ^ 0.
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. 4.2 98.65 1.5 92. 11. two-tailed
Evaluating hospital service quality 79
Table II. 5. standard deviation.56 2. 0.9 86.
Table III. 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.6 39. 10. 7.60 per cent are indicated.6 47.2 84.5 15. 12.5 40.8 45.9 36. b Medical reports: Timea. 2. b detected by clinicians. c Fisher’s exact test.2 13.8 39.3 95.5 27. 9.9 66. deﬁciency frequency. Rank of priority.1 77. 5. and statistical results
. a detected by referring physicians. 3. 4.4 18. two-tailed
0.0 56.002 0. * Areas of improvement with a deﬁciency frequency
. Referring physicians’ ratings – proportions of each item
No.2 35.0.6 52.3 58.1
Figure 1.1 64.5 36. deﬁciency frequencies.IJHCQA 21. 11.002 .6 4.5 3 13 2 1 5 6 11 12 14 6 8 4 8 8 50 9. 13. 8. Def.8 86. 6.4 27. 1.3 45. frequation .001 0. 14. Rank of frequation Rank of frequation priority % priority % p-valuec 5 14 4 2 3 7 11 8 12 9 13 1 10 6 58.3 27.
Variable * Cooperation Medical expertise Accessibilitya.
clinicians rated newsletters signiﬁcantly higher than referring specialists ( p . 0. medical expertise. Our ﬁndings suggest these three improvement areas. . Lack of patient commendation had the highest deﬁciency frequency (87 per cent) and the second lowest rating in the referring physicians group. . and . 0. there were disagreements between the way referring physicians and the way in which clinicians themselves rated some items.61 revealing a statistically signiﬁcant difference (p ¼ 0:019). p ¼ 0:002. referring physicians: 2.
. outpatient services. friendliness.29. . . Moreover. An average mean value for all 14 quality items was calculated for each subgroup: . hospital staff friendliness. p ¼ 0:002. . 0. SD: 0. and .54. Differences were also been found with inpatient resources and inpatient services. and the. outpatient consultations. p . Average rating values and deﬁciency frequencies reveal that clinicians’ ratings were remarkably distinct from those referring physicians scores (mean. medical expertise. cooperation. Quality features interaction Factor analysis revealed two components that explained nearly 52 per cent of the variability in the original 14 variables. Furthermore. There were no signiﬁcant differences between referring physicians’ ratings and those made by clinical department physicians concerning: . clinicians: 2.
Evaluating hospital service quality 81
Comparative evaluations As seen in Table II and III.001). . SD: 0. time interval in which medical reports are supplied. which explains nearly 37 per cent of the variance. cooperation. accessibility in urgent cases. However.69. The ﬁrst component.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.022). . and . 0. There were signiﬁcant differences concerning average rating values and deﬁciency frequencies. is highly correlated with the following variables: .001). referring physicians criticised staff accessibility in urgent cases (64 per cent). this aspect was supposed to be much higher from the clinicians’ viewpoint ( p . clinical department’s perceived reputation. reputation. . p . deﬁciency frequency. Varimax rotation was used to determine what the components represented.032.
in former studies dealing similar questions. Correlating quality items representing a generic quality perception. 4.001 . 1990. 0.002
No. However.0. 3.514 1 0. 0.0.0. An equally important ﬁnding is that inpatient capacities and service offerings were not correlated.001 0.034 .015 0. Signiﬁcant negative correlations were found between geographic range and hospital staff friendliness (p ¼ 0:039). Table IV. 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
. This may be caused by a lack of quality management sense. we considered the response rate acceptable. 0.0. Table IV shows that most variables were highly correlated with these two items.067 0.001 .001 . 2.054 0.001 .001 0.364 0.639 0.0.0.505 0. 6. particularly when we did not remind respondents or offered an incentive for completion. 0. sample of referring physicians 8.015 0.528 0.001 0.647 0.539 0. and the frequency of patient commendations (p ¼ 0:005). the number of referred patients was signiﬁcantly negatively correlated to medical reports’ informational value (p ¼ 0:042). This survey is limited to: .0.465 . were calculated.547 0.594 0. It may be speculated that there is a lack of motivation and incentive for private practice physicians to participate. 9.301 0.471 0. Variable 1.594 0. 0.013 . Discussion Our study described and evaluated the way referring physicians and clinicians rated several quality items from their individual perspectives. equal or even lower response rates have been observed from physician samples (MacDowell and Perry.001 0. The ﬁrst component represents a construct with generic attributes that improvement activities cannot inﬂuence directly. 7.149 0. 1992). 10.369 0. 14.001 .IJHCQA 21. .
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 1.1
The second component is highly correlated with inpatient bed capacities and inpatient service offerings. 12.595 0. Although the study response is low. Beltramini and Sirsi.428 .059 0.001 . Correlation analysis of generic quality perceptions represented by reputation and cooperation with other quality items. and . such as cooperation and reputation.008 .342 0.251 0. 13.001 . one geographical region. Moreover. 11. 0.001 0.000 0. the medical specialty of which the majority of responses were received.001 0.001 . A further interesting point was to test for correlation between questionnaire items and both geographic range and annual number of referred patients (Table V). sampling referring physicians via the manually maintained databank.532 0.006 46 47 51 50 50 49 49 45 46 47 49 48 51 41 0.615 0.348 0.601 0. 5.
102 20. 1980. 6. 7. has been found to be improvable.295 20.183 20.253 20. Critical deﬁciency frequencies indicating relevant areas. 14.174 20. major improvement areas demanding urgent action could be identiﬁed.150 20.421 20. Not only do patients expect a seamless healthcare system and continuity of
.No.059 20. accessibility in urgent cases. The high importance attached to timely and adequate communication back to referring physician was previously reported in other studies (Cummins et al.083 20. 1980.207 0. 12. discharge. hospital stay.231 0.262 20. For interpretation. 3.157 20. In conclusion. hospital administrators and clinicians should pay careful attention to communication tools. such as 80 per cent and more. 2.189 20. which represents a further tangible communication and cooperation aspect. 5. Elija and Marja-Leena.079 20. which are less tangible.320 20.120 20. and .131 48 48 49 48 48 46 46 42 43 44 48 45 48 38 20. our survey questionnaire provides a ready-to-use instrument that identiﬁes crucial improvement areas. Correlation of geographic range and number of referred patients with quality items. and should address this problem by investing in systematic communication improvement programs.042
Evaluating hospital service quality 83
0.007 20. Variable 1.148 0.055 20. proposed procedures.. The present ﬁndings suggest that timely and signiﬁcant information about: . 9. 11.219 0. .005
Note: * Two-tailed test of signiﬁcance
Table V.037 20.075 20. such as medical reports and newsletter articles. 10. Moreover.029 20. such as reputation and cooperation. can be chosen individually for each item and should be monitored over time. are major points for satisfaction and perception of adequate cooperation. such as providing medical reports and newsletters. 4.039 0. Cooperation Medical expertise Accessibility Medical reports: time Medical reports: Informational value Outpatient consultations Outpatient service offerings Bed capacities Inpatient service offerings Friendliness Education and training Commendation Reputation Newsletter
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.. sample of referring physicians
Nevertheless. 8.001 20. Curry et al.032 0. Using this approach. medications. 2005). and those variables. it is important to distinguish between variables that can be directly inﬂuenced by management activities. .161 20. 13.
IJHCQA 21. pp. Although the validity of this latter item remains doubtful. An assumable cause may lie in a few but important referrals from the viewpoint of the referring physician. (2003). therefore. Although we found statistically signiﬁcant disagreements. Before customer satisfaction can be addressed. If the distance between referring specialists and hospitals is great then patient commendations decline. hospitals need to understand stakeholder needs. 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. Regular measurement and reporting to hospital staff members and the executive board is mandatory for a quality improvement process. “Insights from health care in Germany”. care levels and care sectors (Javalgi et al. Working in separate medical realities may diminish understanding for the concerns of others (Kvamme et al.. clinicians tend to rate quality higher than referring physicians. Surveying referral physician perspectives is an essential method for gathering information on health care service perception. Recommendations We cannot have an accurate understanding of how our services are perceived by others without asking them. estimated by clinicians.
References Altenstetter. physicians and the public (Scammon and Kennard. comparative analysis allowed us to conclude that the majority of quality problems are perceived in a similar manner by referring physicians and clinicians. We note that the frequency of patient commendation. A second step.1
care between services but also the physicians who refer patients to higher-level health care institutions. in general. The long-term strategic challenge lies in building creative and sustainable referral networks that promote professional partnership among physicians.
. Health care provider images and satisfaction with those providers vary among consumers. Vol. 1. who refer only a few patients to the clinical department. which is separated into inpatient and outpatient care sectors with spending caps (Altenstetter. 1993). expectations and satisfaction. is equally important. This situation is particularly important in the German health care system. However. proposing a strong positive self-image in terms of services they provide. 38-44. are much more interested in reading and understanding medical reports than physicians who refer a greater number of patients. 93 No. 2003). Private practice and clinician specialists providing health care services at a secondary or tertiary care level have different roles and may often see problems from different perspectives. American Journal of Public Health. 1983). utilizing survey results. One may speculate that physicians. but good working relations across all boundaries is required. the frequency of patient commendation was found to be associated with the geographic range. C. This may be subject to rather infrequent contact. Referring physicians expect management to be shared with their cooperating medical partners. Not competition between specialists.. which makes it difﬁcult for referring physicians to give a valid rating. was signiﬁcantly higher. 2001).
British Medical Journal. (1993).. 4. Rueter. Curry. A population-based.M.. 287-91. (2005). BMC Health Services Research. 500-11. Health Services Research.. (1999). “The referral process: a study of one method for improving communication between rural practitioners and consultants”. R. “Die Bedeutung der Einweiserzufriedenheit fur Krankenhauser ¨ ¨ und ihre erfolgreiche Messung”. G. Health Services Research. Canada. and Coggins. The Journal of Family Practice. “Improving health care strategy planning through assessment of perceptions of consumers. J. 54-8. and Kennard. 8.J.T. Vol. Vol. T. General practitioner-specialist referral process”. (2005). pp. 243 No. Jr. Joseph. 9-17. pp. pp. “Informational inﬂuences on physician referrals”. and Samuelson. “Establishing an effective referring physician network”. P. Vol. Vol. pp. and Koritsas.B. Vol. Journal of Health Care Marketing. B. and Sorbero. and Inui. Vol. (1980). “Managing demand at the interface between primary and secondary care”. Wensing. Franks. R. pp.. P. Internal Medicine Journal. 2. 376-84. “Improving the interface between primary and secondary care: a statement from the European Working Party on Quality in Family Practice (EQuiP)”. (1990). “Patient. MacDowell. 33-9. (2001). Scandinavian Journal of Caring Sciences. Eija. “Communication failure in primary care. Mackesy.A. 40 No. and Austin.. and Nissen.B. Gesundheitsokonomie und Qualitatsmanagement. N. “How physicians make referrals”. 34 No. 41 No. R. R. 312. Journal of Health Care Marketing. and Szecsenyi. (1980). Journal of Health Care Marketing. pp. 5. Jr. A. Failure of consultants to provide follow-up information”. Journal of the American Medical Association. Vol. J. “Home care personnel’s perspectives on successful discharge of elderly clients from hospital to home setting”. T. “Review of the literature on survey instruments used to collect data on hospital patients’ perceptions of care”. “Referrals from general practice to consultants in Germany: if the GP is the initiator.
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. Rice. 16. 10 No. Rosemann. Vol. British Medical Journal. 2. C. M. Crandall. and Mulligan. Chan.F. and Lester. Vol. 1.A. pp. “Variations in primary care physician referral rates”. 3. R. Medical Care. R. Vol.A. Journal of Hospital Marketing.. 10 No. pp. M. O. and Roland. 1008-12. Vol. multi-level modelling approach”. 6. R. 6. J. L. L. Coulter. and Sirsi. and Hays. (2006). (2005). pp. (1983).biomedcentral. patients’ experiences are more positive”. 491-6. Vol. physician. pp. Cummins. W. pp. P. J. 316. and community factors affecting referrals to specialists in Ontario.R.A. Castle. G. Carr-Hill. R. pp.E. pp. W.W. 4. 3.T. “Factors inﬂuencing physician choice of an outpatient surgery and testing facility”. ¨ ¨ Braun. K. Mooney. M. L. pp.W. Zwanziger. (1992). Vol. 2. 1. com/1472-6963/6/5 Scammon. A.J. 1996-2017. Vol. 6 No.. (1990).K. (1998).Beltramini.C. Gombeski. 10 No. 67-74. 13 No.. “Part II. A. F. providers and administrators”. (2003). 1650-2. Quality in Health Care. 6 No. W. Smith.. Piterman. 288-95.S. Journal of Health Care Marketing. Vol. 2. 10 No. Olesen. pp. “Socioeconomic determinants of rates of consultation in general practice based on fourth national morbidity survey of general practices”. 3 No...O. 35 No. 19 No. Javalgi. (1996). N. 10 No. and Marja-Leena. 101-26. Vol. Brown. J.D. and Perry. N. available at: www. Hepner. 6-17. (2005). pp. M.. Vol. 1974-6. S. G.G. 323-9. D. Kvamme. R.
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To purchase reprints of this article please e-mail: reprints@emeraldinsight. “Medicare physician referral patterns”. S. Vol. Nutting. Health Services Research. D. 1. S.IJHCQA 21. and von Schrader.. 331-48. Vasey.com Or visit our web site for further details: www. (1999). “Variability in physician referral decisions”. B. (2002).1
Shea. The Journal of the American Board of Family Practice. Vol..B.uni-muenster. 473-80. C.. J.A. Corresponding author Peter Hensen can be contacted at: hensenp@mednet. P. pp. 15 No.. B. Stuart. 34 No.emeraldinsight. Forrest.
The current issue and full text archive of this journal is available at www. timely and effective responses (Vinagre and Neves. Service levels Paper type Research paper
Introduction Service quality and customer satisfaction are a major goal in modern organizations.com/0952-6862. however. with a sample of 317 patients from six Portuguese public healthcare centres. The results support process complexity that leads to health service satisfaction. Portugal. such as intangibility. Findings – The scales used to evaluate service quality and emotional experience appears valid. Portugal
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. heterogeneity and inseparability. using a revised SERVQUAL scale for service quality evaluation and an adapted DESII scale for assessing patient emotions.emeraldinsight. 1. revealing that all the predictors have a signiﬁcant effect on satisfaction. 2002). Keywords Customer satisfaction. expectations and involvement. Research limitations/implications – The emotions inventory. Public services cannot detach from this general concern. 2008 pp. These services have. mostly because they act on the socio-economic level and serve individuals and organizations that need adequate. distribution and consumption are simultaneous processes and they are
International Journal of Health Care Quality Assurance Vol. patient’s emotions. Portugal. Lisboa. speciﬁc characteristics. Practical implications – Patient’s satisfaction mechanisms are important for improving service quality. 21 No. especially as a service provider. and
The inﬂuence of service quality
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). 87-103 q Emerald Group Publishing Limited 0952-6862 DOI 10. Design/methodology/approach – The approach was tested using structural equation modeling. might be enlarged to other typologies in further research – needed to conﬁrm these ﬁndings. Montijo. Public Sector importance. which involves diverse phenomena within the cognitive and emotional domain. Originality/value – The research shows empirical evidence about the effect of both patient’s emotions and service quality on satisfaction with healthcare services. Their production. forces managers and practitioners to address quality and client satisfaction issues as a priority. Findings also provide a model that includes valid and reliable measures.1108/09526860810841183
. although showing good internal consistency.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).
g. there is a rather limited body of knowledge on the effects that these different types of services have upon consumer satisfaction. related systems/processes. the degree of involvement can vary as well as the duration of consumer experience. Satisfaction. 1999. From an empirical study in six healthcare centres. in order to explain service quality and satisfaction. is perceived as a global consumer response in which consumers reﬂect on their pleasure level. however. Therefore. Price et al. service experience and involvement. Despite the generalized acknowledgment of these differences among service types.g. Bloemer and Ruyter. 1997). perceived service quality and consumer satisfaction are distinct constructs that may be deﬁned and evaluated in different ways. price. which involves several service dimensions speciﬁc to the service delivered.. The wide diversity of services constitutes another factor that poses measurement difﬁculties. Focusing on consumer satisfaction with a public healthcare service (in this study we considered patient as a health service consumer). Customer satisfaction and customer perceptions are therefore often inﬂuenced by those interactions (Bitner et al. 2000). the emotions linked to service experience and the complementary effect of expectations and involvement on patient satisfaction. Theoretical framework Despite seemingly alike. Services can also differ in the degree of technical knowledge and skill required..IJHCQA 21. he suggests that quality is a judgment or evaluation that concerns performance pattern.1
not storable. 1987). Quality is believed to be determined more by external cues (e.. we intend to evaluate service quality dimensions. Traditionally. expectations. involvement seems a variable to be considered in patient satisfaction and emotional response analysis. only cognitive measures were considered such as disconﬁrmation or the perceived service performance (Liljander and Strandvik. in which customers participate in the production (Gronroos.. 1995). service employees and customers (Bitner et al. 1994. we intend to know the service quality dimensions perceived by patients and the relationship between emotion. 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. driven by conceptual cues (e. Satisfaction is based on service delivery predictions/norms that depend on past experiences. Some studies found a signiﬁcant relationship between involvement and the level of emotions concerning service experience (e. Departing mainly from Westbrook’s (1987) and Westbrook and Oliver’s (1991) work. regret).g. Surprenant and Solomon. equity. 1997). Transactions can thus be open or closed. Although
. reputation). the customer perceives a service in all its production processes and not merely as the result of that production. we assume that we can also ﬁnd differing evaluations of the degree of importance (involvement) attached to the service among the patients. We may need separate criteria to differentiate services mainly on the basis of the sort of experience users have with a particular service.. They are created in buyer-seller interactions and they are essentially ¨ activities or processes. several empirical studies revealed that service use has potential to elicit a complex variety of emotional and cognitive responses. the features of these services make it difﬁcult to adopt service quality and customer satisfaction evaluation criteria.. Having this in mind. Considering healthcare services consumers’ differing needs. Consequently. Oliver (1997) identiﬁed a few major elements that differentiate service quality and satisfaction. Service experiences are the outcomes of the interactions between organizations.
Quality is no longer analysed and measured from an internal focus. 1996). Parasuraman et al. Zeithaml et al.g. Regarding dimensionality. tangibles. Cook and Thompson. 2000). which is understood as being transitory and merely reﬂecting a speciﬁc service experience (Martinez-Tur et al.. Mostafa. In short. 2002. 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. service type (contextualized dimensionality). empathy and responsiveness – that consumers are assumed to use in a systematic way to perceive services provided.. Vinagre and Neves. Accordingly. the appropriateness or utility of expectations in SERVQUAL (the meaning of expectations. although it requires an adaptation to the organization under evaluation (Curry. Service quality studies at the consumer level have a decisive impact on the type of research that has been developed ¨ (Gronroos. 1988. Donnelly. we consider a contingent approach in which dimension numbers vary according to.. 1985. The SERVQUAL model includes ﬁve service quality dimensions – reliability. 1999).. 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. we suggest that service quality should be one patient satisfaction antecedent. Cook and Thompson. 1991). the meaning of P-E gaps and the contribution of the expectation scores). 2004). 2000. they suggest that expectations have a tolerance zone between desired service and adequate or minimal acceptable service level (Berry and Parasuraman.. some studies conﬁrmed service quality dimensional variability (e. SERVQUAL is considered a useful and valid instrument to measure service diversity. Gabbie and O’Neill. which implies subsequent reﬁnement of quality dimensions relevant to each service. different authors (Parasuraman et al. (1991) acknowledged that normative expectations (“what services should be”) lead to unrealistic expectations. Wisniewski and Wisniewski. 1995.. Although there is general agreement about the inﬂuence of customer’s expectations in overall service quality and
The inﬂuence of service quality
. In this study. 1998). Regarding expectation criticisms.. Buttle (1995) synthesized some of these criticisms regarding: disconﬁrmation (disconﬁrmation paradigm rather than an attitudinal paradigm).g. Expectations Consumer expectations are central to satisfaction studies. it tends to last longer than satisfaction. among others. 1991. Subsequently. assurance. 2005. they redeﬁned expectation in predictive terms “what a client may expect from an excellent service”. researchers dispute the relationship between perceived service quality and satisfaction (Ting. and service quality dimensionality (the universality of the ﬁve dimensions are not always conﬁrmed). it is now conceived from the exterior (or consumers’) point of view. Parasuraman et al. 1985. Service quality Quality has been used to describe diverse phenomena. 1990. 1990) deﬁned service quality as a degree and gap between service perception and consumer expectations. 1988) and validated (e. Among consumer satisfaction theories.perceived service quality may be updated at each speciﬁc transaction or service experience. Zeithaml et al. As an alternative to the universal SERVQUAL ﬁve-factor structure. Nevertheless. 2005. 2001). Some authors criticise SERVQUAL.
the mechanism by which expectations may inﬂuence satisfaction directly (Oliver. 1991). some emotions experienced in the context of interpersonal relationships may be different from those experienced during a consumption experience. 2001). Izard’s (1977) Differential Emotions Scale (DES). 2000. Oliver and DeSarbo (1988) mention theoretical support for those effects. 1980). The DESII instrument is a discrete emotions inventory.IJHCQA 21. Dube and Menon. as emotions are context speciﬁc.g. However if disconﬁrmation is too strong then the consumer may strengthen his or her negative perception thus widening the gap. However. 1995). They state that expectations cause an assimilation effect while discrepancy causes a contrast effect. When the consumer acknowledges a gap. Although involvement represents a more complex construct (Kim. In this latter case. is used to measure emotional experience or emotional reactions perceived by the individual during a time period. 2004). measured on a ﬁve-point Likert-scale. which implies that we should consider ´ examining positive and negative emotion effects separately (Babin et al. However. 1993). if the discrepancy between the consumer’s expectations and perception is small then perceptual judgment will reduce this difference. designed to measure basic emotions or combinations of emotions experienced by the individual. 2000. self-administered. Andreassen.1
customer satisfaction. because these are measures developed in other contexts. 2005). therefore. Generically. as Richins (1997) highlights. It comprises ten subscales with three items each representing the frequency with which individuals express each of ten basic emotions.. if the discrepancy is too large then we need to obtain a contrasting perception (Bridges. Involvement Involvement is linked to studies on consumer satisfaction. The role of expectations as an assimilation agent provides.. It is assumed that consumers create expectations prior to their service experience against which performance is evaluated. while DESII is a measure of emotional experience frequency at a given period and is often used in consumer-experience research. Consequently. considerable work remains to be done regarding the exact way this process takes place (Coye. Several studies found a separate effect of expectations and disconﬁrmation on satisfaction (e. High levels of satisfaction may include positive and negative emotions (Arnould and Price. DES is a measure of emotional state intensity. difﬁculties may arise when DESII is used for consumer behavior research. originally conceived to measure an individual’s emotional state. Perception can disconﬁrm expectation (either for “worse” or “better”) or conﬁrm it (“neutral” comparison). we assume that a patient is involved when the
. 2005. he or she attempts to reduce this space. Different scales have been used in consumer emotion studies. 1997). Oliver. Emotions and consumer experience Emotions refer to a set of responses occurring especially during consumer experience (Westbrook and Oliver.. Assimilation effect corresponds to a narrowing of the gap (leading to an assimilation of expectations with perceptions) while the contrast effect is the opposite. individuals tend to respond according to their expectations because they are reluctant to admit wide discrepancies. involvement is viewed as a motivational construct that inﬂuences subsequent consumer behaviour (Dholakia. Price et al. According to the assimilation theory. Within consumer psychology. “contrast effect” occurs. 1993).
1997). considering the interaction between the two in service experience. Zaichokowsky. 1993). 1993. we assume an interrelation between cognitive variables in forming emotions and satisfaction (Westbrook and Oliver. 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. However. Within this context. the involvement effect is insufﬁciently explored compared to other satisfaction predictors. we depart from the more restricted conception of involvement: the degree of importance attributed to the service by the patient. opposing the purely cognitive nature of service quality evaluation. H4. attachment and/or motivation. Consequently. Bridges. especially at the service level. Positive emotions have a positive effect on patient satisfaction. service quality and emotions on satisfaction. However.. 1991). Expectations have a positive effect on patient satisfaction. values and interests (Zaichkowsky. 1995). 1992). Service quality has a positive effect on patient satisfaction. there should be a greater tendency to evaluate aspects relating to attention received during the interaction established along the service experience (Shemwell et al. these may be considered distinct. involvement is similar to importance. service quality is considered mostly a cognitive construct while satisfaction has been considered a more complex concept that includes cognitive and affective components (Oliver.. Therefore:
The inﬂuence of service quality
. Despite studies that relate involvement with satisfaction.service is relevant according to the service’s characteristics and the patient’s needs. Negative emotions have a negative effect on patient satisfaction. an individual may be interested in a service or activity even though that service or activity may not be important to him or her. Satisfaction predictors: theoretical model of analysis Acknowledging that consumer experience is complex. calls attention to the important role emotions may play when associated with other cognitive variables that explain these phenomena. it corresponds to a product’s or service’s perceived importance (Mittal. 1998) and emotional aspects. In our study. 1985) and despite “involvement” semantic distinctions. H2.g. Therefore. Usually. The diversity of emotional experiences is explained as a function of emotion-cognition interactions resulting in cognitive-affective structures (Izard. these relational dimensions are permeable to a strong emotional inﬂuence. Acknowledging potential expectation effects. 1985).g. or that conceive involvement as a mediator of disconﬁrmation (e. 1997). In these cases. H3. Services with more qualiﬁed or more credential properties imply that a consumer’s capacity and ability to evaluate the service provided is reduced. In this respect. Involvement has also been operationalized distinctly (e. perceived service quality can also include dimensions that are mostly relational. Some researchers argue that emotional versus cognitive saliency depends on the type and nature of service transactions. it is foreseeable that expectations are related to the frequency with which patients experience positive or negative emotions. interest.. we hypothesized that: H1. Bridges. For example.
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. Patient involvement has a positive effect on positive emotions. 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. Patient involvement has a negative effect on negative emotions H10. These variables and measures were adopted:
Figure 1. 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. Expectations have a negative effect on negative emotions.1
H5. We obtained 317 valid responses from patients in six healthcare centres. H8. Consequently. satisfaction and other predictors such as expectations and emotions. Research model
. Patient involvement has a positive effect on expectations. Patient involvement has a positive effect on patient satisfaction. These assumptions led us to make the following predictions: H7.IJHCQA 21. H6.
(E21) “My doctor would have a good professional preparation”. Service expectations quality scale. “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). This instrument includes 28 items for the expectations scale and 28 items for the perceptions scale... 1992. Following recommendations in the literature (e. we used a satisfaction expectation measure focusing on the service to be provided. before consultation. 1992) to measure expectations and perceptions. Examples include (E3) “Staff would have good appearance”.. taking into account a series of hospital service characteristics. Consumer satisfaction is the main dependent variable in our study. (P17) “I feel safe in my relationship with nurses”. (P26) “My doctor understands my speciﬁc needs” Satisfaction measure.. we adapted Izard’s (1977) “Differential Emotions Scale” – DESII – used and validated in consumer studies (e. we used an adapted SERVQUAL scale (Parasuraman et al. We used a ﬁve-point Likert scale ranging from “completely disagree” (1) to “completely agree” (5).Service quality. 1987. Using the same 28 items. Patients were asked. (P8) “They provide services at the promised time”. 1997) proposal. Service perceptions quality scale. (E15) “My doctor instils me with conﬁdence” (E19) “Nurses would be always courteous with me”. Following Oliver’s (1981. what they thought – on the basis of their experience – what could be expected from services provided in a healthcare unit. “Generally I am satisﬁed with this healthcare centre”. 1990. 2004. “Generally I am satisﬁed with the services of support”. Expectations. Emotions. Westbrook. (E24) “The doctor would give me personal attention”. We included positive and negative emotions scales but we excluded the “surprise” item owing to its ambiguity. 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. In order to obtain the users’ emotional reactions to the services provided. Babakus and Mangold. (P18) “I feel safe in my relationship with the auxiliary staff”.g. 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). this scale asked patients how they considered services that were provided. 1991) but not particularly in healthcare services. This scale ´ was developed by adapting Donavan and Hocutt’s (2001) and Dube and Menon’s (2000) items on the relationship between patient’s emotions during hospitalization and their satisfaction. Carman. (P16) “I feel safe in my relationship with my doctor”. “Generally I am satisﬁed with the level of services performed”. We asked respondents to predict the degree of anticipated satisfaction (“what would you expect from this service”: “to feel satisﬁed with this medical consultation”. Examples include: (P4) “Materials and documents are clear and visually appealing”. Vandamme and Leunis. (E5) “They would fulﬁl their promised service at the time they promise to do so”. 1988) for the particular healthcare sector contexts. Westbrook and Oliver.
The inﬂuence of service quality
. We considered the existing measures’ diversity in the literature.g. Kilbourne et al. This scale consists of ﬁve items and includes: “Generally I am satisﬁed with my doctor”. “Generally I am satisﬁed with the nurses”.
In this model. service quality results
. sample size. Considering Hoyle and Panter’s (1995) recommendations. a service is considered to be quality whenever perceptions exceed user’s service expectations. Thus deﬁned. The ﬁrst step consisted of verifying the model’s ﬁt to the data through ﬁt-measure analysis. with means and intercepts estimate owing to missing data and indication of the saturate and independent model measures of ﬁt. adopting theoretical criteria for retaining factors with Eigenvalues higher than 1. Internal consistency analysis of the factor structure found.90 for the expectations scale and 0. the service quality factors (i.. Liljander and Strandvik. . Our analysis was done using structural equation modelling (SEM) by means of AMOS 4. 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. and Verbeke and Bagozzi. or no normality). Then.0. we adopted the Incremental Fit Index (IFI) type 2 index. In a second step. results were analysed. Given the controversy regarding the indices that one should use in evaluating the model ﬁt in SEM.97 for the emotions scale. Following Hoyle and Panter’s (1995) recommendation. Factorial structure identiﬁcation with an exploratory factor analyses performed on the items for each scale (according with the procedures adopted by Mano and Oliver. the signiﬁcance of the structural model parameters were analysed (path coefﬁcients). the revised questionnaire was pre-tested on a sample of healthcare public service users in order to test its consistency. Internal consistency analysis (Cronbach’s alpha). Was measured in a direct way with a single item that intended to identify the degree of service importance to the patient by the healthcare centre (“The services given in this healthcare centre are very important for me” in a Likert ﬁve-point format). Results Service quality measure According to extant literature. positive and negative emotions) are treated as observed components of the respective constructs. applying Varimax Rotation and deleting items not satisfying the following criteria: loadings equal or above 0. the Comparative Fit Index (CFI). .6 in the dominant factor and cross-loadings below 0. Measures showed a good internal consistency with Cronbach’s alpha around 0. 2000).4 in the remaining factors. Data analysis Psychometric measure validation followed the recommended procedures: . sample size and selected estimation method. which is less sensitive to sample size and non-normality and Tucker-Lewis Index (TLI) also a type 2. 1997. suggesting that indices’ characteristics depend on data.e.g. it is cautious to use more than a single index when substituting the chi-square. a type 3 index and the Root Mean Square Error of Approximation (RMSEA).1
Involvement. 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. 1993. Once the models were speciﬁed and estimated.IJHCQA 21.
1992. it integrates items from the Assurance factor concerning Nurses and Auxiliary staff. By analysing the saturation matrix after Varimax rotation (Table I).76. comprehending simultaneously in the same factor the Assurance regarding their professional competency and empathy towards the patients. (3) Employee’s assurance. With factor loadings ranging from 0. The scale presented a high internal consistency (a ¼ 0:97). are disaggregated in two groups corresponding to distinct occupational groups: physicians.69. Regarding the theoretical model.84 to 0. 1991). grouped by valence (positive and negative emotions within the emotional experience). we extracted four components that explained 67.77 to 0. it integrates all items concerning medical performance. it integrates all items from the Reliability factor plus two more from the Response Capacity factor in the original scale.60 are also used in the literature (e. nurses and auxiliary staff. 2002. we used the SPSS “compute variable” function to calculate 28 new variables representing the result of the numerical expression (perception – expectation) for each item. so alpha could be lower in scales with fewer items. With factor loadings ranging from 0. 2004. The scales showed a good internal consistency. Babakus and Mangold. Nunnaly (1978) indicated 0.g. we checked subscale validity and consistency. it seems justiﬁable that service quality construct dimensionality is focused on the gap between perceptions and expectations (Vinagre and Neves.68.in the gap between user perceptions and respective expectations. Vandamme and Leunis.95. both concerning speciﬁcally the relation with the service provider. 1).64..72 to 0. In order to identify variables concerning service quality. Parasuraman et al. Cronbach alpha varied from 0. The global service quality scale presented a Cronbach alpha of 0.. The extracted factors are interpretable and allow us to identify four service quality dimensions: (1) Reliability. Alpha coefﬁcient is dependent not only on the magnitude of correlations among items but also on the number of items in the scale.01 per cent of total variance. Considering that the scale comprehends differing and opposite valences. Measure of emotions in service experience The DESII scale showed high internal consistency for all 30 items (a ¼ 0:91). we intended to identify service quality scale structure through Principal Component Analysis (PCA). W So.7 to be an acceptable reliability coefﬁcient but lower values as 0.
The inﬂuence of service quality
. it groups two items from the physical elements. Wright. we eliminated 11 items owing to cross-loading. (4) Tangibles. Considering the construct’s multidimensional nature. (2) Physician’s assurance. Aspy et al.97 for Reliability. 1992. The Empathy and Assurance dimensions.. 2002). Although with fewer items. With factor loadings ranging from 0. we fused Reliability and Response Capacity. the Physical Elements dimension was kept. Using Kaiser’s criterion (“Eigenvalue” . 2007. With factor loadings above 0. From this point of view.67 for the Physical Elements scale (which also has fewer items) to 0.
77 0.64 0.21 0.82 0.22 0.83 for “Interest” and 0.27 0.77 0.7 0.01 0.84 for the total scale.27 0.90 for “Enjoyment” (in Izard’s.37 0.32 0.11 0.14 0.25 0.21 0.75 0.06 18.19 0.66 0.35 14.27 0.12 0.15 0.95 0.13 0.23 0.33 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 79.72 10.18 0.82 0.27 0.28 0.17 0.08 0.15 0.68 0.3 0. 1977 study.25 0.69 67.23 0.21 0.28 per
. Negative emotions Our PCA on the seven DESII negative valence subscales revealed four interpretable components (Varimax rotation with Kaiser criterion) explaining cumulatively 78.33 0.72 0.56
Tangibles 0.09 0.34 0.37 0.3 0.12 0.22 23.33 0.IJHCQA 21.22 0.23 0.26 0.76 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.28 0.69 0.22 0.87 respectively) and 0.17 0.35 0.24 0. Cronbach alpha for these subscales was 0.93
Components Physician’s Employees’ assurance assurance 0.23 0.21 0.1
Statement number code QS5
Reliability 0. The internal consistency analysis showed a Cronbach alpha of 0.3 0.22 0.73 0.73 0.76 0.31 0.37 0.73 0.84 0.15 0.88 0.73 0.76 and 0.67
Table I.88 per cent of total variance.
85 0. Seven items had to be discarded in the rotated matrix owing to unacceptable cross-loading (Table II). IFI ¼ 0:99.09 0.39 0. p .28 0.86 0. “distress” and “fear”.08 0.87 to 0. we started with the measurement model factorial structure analysis as well as its adjustment to data. Structural model Following Anderson and Gerbing’s (1988) recommendations regarding Structural Equation Modelling.92 for the total scale.27 0.13 0. Factors extracted allowed us to identify four negative emotions: “disgust”. All the remaining factors were maintained.73 0.24 0.34 31. However. Factor “Shame” absorbs one factor item that had disappeared (namely.96 0.18 0.88
Table II.60 78. good internal consistency with alpha values ranging from 0.83 0.57
The inﬂuence of service quality
Items Downhearted Sad Discouraged Feeling of distaste Disgusted Feeling of revulsion Contemptuous Scared Fearful Afraid Sheepish Bashful Shy Guilty % Of explained variance (with rotation) % Of explained variance (with rotation) Factor internal consistency (Cronbach alpha) Factor internal consistency all items (Cronbach alpha)
Disgust 0.27 0.33 0.87 0. “shame”.77 0.90.07 0.79 0.22 0.20 0.10 0.24 0.66 17.84 0.001.19 0. By applying the Kaiser criterion we extracted a single factor that accounted for 71.27 0.23
Fear 0.03 0.25 15. In a second phase.16 -0. the hypothesized model was evaluated.25 0.89 0.90 0.23 0. Satisfaction expectation scale Three items composing this measure revealed a high Cronbach alpha of 0.40 0.19 0. df ¼ 51.21 0.37 0. The measurement model was estimated without mistakes or warnings (from the program built in control processes) and presented good ﬁt indices. Satisfaction measure In order to verify the measure’s one-dimensional character we developed a PCA with ﬁve composing items. the second item in Guilty).30 0.16 0.72 0.85 0. The subscales we found presented.96 for the subscales and 0.81 0.22 0. Our results indicated that items composing “Aversion” and “Despise” factorise into a single factor.37 0.14 0. in order to validate the latent variables.12 0.86 0.27 0. TLI ¼ 0:99.74 0.88.12 0.84 per cent of total variance with a Cronbach alpha of 0.24 0.cent of total variance. Negative emotion’s factor structure: rotated component matrix (Varimax)
.84 0.21 0.08 0. imposing two co-variances has shown to improve the ﬁt indices (x2 ¼ 106:89.11 0. thus conﬁrming our global satisfaction scale’s one-dimensionality hypothesis.92 0. 0.18 0.29 0.19 13.
Components Shame Distress 0.16 0.
p . The estimated structural model corroborated our hypotheses. Results showed that the model explains 61 per cent of the satisfaction variance (R 2 ¼ 0:61). The predictors we considered had a direct effect on patient satisfaction. df ¼ 54. The perceived service quality.IJHCQA 21.
Figure 2. indicating that latent variables were actually depicting different constructs. 0. Results showed that the structural model has good ﬁt (x2 ¼ 134:46. TLI ¼ 0:99. IFI ¼ 0:99. Estimated structural model
. 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.1
CFI ¼ 0:99 and RMSEA ¼ 0:052). Figure 2 presents the estimated structural model with the respective parameter values. As the measurement model revealed good ﬁt.001. CFI ¼ 0:98 and RMSEA ¼ 0:061). All estimated parameters were signiﬁcant.
These modiﬁcations may have. all the remaining measures refer to the human element linked to service performance. auxiliary staff. Service quality measures have shown that with the exception of physical elements.001) and an indirect effect (b ¼ 0:12. 0. Regarding the dimensions proposed by Parasuraman et al. assurance. p . We departed from the assumption that this multidimensionality was equivalent to ﬁve quality dimensions proposed by Parasuraman et al.001). “assurance with the nursing and auxiliary staff”. As Sureshchandar et al. nurses. p . (2002) highlighted. patients have no “skill” to evaluate exactly the service’s technical reliability. given the healthcare services’ credential. we considered that the service quality construct is multidimensional. 0. a multiplicity of events of service and interactions. p . 0. 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.001) and an indirect effect (b ¼ 0:28.001). Expectations had a direct effect (b ¼ 0:37. We thus veriﬁed that positive and negative emotions were partially mediating the effect of expectations and involvement on satisfaction. In our study. empathy and tangibles. (1991) acknowledged.(1988). considering several studies developed by other researchers. We believe that this approach is preferable to the idea of the ﬁve-factor universal structure present in the SERVQUAL scale. Physician’s assurance. responsiveness. (1988): reliability.
The inﬂuence of service quality
. the type of the service. From the PCA we identiﬁed four dimensions: Reliability. 1989) statement that patients often are in no position to assess care process technical quality and they are sensitive to interpersonal relationships. 0.the expectation and the emotions (especially the positive ones) all predicted satisfaction. among others. the interaction/intervention element’s importance has been acknowledged by many researchers. 2002) and that it is necessary to adopt a contingency approach in which the number of dimensions varies according to. However. administrative staff) and consequently. 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. two dimensions were clearly kept: “reliability” and “tangibles”. somehow constrained the possibility of replicating the study and. we acknowledged that these dimensions lacked stability as well as the possibility that variations may occur depending on the characteristics of each service. so the interaction dimensions gained greater saliency: “assurance and empathy with the physician”. As predicted. 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. The involvement also had a direct effect on satisfaction (b ¼ 0:15. This result is also consistent with Donabedian’s (1980. Conclusions and recommendations In our initial discussion. therefore. The remaining two dimensions seemed to be speciﬁc to this type of service. SERVQUAL was minimally altered to guarantee its adaptation to Portuguese public healthcare centres’ context. p . This study provides further support for the idea that service quality construct dimensions vary (Vinagre and Neves. Employee’s assurance and Tangibles. lowered the likelihood of ﬁnding similar results.
103 No. L. Vol. Journal of Counseling and Development. Babakus. “Modelling consumer satisfaction and word-of-mouth: restaurant patronage in Korea”. Andreassen.. Expectations also have a direct effect on emotions: the higher the expected satisfaction the more individuals tend to experience positive emotions and. 20.. European Journal of Marketing. T. B. 82 No. 133-9. From a management view point. Eun-Ju. pp. mainly positive ones. Satisfaction also varied with the involvement seen as the importance level of the service to the patients. Results also supported the process complexity that leads to satisfaction with a service. L. R. Rodine. The higher the individual involvement. 268-76. These results support the assimilation effect of expectations. on the patient’s satisfaction. and Marshall. Journal of Services Marketing. pp. 767-86. J. “River magic: extraordinary experience and the extended service encounter”. 6. Even when performance is perceived as high quality.L. greater or lesser degree of involvement) are also operating within these dynamics. the results showed that individuals experience pleasant or unpleasant emotional states following expected levels of satisfaction. K.F. 1980). Vol. S. McLeroy. M. it is necessary to take into account relational aspects between the service provider (physicians..IJHCQA 21. Our study highlights the importance of relational and emotional aspects in patient satisfaction. satisfaction levels may be affected if the providers of these services disregard the patient’s emotions and if. 3. a more open or closed transaction. more or less qualiﬁed. Vol.B. although showing good internal consistency. Therefore. nurses and auxiliary) and the patients and the goodness of interpersonal skills in patient patient’s satisfaction (Donabedian. Arnould. Oman. HSR Health Services Research. Yong-Ki. the less they tend to experience negative emotions. and Grifﬁn. L. “Structural equation modelling in practice: a review and recommended two-step approach”. The involvement also had a direct and signiﬁcant effect on emotions: the more important the service is to the individuals the higher the number of positive emotions and the lower the number of negative emotions they experience.W.g. they do not know how to manage those emotions. pp. Vol.. (2004). (2000). (1988). K. (2005). “Antecedents to satisfaction with complaint resolution”.J. 19 No..1
The scale used to evaluate the emotional experience appears valid. operating like a self-fulﬁlling prophecy.
. 3. Future research could develop the idea of dimension variability regarding the service quality dimensions and test whether emotions experienced in speciﬁc service contexts (e. 24-45. 26 No.
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The inﬂuence of service quality
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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. 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. The “reliability and fair and equitable treatment” factor was found to be the most important healthcare service quality dimension. doing less business or switching to alternative service providers. Keywords Health services. Zeithaml and Bitner (2000) described how customers express such intentions in positive ways: . Design/method/approach – A questionnaire was administered to 750 and 34 per cent responded. based on factor and reliability analysis. 104-124 q Emerald Group Publishing Limited 0952-6862 DOI 10. Service levels. Human needs are states of felt deprivation such as physical needs for food. Originality/value – Adds to the existing body of research on service quality and demonstrates that SERVQUAL is not a generic service quality measure for all industries. 2008 pp. .1108/09526860810841192
.com/0952-6862. increasing their volume of purchases. or . 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. University of Mauritius. Retaining customers may be more proﬁtable than attracting new ones. On the other hand. praising the ﬁrm.htm
IJHCQA 21. Therefore.1
The relative importance of service dimensions in a healthcare setting
Rooma Roshnee Ramsaran-Fowdar
Faculty of Law and Management. agreeing to pay a price premium. clothing and safety.emeraldinsight. 1. Private hospitals.The current issue and full text archive of this journal is available at www. social needs for belongingness and affection and individual needs
International Journal of Health Care Quality Assurance Vol. Mauritius Paper type Research paper
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. 21 No. . customer dissatisfaction may lead to unfavourable behavioral intentions such as negative word-of-mouth. Mauritius
Purpose – The paper aims to focus on an augmented SERVQUAL instrument that was used to measure private patients’ service expectations and perceptions. preferring the company over others. Clancy and Schulman (1994) calculated the cost of attracting new customers to be approximately ﬁve times that of keeping current customers happy. Findings – A new service quality instrument called PRIVHEALTHQUAL emerged from the study. Reduit.
1993a.. Cronin and Taylor. 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. In their popular measuring service quality framework. Zeithaml et al. These service quality surrogate indicators can be used by patients to assess service provider efﬁcaciousness. 1990). it has been subject to criticisms conceptually and methodologically (Babakus and Mangold.. 2000). Wants are the form taken by human needs as they are shaped by culture and individual personality. staff appearance. Parasuraman et al. desired expectations as a comparison against which service performance is assessed. 1993b). and (5) empathy. additional research is necessary to gauge its applicability to healthcare services. (2) reliability. Teas. Carman. 1993. Given healthcare’s credence. 1990. It also illustrates the difference between perceived service and desired service – known as the Measure of Service Superiority (MSS) and the difference between perceived service and adequate service – labeled as the Measure of Service Adequacy (MSA).. This model proposes that service expectations can be separated into an adequate standard and a desired standard (Zeithaml et al. Speciﬁcally... 1993. Since SERVQUAL was generated outside healthcare and has limited examination in the healthcare literature.. research on consumers’ multi-expectations. Although SERVQUAL proved to be a robust service quality measure. Parasuraman et al. 1988). One of these criticisms is SERVQUAL’s inappropriateness as a generic measure for all service settings. Ofﬁce aesthetics. Exactly what are consumers’ needs and wants in a healthcare context? By and large. 1994). Brown et al. 1992. Spreng and Singh. (3) responsiveness. 1993). which consists of ﬁve essential service quality dimensions: (1) tangibles. The most widely accepted measurement scale for service quality is SERVQUAL (Parasuraman et al.
Importance of service dimensions 105
. 1993. (4) assurance. 1989. relationship between patient and doctors and the punctuality of appointment among others may be medical care quality indicators. researchers proposed that multi-expectation standard approaches may be more appropriate for service quality models (Boulding et al. Between these two expectation levels lies “tolerance zones” that represent a performance range consumers consider acceptable.for knowledge and self-expression. There is research that service quality is contingent upon service type (Babakus and Mangold. 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. there is a need to test if SERVQUAL is a comprehensive patient evaluation of healthcare service quality measure or if additional dimensions are needed. 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. 1989). (1988) used a single expectation standard. 1993. Recently. However. Within each dimension there are several items (22 in total) measured on a seven-point scale from strongly agree to strongly disagree.
People at the bottom of the socioeconomic ladder obviously cannot access paid services. there were 1. The Mauritius healthcare system The Republic of Mauritius has a total area of 720 square miles and a population of 1. one bed for 315 inhabitants or 3. Singapore and other developed countries where average life expectancy is above 75 years and infant mortality rates is below seven. poor remuneration. 2002). employs over 400 doctors and provides primary and secondary services in 14 private clinics. 8. At the end of 2001. Mauritian medical care is freely provided by the state and there is also a well-established private sector.8 per cent in France and 13 per cent in the USA (Ministry of Health and Quality of Life.8 per cent of its Gross Domestic Product on health compared to 3. many nurses have migrated.2 million residents (Central Statistics Ofﬁce. the number of doctors and nurses employed per 100. 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. representing one doctor for every 1. 2001. Mauritius spends about 2. which absorbs 32 per cent of the country’s total health expenditure.1
tolerance zones. inability to take initiatives and poor leadership. Consequently. private medical services were identiﬁed as a suitable study setting to explore professional service quality and its evaluation from the clients’ perspectives. All impede patient service delivery in the public sector.9 per cent in Seychelles.700 nurses. Furthermore.IJHCQA 21. Given the physician shortage. patients have to wait in long queues in the public hospitals.716 at the end of 2001. Private general practitioners (GPs) were selected because they deal with patients on a long-term basis. in comparison to developing countries. Nevertheless. The number of doctors registered has declined over the years since these professionals prefer to work overseas where they are better remunerated. The total number of beds in government institutions was 3. for instance. that is. low working life quality.000 population in Mauritius is signiﬁcantly below that found in countries with better levels of health. Mauritius has made remarkable progress addressing citizens’ healthcare needs. The public sector employs over 690 doctors (including about 245 specialists) and around 2. 5.3 per cent in Singapore.000. Similarly. Compared to other African countries. 2002).2 beds per 1. 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.107 doctors in Mauritius. new measures are needed to improve its performance to reach the levels achieved by places such as New Zealand.089 inhabitants. 2003).9 per cent in Belgium. The private sector has 588 beds of which 283 are single rooms (Ministry of Health and Quality of Life. Healthcare service performance is also relatively low in Mauritius compared to other countries because of stafﬁng differences. Often. Although Mauritius is doing well. The private sector. Presently. MSS and MSA is in the exploratory stage. there is a serious demoralisation problem among hospital employees resulting from cumbersome workload. the government allows public doctors to practise privately as part of its staff retention strategy.000 live births. Consequently. Indeed. 9. One reason for this difference in health status may be the relative level of investment in the health services in different countries. 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
. 8 per cent in New Zealand.
Interactive quality involves contact between the customer and service personnel. (1985) deﬁned service quality as an overall evaluation. what is offered and received).insurance. to identify the most important service quality dimension in a healthcare setting. distinguished two types of service quality: (1) technical quality refers to core service delivery or service outcome (i. and . This idea was supported by exploratory research conducted by Parasuraman et al. The researchers also identiﬁed two inter-related service quality dimensions. “outcome” quality and “process” quality. product repair and maintenance).e. customers’ expectations) with the seller’s actual service performance (Parasuraman. we seek to accomplish the following speciﬁc objectives: . securities brokerage. ¨ Groonroos (1982). was to conduct empirical research on service quality frameworks. Literature review Different theoretical perspectives on service quality were developed during the 1980 s. while (2) functional quality refers to service delivery processes or the way in which the customer receives the service (i. 2000). credit card. therefore. Lehtinen and Lehtinen (1982). (1985) study was the most extensive research carried out into customer service
Importance of service dimensions 107
. while functional quality may consist of the doctor’s waiting room. Along the same line. Parasuraman et al. similar to but not the same as an attitude. Olshavasky (1985) also viewed quality as a form of overall service evaluation similar in many ways to attitude. which refers to the degree and direction of discrepancy between customers’ perceptions and expectations. discussed three kinds of quality: (1) physical. how the service is offered and received). Consequently. Addressing the major issues discussed above. and (3) corporate. Physical quality includes structural aspects associated with services such as the reception area. for example. doctor’s ofﬁce hours and secretary’s behaviour.’s. (1985) using twelve consumer focus-groups in four industries (banking. Topics discussed with focus group members included the meaning of quality in the service’s context. Parasuraman et al. The study revealed that customers used the same general criteria to arrive at an evaluative judgement regarding service quality. which correspond to the ¨ dichotomy proposed by Gronroos (1982) and to the “physical” and “interactive” quality characteristics identiﬁed earlier by Lehtinen and Lehtinen (1982). Zeithaml (1988) later deﬁned service quality as the consumer’s assessment of overall excellence or superiority of the service. to measure service quality in a private healthcare setting. Our purpose. on the other hand. From these earlier writings. Corporate quality includes image and reputation.e. service quality characteristics and the criteria used by customers when assessing service quality.e. Technical quality can relate to the surgeon’s performance. examination room and medical equipment. it can be seen that service quality notions arise from a comparison of what customers feel a seller should offer (i. (2) interactive.
Zeithaml et al. developed by Parasuraman and his colleagues. followed by responsiveness. deﬁned service quality as three constructs: interactive.’s (1985) well-known SERVQUAL model. desired expectations (what the consumer feels a service provider should offer) was used as a comparison against which service performance was assessed. (1990) reported service reliability as the most critical dimension perceived by customers. long-distance telephone and retail banking services. the instrument has been criticised conceptually and methodologically. replication studies by other investigators failed to support the ﬁve-dimensional factor structure obtained by ¨ Parasuraman et al. Because some service quality determinants are perceived generically. while others are industry. (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. customer’s physical or emotional status and other non-medical characteristics can inﬂuence customers’ service quality perceptions.’s (1985) ﬁve service quality dimensions.. other studies (Carman. two insurance companies and a long-distance telephone company. Parasuraman et al. some researchers such as (Boulding et al. Zeithaml et al. 1990) in a dental school patient clinic. 1990. in their study of credit-card. Despite its widespread use. That is. Groonroos (1982) conceptualised service quality as a two dimensional construct comprising technical and functional quality. The 22-item SERVQUAL instrument. However.1
quality perceptions. however. Babakus and Mangold (1989) argue that SERVQUAL’s dimensional instability results from the type of service sector under investigation. 1994) suggest that multi-expectation standard approaches may be more appropriate in service quality models. One main criticism is the applicability of the ﬁve SERVQUAL dimensions to different service settings. Lehtinen and Lehtinen (1982). Zeithaml et al. (1988). Turner and Pol (1995) also reported that quality dimensions are not equally important. This ﬁnding consistently cropped up in other studies such as Zeithaml et al. They suggest that environment. Moreover. McDougall and Levesque’s (1994) study also did not support Parasuraman et al. business school placement centre. empathy and tangibles. (1993. For example. motor care tire centre and acute care hospital. Respondents considered reliability as the most important and tangibles the least important dimension. 1993) demonstrated that service encounter situational characteristics such as customers’ prior experience. (1993) pooled insights from past expectation
. (1990) reported. which underpin service quality. physical and corporate quality. The SERVQUAL instrument is described by Parasuraman et al. time or day of the week or whether customers are given an expectation about waiting time may affect the relative importance of various quality dimensions. They revealed only three underlying elements: tangibles.or situation-speciﬁc. Mowen et al. assurance. 1992) and up to nine (Carman. In a study of 1936 customers in two banks. (1991) as a reliable and valid service quality measure with relatively stable dimensions that apply across many service industries. Attempting to capture the essence of various comparison standards. (1993) and Parasuraman et al.IJHCQA 21. (1990). research indicates the possibility of two public utility sector dimensions (Babakus and Boller. included ﬁve service quality dimensions described above. that customers rated all ﬁve SERVQUAL dimensions important. repair and maintenance. contractual performance (outcome) and customer-employee relationships (process). a single expectation standard. On the other hand. In Parasuraman et al. Lately.
Additionally. incorporates this expanded expectation conceptualisation. (1994) found that tolerance zone measures had convergent and predictive validity. This service quality framework combines adequate. Parasuraman et al. Separating these two expectation levels is a “tolerance zone” that represents a service performance range a customer would consider satisfactory. In other words. The three-column format (Table I) involved obtaining separate desired. or the minimum level of service customers are willing to accept without dissatisfaction. termed adequate service. (Berry and Parasuraman. Hence. However. The tolerance measures were also less susceptible to response errors compared to single expectation measures. Parasuraman et al. 2000).conceptualisations with ﬁndings from a multi-sector focus-group study to develop an integrative customers’ service expectation model. (2) service level adequacy. adequate and perceived service ratings using
Importance of service dimensions 109
. customers also have an expectation threshold. If the correlation between two measures is high then the initial measure is said to have predictive validity. 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. Moreover. and (3) a speciﬁc company’s perceived service. 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. On the other hand. The latest SERVQUAL modiﬁcation. A performance below the tolerance zone (or below the adequate service level) will engender customer frustration and dissatisfaction and decrease customer loyalty (competitive disadvantage). most customers are realistic and understand that company staff cannot always deliver the preferred service level. customers will be satisﬁed if performance falls within their tolerance zone (competitive disadvantage). 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. therefore. the tolerance zone provides detailed and probably more accurate managerially diagnostic information and thus better strategy decisions (Teas and DeCarlo. desired and predicted expectations along with perceived performance. Convergent validity is the extent to which the scale correlates positively with other measures of the same construct. For each SERVQUAL attribute. 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. 1991). As mentioned earlier. 2004). (1994) modiﬁed SERVQUAL’s structure to capture the MSS and MSA gaps. 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. three values (on a nine-point scale) are measured: (1) customers’ desired service level. A performance level above the tolerance zone (or above the desired service level) will surprise and create customer delight and strengthen their loyalty (customer franchise). the tolerance zone is a service range within which customers do not pay explicit attention to performance.
. 1 2 3 4 5 6 7 8 9 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
specialists.three identical. user-friendly forms). Gabott and Hogg (1994) reported six factors that affect consumer satisfaction: (1) service range (e. waiting room facilities. sex. decoration). age. bedside manner. waiting room. (2) pre-examination comfort (e. number of doctors).g. home visits). reported two major additional dimensions not captured by SERVQUAL: caring and patient outcomes. Peyrot et al. “professional competence” and “communications” as factors signiﬁcant for both physicians and patients in service quality evaluation. and (6) responsiveness (time spent with doctor and time spent in waiting room). Using principal components analysis and Varimax rotation. anger or disappointment with life after medical intervention”. with emotions approaching love for the patient” and an “outcomes” dimension that included “pain relief. ofﬁce visit. (1994). The perceived – desired and perceived – adequate differences were used to calculate MSS and MSA respectively. Healthcare sector service quality Previous SERVQUAL tests in health care settings yielded mixed ﬁndings. On the other hand. The perception-only ratings (Column 3) were found to have the most predictive power.g. Brown and Swartz (1989) identiﬁed “professional credibility”. receptionist’s manner. “service customisation” and “knowledge of the professional” dimensions. parking.g. explanation). and personal issues. (2) empathy (e. human involvement. (3) physical access (e. helpfulness. appointment time convenience). access by public transport.
Importance of service dimensions 111
. (1993) separated service attributes into three factors using factor analysis: (1) staff behaviour (friendliness. on the other hand.g. (4) doctor speciﬁc (e. A GP (1) (2) (3) (4) satisfaction study by Drain (2001) yielded four factors: care provider. Bowers et al. Babakus and Mangold (1992) found the instrument reliable and valid in hospitals. facilities for disabled). life saving. side-by-side scales. one practical problem with the three-column format is that it calls for three separate ratings that respondents may ﬁnd more time-consuming. access to care. research conducted by Haywood-Farmer and Stuart (1988) suggested that SERVQUAL was inappropriate for measuring professional service quality since it excluded “core service”. The “caring dimension” implied a “personal. (1994) concluded that if the primary goal was to maximise the variance explained in overall service ratings then the perceptions-only scale appeared to be the best. and (3) examination comfort (physical comfort and time in the examination room). (5) situational (e.g. waiting time.g. Parasuraman et al. Additionally. However.
research indicates that perceived service quality is contingent upon service type. few studies including Babakus and Mangold (1992). overall (second order) service quality factor. However. A different argument is proposed for consideration in a healthcare environment. however. (3) same gender as the patient. In short. . maternal and child health centres): (1) assurance. However. studies show that SERVQUAL does not cover all healthcare services dimensions that are important to patients. Although Berry and Parasuraman (1991) argued that the SERVQUAL “reliability” dimension is the outcome of service performance representing the core service. and (4) reliability and responsiveness. (2) tangibles. which implies that one generic service quality measure is inappropriate for all services. Most important dimension in healthcare service quality In many quality studies the reliability dimension – the ability to perform services dependably and accurately – stands out as the most important customer service quality perception determinant. Kilbourne et al. 1994b) reported that SERVQUAL was a consistent and reliable one-dimensional scale. Morrison et al. tangibles. Loaded together these dimensions accounted for approximately 68 per cent of the variance in both settings.
.’s (2004) study also showed that SERVQUAL captures service quality multidimensionality: . Recently. Lam (1997) and Taylor (1994a. (4) advising.1
Dean (1999) identiﬁed four stable dimensions using SERVQUAL to compare service quality dimensions in two different healthcare settings (medical centre. it is hypothesized that: H1. Therefore. 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. . (2) doctor-patient relationship. using factor analysis. responsiveness. Therefore.IJHCQA 21. (2003) identiﬁed ﬁve main service attributes that explain people’s GP service preferences: (1) communication. (3) empathy. as well as an . reliability and empathy. Core outcome is the most important healthcare service quality dimension. and (5) empowering patients to make decisions. there has been limited recent published work on service quality dimensionality after the mid 1990s.
age. the 47 service quality items measured on a seven-point scale from low to high. 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. address. Respondents circled the appropriate number on a seven-point scale from Low (1) to High (7). (1994). Next. and their GP service ratings. education level. hypothesis. magazines. responsiveness. (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. Our questionnaire was designed taking preliminary considerations such as the research questions. residence. reliability. Our modiﬁed SERVQUAL-type questionnaire for use in the healthcare sector was constructed by retaining some items from the updated SERVQUAL dimensions: tangibles. These scales add strong diagnostic value and the three-column format possesses comparable reliability and validity to other formats studied. and used the regression purposes. Parasuraman et al. adequate and perceived service scales. 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. their friends and other associates. each item investigated was checked once again before verbally and structurally being changed to reﬂect our research needs. Selected items were reﬁned and paraphrased in both wording and contextual applications as appropriate to suit our research purposes. occupational status. 1996). Additionally. response format. All items were phrased positively as suggested by Parasuraman et al. including gender. (1994). target respondents. Consequently. Service quality questionnaire items (1) Ability to get an appointment at a convenient time to me. ethnicity.’s (1994) three-column format was used with three identical desired. occupation.
Importance of service dimensions 113
. The list below summarises the questionnaire’s 47 service quality items. A convenience sample was used by choosing people working at the Mauritius University. monthly household income and private healthcare payment mode. our questionnaire consisted of three sections: (1) Section A included 47 statements on different aspects of GP services. Respondents were subjected to a set of open-ended questions on their quality perceptions of services provided by private GPs. Respondents were chosen to achieve age. after carrying out in-depth interviews on healthcare quality with patients. (2) Appealing materials such as pamphlets. posters and so on. respondents were asked to rate the overall quality of GP service on a seven-point Likert scale. newspapers. empathy and assurance from Parasuraman et al. question wording and questionnaire sequence into consideration (Kinnear and Taylor. Detailed notes were taken during interviews and these were eventually compiled into a report. marital status. personal income and marital status diversity.Method We used a cross-sectional quantitative research design. (3) Section C covered respondent demographics. Their choice best reﬂected their desired and minimum service level expectations.
Willingness to help patients. GP having patients’ best interest at heart. Punctuality of appointment. waiting room. Courteous and friendly doctor. Honesty and integrity of physician. Ability of support staff to inspire trust and conﬁdence in patient. Reliability in handling the patient’s problems. GP’s emphasis on prevention of health problems. Knowledgeable and skilled GP. Physician reputation. Professional appearance/dress of the support staff. GP’s readiness to respond to the patient’s questions and worries. GP’s medical qualiﬁcations. GP’s emphasis on patient education. Uniform fees and other charges for all patients. Prompt service without an appointment. Ability of GP to inspire trust and conﬁdence in patient. Convenient hours of operation. GP making patient feel good emotionally and psychologically. Maintaining accurate and neat records of the patient’s medical history.g. GP accessibility at odd hours in case of emergencies. Highly experienced GP. Clear display of GP’s qualiﬁcations. Careful diagnosis of the patient’s problems. Professional appearance/dress of the GP. GP’s familiarity with latest advances in medical ﬁeld/products. Convenient clinic location. Courteous and friendly support staff.
. GP’s willingness to listen carefully to patients. Prescription of affordable medicines. Modern medical equipment. tables and amenities).IJHCQA 21. Physician compliance with hygienic and other precautions. Knowledgeable and skilled support staff. chairs.1
(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. Visually attractive and comfortable physical facilities (e. GP accessibility by phone.
if necessary. A total of 750 questionnaires were distributed and administered in two stages. We used a convenience sample. there should be at least four or ﬁve times as many observations (sample size) as there are variables. every attempt was made to randomise the data collection process. Personal conduct and manners of the GP.e. Thus. neighbour. (46) Remembering names and faces of patients. other relative or associate. Positive medical outcome of treatment. (47) Thoroughness of explanation of medical condition and treatment. (1999) suggest that. Quality of GP’s referral contacts (i. Physician’s willingness. 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.000 females (Central Statistics Ofﬁce. three were omitted from our data analysis owing to incomplete or missing information – a ﬁnal response rate of 34 per cent. Response rate From 750 questionnaires distributed over a period of ﬁve months in 2003. families and friends. 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. 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. First. Completion instructions were given to each receptionist. the response rate achieved was
Importance of service dimensions 115
. (45) Reassuring the patient about the recovery. schools. Second. 150 questionnaires were hand-delivered to the receptionists in ﬁve randomly selected private GPs. Basilevsky (1994) and Hair et al. Physicians making patients feel safe and relaxed during their visits. Sommers (1999) reports that for scientiﬁc validity. as a rough guideline.(39) (40) (41) (42) (43) (44)
Maintenance of patient conﬁdentiality. 2003). contacts with specialists. Respondents must also have visited a private GP during the preceding year and be over 18 years of age. to refer the patient to a specialist. Of these. our 34 per cent response bettered the Mauritian 15-25 per cent national response-rate average. Questionnaires were also sent to workplaces. a total of 260 were completed and returned. They were requested to ask visiting patients to ﬁll in the questionnaire when waiting for the doctor’s consultation. Moreover. Completed questionnaires were then collected by the researcher over a period of two months. They were asked to ensure that each was an immediate family member. Since there is a maximum of 47 items. laboratories). Therefore. This allowed recollections of their visit experience in order to be able to remember and answer the purchase and post-purchase situations and feelings appropriately. a survey must achieve a rate of response that includes at least 30 per cent of the patients whose opinion was sought. hospitals. Owing to the relatively large University and other contact commuter base. pharmacies. a sample size of 188 to 235 respondents would have been appropriate. 600 questionnaires in batches of two were distributed to Mauritius University undergraduate and postgraduate students.
it does not mean that these constructs are unrelated to overall service quality. The resulting respondent proﬁle was deemed to be encompassing and fairly well distributed.’s (1994) recommendation. Factor rotation maximises the loadings’ variance on each factor thus minimising factor complexity (Tabachnick and Fidell. Moreover. the MSS format was found to be superior.
. 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. A comparison of two possible formats is needed to determine which should be used to decide the factor structure for further analysis. Factor structure reliability was tested for internal consistency after items were grouped. 1989). According to Table III. Cronin and Taylor. To test instrument scale validity. Overall service quality ratings were used as the dependent variable. the factors derived from the MSA construct were slightly superior to the MSS score format. Results are illustrated in Table III. with maximum likelihood method. Although MSS and MSA scores produced fairly low R 2 values. MSS convergent and predictive validity were superior compared to the MSA format (Table IV) by the higher R 2.1
considered adequate for the study.8 per cent. Nevertheless. principal component analysis was used to extract the maximum variance from our data. Based on the total variance explained. and . was chosen for our factor analysis second stage. Raw data were initially organised into MSS and MSA. Cronbach alphas. Table IV summarises two factor analysis results derived from MSS and MSA scores based on: .40 was considered. We can.IJHCQA 21. Both MSS and MSA scores from 47 service quality items were factor analysed using Parasuraman et al. McDougall and Levesque. empirically supporting the superior predictive power of this scale compared to the difference-score measures (Babakus and Mangold. Data analysis We examined dimensionality using factor analysis.3 per cent of the variation in overall service quality and MSA scores 9. There could be a nonlinear relationship between them that is not captured by R 2. MSS scores explained 19. therefore. The Varimax rotation technique. the total variation explained. 1992. Therefore. 1992. conﬁrm the service quality scale’s convergent and predictive validity. In the initial stage of factor extraction. Only factors with Eigenvalues greater than one were retained and a decision rule of factor loadings in excess of 0. 1994). Comparing individual factor Eigenvalues revealed that results were relatively equivalent. while MSS (sum of MSS means of 44 service statements retained from MSS construct divided by 44). Three different regressions were done. a regression analysis was performed to assess the questionnaire’s convergent and predictive properties. eigenvalues. Table II provides a summary of the respondents’ demographics. MSS scores explained the item loadings in a better and sound conceptual way. Findings and discussion Table III shows that the perceptions-only scale had higher R 2 value than the other two measures. The same conclusion was reached when comparing the Cronbach alphas. .
1 3.4 12.2 51. doctors.2 3.2 44.000 Above Rs 50.1 34.8 8.8 32.1 5.1 16.2 3.8 50.6 3.000 Rs 10.8 72.9 14.1 61. etc.000 Rs 30.4 3.9 25.8 1. lawyers.5 7.0 11.000 Rs 40.001-50.9
Importance of service dimensions 117
Table II.001-20.001-20.4 49. Respondents’ demographic proﬁle
.0 8.0 0.0 17.000 Rs 10.) Self-employed Others Highest level of education completed CPE (cert.1 0.000 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
% 49.7 24.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.3 36.001-40.9 20.1 6.0 44 56 40. 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 15.2 51.3 14.
“Fairness and treatment equity” was also associated to the “reliability” dimension. therefore.000 0.189 0. Moreover. Our study adds to the large body of service quality research.76 4 5 2 2 4.545
df 1 1 1
Sig.193 0.95 0.72
Table IV.2 4 7. We also show a need to examine current tools that measure service standards in the professional services domain. Proportion of variance in overall service quality (dependent variable) Perceptions-only (overall) MSS (overall) MSA (overall)
R2 0. Comparison between MSS and MSA score formats
. of items 19 5 15
MSA format 65. One way to test core outcome ` dimension importance (vis-a-vis other service quality dimensions) is to examine its
Independent variable used Table III.72 No.337 0.’s (1988) SERVQUAL dimensions.91 0. Clearly. our study provides evidence that expectations drive service quality diagnostic evaluations by consumers and. which were obtained using factor and reliability analyses on data from private healthcare settings.94 0.2 1. Consequently.9 4 Cronbach Alpha 0.1 4.294 21.092 47.8 0.75 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.340 0.IJHCQA 21. Although some dimensions were relatively equivalent.4% Eigenvalues 9.2 6.81 2 0.5 0.9 0. there were two additional dimensions with high Eigenvalues and Cronbach alphas.000
MSS format 63. an understanding of both adequate and desired expectations is necessary to avoid service shortfalls and achieve better resource allocations. managers should not continue to ignore consumer expectations. we named our new service quality instrument PRIVHEALTHQUAL.6 3.97 0.1
Proposed service quality scale for private healthcare Table V compares service quality dimensions generated from the MSS format we used with Parasuraman et al. From our comparisons it can be said that an augmented and modiﬁed SERVQUAL instrument can be used in a private healthcare context.098
Adjusted R 2 0.4 3.8 1.6 Cronbach Alpha 0. which demonstrates that SERVQUAL is not a service quality generic measure for all industries. which largely explain the total variance: “Core Medical Services/Professionalism/Skill/Competence” and “Information Dissemination”.87 0.000 0.094
F 102. of items 13 8 9 4 Eigenvalues 6. 0.
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.
7. The Pearson product-moment correlation coefﬁcient (r) indicates the degree that quantitative variables are linearly related in a sample. Assurance – courtesy and knowledge of staff and their ability to inspire trust and conﬁdence
2 Reliability – ability to perform the expected service dependably and accurately
4. The signiﬁcance test of r evaluates whether there is a linear relationship between two variables in the population. knowledge. 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. effectiveness and beneﬁt to the patient. equipment and appearance of personnel
Service quality dimensions in private healthcare (PRIVHEALTHQUAL) 1.SERVQUAL dimensions 1. Tangibility/image – physical facilities. accurately. technical expertise.
Responsiveness – willingness to help customers and provide prompt service
Empathy – caring. image and appearance of GP Reliability/fair and equitable treatment – ability to perform the service dependably.
6. Tangibility – physical facilities. 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. individualised attention provided to patients by physicians Core medical services/ professionalism/skill/ competence – the central medical aspects of the service: appropriateness.
. Here. we shall use the PRIVHEALTHQUAL scale derived from the MSS scores.
4. individualised attention provided to customers
5. caring. The square of the correlation gives the proportion of criterion variance that is accounted for by its linear relationship with the predictor.
001 255 0.098 0. we conclude that core outcome is not the most important dimension in health care service quality.
. In fact.097 0.100 0. (two-tailed) n Pearson correlation Sig. (two-tailed) n Pearson correlation Sig. “Reliability” includes “careful diagnosis of the patients’ problems”. Correlations between service quality dimensions.210 * 0. This new dimension included items such as “uniform fees and other charges for all patients”. consistent with Sureshchandar et al. Our study supports Carman’s (1990) argument – that SERVQUAL scale items/dimensions need to be modiﬁed to suit particular industry settings. 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. and physician’s willingness to refer patients to a specialist if necessary”.122 255 0. This reﬂected patients’ views that everyone should be treated alike by their GP. the dimension “Reliability/Fair and Equitable Treatment” is the most important. Consequently.175 * 0.000 255 0.’s (2003) studies.119 255 0.’s (2002) and Hellier et al. our research adds to the large body of previous research on service quality.247 * 0.213 * 0. However.IJHCQA 21. (two-tailed) n
What is your evaluation of the overall service quality you receive from your GP? 0. overall service quality evaluation and satisfaction
Note: * Correlation is signiﬁcant at the 0.005 255 0. is not supported – consistent with many studies including Zeithaml et al. (two-tailed) n Pearson correlation Sig. (two-tailed) n Pearson correlation Sig.1
MEDETAN Pearson correlation Sig. (two-tailed) n Pearson correlation Sig.113 255
MEDEEQUI Table VI. (two-tailed) n Pearson correlation Sig. ‘GP’s medical qualiﬁcations’. we suggest that seven service quality dimensions are applicable to private healthcare. therefore. Berry and Parasuraman (1991). a new dimension “Fair and Equitable Treatment”. Thus. followed by the “core outcome”. Hypothesis H1 given earlier. (1990).001 255 0.01 level (two-tailed)
From Table VI. “assurance/empathy” and “equipment and records” dimensions. was associated with the “Reliability” dimension.
Recommendations A number of issues limit our ﬁndings’ generalisabilty. The sample, for instance, consisted of university students, their friends and relatives, patients and their friends and neighbours at a few private GPs medical clinics. There is a risk, therefore, that our sample might not represent the population served by private Mauritian GPs. However, a counterargument is that our sample was geographically spread since university students came from all over the island. Therefore, results might be generalized for the whole island. Nevertheless, our reesults may not be replicable outside Mauritius in that patients’ cultures, private GP practices abroad and other factors including the healthcare system are likely to be different. The sample size (257 usable responses) can be argued to be moderate. However, this number more than satisﬁed the criterion laid out by Basilevsky (1994) and Hair et al. (1999). Another limitation is that a longitudinal study would provide greater diagnostic value than our cross-sectional design. Changes in perceptions and expectations could thus be tracked over time. This research was also limited to the Mauritian private healthcare sector. Further research, therefore, could also focus on studying other service settings.
References Babakus, E. and Boller, G.W. (1992), “An empirical assessment of the SERVQUAL scale”, Journal of Business Research, Vol. 24, pp. 253-68. Babakus, E. and Mangold, W.G. (1989), “Adapting the SERVQUAL scale to health care environment: an empirical assessment”, in Bloom, P., Weitz, B., Winer, R., Spekman, R.E., Kassarjian, H.H., Mahajan, V., Scammon, D.L. and Leay, M. (Eds), AMA Summer Educators’ Proceedings: Enhancing Knowledge Development in Marketing, American Marketing Association, Chicago, IL. Babakus, E. and Mangold, W.G. (1992), “Adapting the SERVQUAL scale to hospital services: an empirical investigation”, Health Services Research, Vol. 26 No. 6, pp. 767-86. Basilevsky, A. (1994), Statistical Factor Analysis and Related Methods: Theory and Applications, John Wiley, New York, NY. Berry, L.L. and Parasuraman, A. (1991), Marketing Services: Competing through Quality, The Free Press, New York, NY. Bloom, P.N. and Reeve, T. (1990), “Transmitting signals to consumers for competitive advantage”, Business Horizons, Vol. 33, July-August, pp. 58-66. Bowers, M.R., Swan, J.E. and Koehler, W.F. (1994), “What attributes determine quality and satisfaction with healthcare delivery?”, Health Care Management Review, Vol. 19 No. 4, pp. 49-55. Boulding, W., Karla, A., Staelin, R. and Zeithaml, V.A. (1993), “A dynamic process model of service quality: from expectations to behavioural intentions”, Journal of Marketing Research, Vol. 30 No. 1, pp. 7-27. Brown, S.W. and Swartz, T.A. (1989), “A gap analysis of professional service quality”, Journal of Marketing, Vol. 53 No. 4, pp. 92-8. Brown, T.J., Churchill, G.A. Jr. and Peter, J.P. (1993), “Improving the measurement of service quality”, Journal of Retailing, Vol. 69 No. 1, pp. 127-39. Carman, J.M. (1990), “Consumer perceptions of service quality: an assessment of the SERVQUAL dimensions”, Journal of Retailing, Vol. 66, Spring, pp. 33-55. Central Statistics Ofﬁce (2003), Housing and Population Census 2000, Ministry of Economic Development, Financial Services and Corporate Affairs, Port-Louis, April.
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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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A.A. L. (1993). L. (1996). 1.IJHCQA 21. Zeithaml. Delivering Quality Service: Balancing Customer Perceptions and Expectations. pp.emeraldinsight.L. NY. 21 No. Vol. Further reading Zeithaml.mu
To purchase reprints of this article please e-mail: reprints@emeraldinsight. A. Journal of the Academy of Marketing Science.. V. Berry. Vol.L.ac. New York.1
Zeithaml. V. V.A. (1990). and Parasuraman. 1-12.A. and Berry. 31-46.. Berry. A. and Parasuraman. pp. Journal of Marketing.L.com Or visit our web site for further details: www. “The nature and determinants of customer expectations of service”.. Corresponding author Rooma Roshnee Ramsaran-Fowdar can be contacted at: rooma@uom. The Free Press. Parasuraman. “The behavioural consequences of service quality”. 60.com/reprints
They identify useful practices and ﬂag potentially harmful ones. Yet.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. “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”. said Dr Ala Alwan. The guidelines address this gap. 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. The guidelines have been developed by staff from 27 agencies through a highly participatory process. 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. The guidelines have been published by the IASC. a committee that is responsible for world-wide humanitarian policy and consists of heads of relevant UN and other intergovernmental agencies. Vice President for Humanitarian Policy and Practice of InterAction. and clarify how different approaches complement one another. “These new IASC guidelines are a signiﬁcant step towards providing better care and support to people in disaster. most individuals have been shown to be remarkably resilient. when communities and services provide protection and support. Assistant Director-General for Health Action in Crises at the World Health Organization. Effective healthcare outcomes
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. Sri Lanka and Sudan among many others involve substantial psychological and social suffering in the short term. and NGO consortia. Recent conﬂicts and natural disasters in Afghanistan.and conﬂict-affected areas worldwide”.
. said Mr Jim Bishop. Indonesia. While this is increasingly recognised. Community healthcare. These can threaten peace. Until now. many actors identiﬁed the need for a coherent. systematic approach that can be applied in large emergencies. which if not adequately addressed can lead to long-term mental health and psychosocial problems. people’s human rights and development. many people involved in emergency response have viewed mental health and psychosocial well-being as the sole responsibility of psychiatrists and psychologists. Red Cross and Red Crescent agencies. the consortium of USA-based international NGOs.
Division for International Protection Services at the Ofﬁce of the United Nations High Commissioner of Refugees. and women’s groups to promote psychosocial well-being. and local contributions to mental health and psychosocial support are easily marginalised or undermined.” “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. Quality healthcare. They emphasize the importance of building on local resources such as teachers. Coordination of mental health and psychosocial support is difﬁcult in large emergencies involving numerous agencies. NGOs can play a major role in this regard. Treating survivors with dignity and enabling them to participate in and organize emergency support is essential. healers. Deputy Director.int
Future oncology healthcare strategy on the agenda of the Portuguese EU council presidency
Keywords Healthcare strategy. 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.1
“The new guidelines present a major step forward to much better protect the mental health and psychosocial well-being of displaced persons using an integrated approach in collaboration with all partners” said Ms Ruvendrini Menikdiwela. The guidelines stress that the way in which humanitarian aid is provided can have a substantial impact on people’s mental health and psychosocial well-being.who. They focus on strengthening social networks and building on existing ways community members deal with distress in their lives. The guidelines include attention to protection and care of people with severe mental disorders.IJHCQA 21. as well as access to psychological ﬁrst aid for those in acute distress. remarked: “Achieving improved psychosocial support for populations affected by crises requires coordinated action among all government and non-government and humanitarian actors. Head of the Health and Care Department at the International Federation of Red Cross and Red Crescent Societies. The guidelines have a clear focus on social interventions and supports. including severe trauma-induced disorders.” said Ms Manisha Thomas. where cancer will be an important part of the agenda. These guidelines give sensible advice on how to achieve that. health workers. ESMO
. For further information: www. 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. Dr Bruce Eshaya-Chauvin. focusing on the topic of health and migration. Affected populations can be overwhelmed by outsiders. acting Coordinator of the International Council of Voluntary Agencies.
we will be able to achieve the expected relevant outcome: survival. as well as newcomers”. Director of the ESMO Political Ofﬁce in Brussels. morbidity and mortality worldwide. Professor Mellstedt continued. this Round Table will address crucial issues in terms of the EU health agenda. Appropriate tools will need to be identiﬁed for the proposed policies to be effectively implemented. which are built on large coalitions and involve the necessary sectors. ESMO. and . ESMO President. said Professor Mellstedt. “The impact of this meeting will inﬂuence the future oncology healthcare strategy throughout the European Union”. “The selection of such topics reﬂects the importance politicians place on assuring best quality healthcare. health determinants. comprehensive cancer control plans consisting of a variety of activities and strategic approaches. to be a key partner in this meeting for aspects related to cancer. such as facing speciﬁc health problems. health services and patient mobility. with a wide expertise. Cancer is one of the major causes of disease. Although great scientiﬁc progress has been achieved in oncology and continues to be achieved.
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. and by advocating together to get support and the appropriate political commitment. together with the Portuguese Presidency. member of the MAC (Members of the European Parliament Against Cancer). . National Coordinator of Oncological Diseases in Portugal. ESMO. for the prevention and control of cancer. better quality of life. will stress the following instruments: . and Mr Alojz Peterle. Professor Mellstedt said. and patient satisfaction”. Under the broad theme of creating a “European Health Strategy”. “Only by sharing expertise and exchanging best practices in Europe. said Pascale Blaes. and its connections with other speciﬁc and global issues under discussion. “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”. the experts and the key forces gathering in Lisbon will call upon the European institutions to put cancer on the political agenda as a priority and will request the national governments to develop policies. “The Portuguese representatives. population-based cancer registries. including a comprehensive overall strategy. a service that touches the lives of every single EU citizen. he said. The Round Table session on cancer will be chaired by Dr Joaquim Gouveia. screening programs. “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”.has been invited by Dr Joaquim Gouveia. The meeting will open with a welcome address by Professor Hakan Mellstedt. As a main actor in the ﬁeld.” The common objective of the meeting will be to create capacity building for developing and implementing effective policies and programs. cancer remains a huge public health challenge and a tremendous threat. with prominent participation of Dr Marija Seljak. “It will certainly be complicated but is highly challenging”. Slovenian Public Health Director. “The interactive format of the meeting. acknowledged Professor Mellstedt.
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’”. Kay Usher. The combination of performance data. the EQ5D patient-reported outcome measure compared to a major new normative database. Quality improvement measures
UK hospitals can now combine their clinical data with both patient-reported health outcomes and a measurement of patient experience.IJHCQA 21. target and evaluate quality improvement initiatives.1
will guarantee a high value contribution to the global debate on cancer and health in Europe. and judge them against national benchmarks. the leading independent provider of healthcare information. said: “This combination will provide a patient-focused picture of the quality and effectiveness of the service provided by a clinical specialty over time. For further information: www. applied to particular clinical specialties. for the ﬁrst time. The new service. is being developed jointly by CHKS. and bespoke patient experience questionnaires developed to national standards by the Picker Institute.info/
Quality improvement: patient-reported outcomes and experiences now integrated with clinical data for the ﬁrst time
Keywords Patient feedback.” The data tools included are: CHKS’ admitted patient care data set. the charity which is a leading authority on capturing patient and staff feedback and using it to improve services. Clinicians will be able to see how their own activity compares to the health outcomes reported by patients. Hospitals will be able to measure the three sets of indicators.medicalnewsblog. over time. correlate activity performance data with patient health and patient experience. Healthcare standards. business manager at the Picker Institute. “Patient Driven Quality”. outcome data and patient experience data gives UK hospitals the ability to: . By staging the measurements hospitals will be able to judge the impact of quality improvement measures through the litmus test of what difference they are making for patients.
. . and the Picker Institute. and what patients say about their experience of receiving that care and treatment.” 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. Paul Robinson. external relationship manager at CHKS. said: “There is considerable interest within the health service in the potential of PROMs – patient-reported outcome measures.
and assistance with eating. coordinated on behalf of the Commission by the Picker Institute.000 patients at 167 acute and specialist trusts responded to the survey. In autumn 2006. Performance standards. Anna Walker.pickereurope. Of the patients who indicated that they needed help eating. . Just 2 per cent of patients said the overall care they received in hospital was “poor”. . few patients rated the food as “poor” – just 2 per cent in one trust. There was variation in how trusts scored on single-sex accommodation. Quality improvements
Patients have given a vote of conﬁdence in the overall care provided by NHS hospitals with nine out of ten people surveyed by the Healthcare Commission rating it as “excellent”. these ﬁgures varied between 2 per cent and 42 per cent. This compares with 92 per cent in the 2005 survey. . The results also highlighted considerable variation in the performance of acute trusts on a range of issues relating to dignity in care. The ﬁndings are from the Commission’s inpatient survey. 11 per cent of patients nationally said they shared a room or bay with a patient of the opposite sex. 80. Among trusts. . or more. There were encouraging signs on cleanliness with 93 per cent of patients saying their room or ward. mixed-sex accommodation. Chief Executive of the Healthcare Commission. But in most other trusts. There were 30 trusts where one in ﬁve. . but we must never forget that most patients
. 84 per cent in this survey compared with 78 per cent in 2005. And compared with the Commission’s previous inpatient survey in 2005. These include the standard of food. the biggest test of the experiences of patients in NHS hospitals in England. The survey highlights include: . “very good” or “good”.org
Patients give vote of conﬁdence in overall care provided by NHS hospitals in largest national survey
Keywords Patient satisfaction. answering calls for help. and benchmark their own performance and reputation against the national data set. 20 per cent said they did not get enough.
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For further information: www. More patients said they waited six months or less for planned admissions. said: “We all hear a lot of negative comment about the NHS..
demonstrate efforts to meet standards for better health. was “very clean” or “fairly clean”. Looking at planned admissions only and excluding those who stayed in critical care units. more people responded positively to questions about cleanliness and efforts to control infection through handwashing. patients rated the food as “poor”.
“Patients have the right to expect all hospitals to get the basics right. trusts need to improve the patient’s journey through all parts of the hospital. As part of this. all contractors will be asked to complete an annual patient satisfaction survey.healthcarecommission. But.1
have consistently rated the overall quality of their care as good or excellent. to be published later in the year. It is also clear that for a signiﬁcant minority of patients. Options (1) and (2) would only be recommended if a contractor had the time. where there are problems it seems as if there are a minority of trusts that are letting the rest down. (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.IJHCQA 21.” The Commission will feed the results of the inpatient survey into its annual assessment of NHS trusts. There may be scope to reduce this by looking at delays in admissions units. (1) Print. (3) Outsource the print.org. PSNC and the Department of Health are deciding on the ﬁner detail of the survey and an announcement is expected soon. implement and evaluate the survey yourself. it has inspected 23 trusts where performance data raised particular questions. 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. “Looking at waiting times. The NPA will have member support ready as soon as the announcement is made. Results should be fed in to PCTs by the end of the ﬁnancial year – therefore the ﬁrst set will be due by March 2008. the National Pharmacy Association (NPA) will be offering its members three levels of support to match these options. from arrival at A&E to discharge. which will form one of the Clinical Governance requirements. evaluation and reporting of results. Continuous improvement
Under the new community pharmacy contract in England and Wales. like offering help with eating and answering calls for assistance. For example. For further information: www.uk
Patient satisfaction surveys made easy: Department of Health
Keywords Clinical governance. “The results also suggest that we need a fresh drive to tackle a set of issues related to treating patients with dignity. There are likely to be two or three options available to contractors.
. implementation. When the requirement is introduced. which uses information to target inspections and ultimately leads to an annual performance rating. expertise and resource in-house to cope with a survey. the NHS is performing below standards on segregated accommodation. Completion will therefore be mandatory. too many patients still say they wait a long time while being admitted. Patient experience.
The £3. Patient empowerment
Patients are being given more choice over where they are treated. Healthcare standards. provides pharmacy contractors with a validated questionnaire which focuses on the ﬁve domains of patient experience as deﬁned by the Department of Health.The STANDpoint system from Customer Research Technologies conducts all the research electronically and provides speedy analysis results. This is a practical guide showing how to design. in-store materials to explain the survey to patients. sealable envelopes to ensure patient conﬁdentiality. 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. A new web site is being launched in an attempt to strengthen patient choice. CRT simply delivers the device to the pharmacy and collects it two weeks later. (CFEP) UK Surveys. says: “A resource pack will be available to members free of charge. Ministers also hope it will lead to detailed data on clinical outcomes being published – to date only heart surgeons reveal performance statistics. 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. Results are returned to contractors within the next ﬁve days. including benchmarked data and patient comments will then be produced. a ballot box.
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NHS web site aims to boost choice
Keywords Patient choice.
. However. Simon Ellison. The completed questionnaires will be analysed and the results fed back to the contractor. we are conﬁdent that the feedback members will gain from their patients will mean that they gain a high return on their investment. please contact us on r. The NPA has also commissioned CFEP to produce a resource pack to guide its members through the complex area of patient surveys.co. will be validated. from encouraging patients to complete the questionnaire to the analysis and actions arising from the results. NPA Commercial Director. 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. 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.” Raina Jordan. an independent company that specialises in producing patient feedback surveys for healthcare professionals. implement.uk”. available in various languages.6m NHS Choices web site will include information on issues as varied as waiting times. A high quality report of the results. The entire survey process. hospital ratings and general cleanliness. analyse and evaluate the results of the survey. pens and a large self-addressed envelope in which to return the completed questionnaires. The service includes the supply of an appropriate number of questionnaires. More than that. It is aimed at helping patients choose where they want to be treated when they need non-emergency surgery.
One of the problems with the internet is that some of the information about health is top quality and some of it is rubbish. The multi-media web site has sections giving advice on healthy lifestyles and also allows users to carry out an online health check.1
Patients have been given a choice of where they can go to be treated for non-emergency treatment since last year.” For further information: www. patients are given a choice of at least four local hospitals and the top-performing foundation trusts. which was already available via a Healthcare Commission web site. The Royal College of General Practitioners says that services are confusing. The health secretary said: “We now have to do this with other procedures. 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. While the RCGP recognises that good quality urgent care exists in some areas. It has detailed information on 40 of the most common diseases and also uses data compiled by the Healthcare Commission on hospital performance. GP practices and health organisations to improve urgent care services for patients. The RCGP plan recognises the pivotal role of GPs and includes across-the-board recommendations for the Department of Health.with the internet age resisting progress is fruitless.uk
Signposting the way to better out of hours services for patients
Keywords Healthcare information. .IJHCQA 21. And that will be extended to all specialities by April next year. including ratings and MRSA rates. fragmented. Health Secretary Patricia Hewitt said: “We know patients and the public are thirsty about getting information on health. of highly variable quality and that urgent action is needed to restore conﬁdence in out-of-hours services. Service delivery. “What NHS Choices will do is give the public access to the best information about health. it highlights a clear need for better signposting as patients are often unable to determine
. Primary Care Trusts (PCTs). . At the moment. 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. 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. Later in the year people needing hip and knee operations will be able to choose from any hospital. 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.nhs.” Ms Hewitt is also hoping the web site will push doctors into releasing information about the results of treatment. The web site includes death rate data from individual heart units.
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. and to kickstart action in improving urgent care services. a practising GP in Leicester. (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
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.” 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. 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 will shortly launch a national Out of Hours Clinical Audit Toolkit. (4) Quality standards including clinical outcomes to be monitored and enforce. (2) All GP practices to have a system for responding to and dealing with urgent care during surgery hours. RCGP Chairman Professor Mayur Lakhani. walk-in centres and minor injury units to foster integration and co-ordination of care between providers. Athough no longer contractually responsible for out of hours work. (7) The Department of Health to make urgent care a priority and set a clear national strategy. To address this. planning and support for urgent care and out of hours services.” “Nonetheless we acknowledge that this has been a difﬁcult issue for the profession and that many GPs agonised over their decision to opt out of 24 hour contractual responsibility. emphasising the necessity for high clinical standards. (3) PCTs to develop Urgent Care Networks comprising GP practices. The action plan calls for: (1) Care to be conﬁgured around the needs of patients with better signposting for access. and training opportunities in urgent care for GP Registrars. 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. which will enable PCTs to monitor clinical outcomes. (5) Engagement with local GPs and recognition of their key role in leadership. (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. (6) Stronger multidisciplinary urgent care teams whose members have been trained to nationally agreed standards.the most appropriate service to access. It has also identiﬁed concerns about variation in quality of out of hours services. GPs are still involved in OOH rotas and a large proportion of OOH is still provided by GP co-operatives. (8) Emergency care practitioners to be trained to a deﬁned national standard including an assessment of competence.
and this plan will go a long way towards demystifying the maze that currently exists. hospitals can improve survey responses. Chair of the RCGP Patient Partnership Group. 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. Through an increased reliance on management companies who provide environmental services (EVS) to help enhance the patient experience. not the lucky few. Some PCTs have managed to get it right so why not others? “The Out of Hours Toolkit will help to ensure that the spotlight remains on high standards of patient care – measurement of clinical quality is essential. As the proven experts in providing urgent care. Any attempt to downgrade the role of GPs will lead to further diminution of quality and put pressure on other parts of the NHS. Chief Nursing Ofﬁcer and
. says Laura Fortin. Professor Lakhani said: “A step change in policy is needed. 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. We urge that PCTs be held to account for the quality of their out of hours services.medicalnewstoday.1
GP Registrars. Clear signposting to appropriate care is essential. Being ill in the middle of night is frightening experience and patients need to be sure the NHS will be there for them. said: “Patients are very confused and bewildered about which services may be available to them outside GP surgery appointments. Financial management.” For further information: www.” Ailsa Donnelly.com
Outsourcing improves patient satisfaction
Keywords Patient experience. “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. Urgent care competencies should also be incorporated within GP appraisal and CPD. “The majority of care is still provided by GPs. 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. “Everyone has struggled with patient satisfaction and the surveys in general. 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. it is important that GPs have a strong inﬂuence on urgent care. but we see HCAHPS as an opportunity”.IJHCQA 21.
accomplishing gains in EVS often proves elusive. can transform that facet of hospital operations into a high-scoring asset when surveys get ﬁlled out. “There are studies out there that show a deﬁnite correlation between patient satisfaction and your bottom line. St Joseph was one hospital who chose this route. and management has to seek out what is best for their operation”. Dirty places tend to trigger a sense of doubt. “It made sense for us to go with Medi-Dyn because we share a similar vision and value system with them. and cleanliness of the hospitalthe HCAHPS survey provides a standardised instrument and data collection methodology for measuring patients’ perspectives on hospital care. Celebrating its 30th birthday. states St Joseph’s Fortin.” Composed of 27 items that encompass critical aspects of the hospital experience – such as the responsiveness of hospital staff. 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.2 million ft2 St Joseph Medical Center in Houston. McKee is part of the Phoenix.” The challenge of improving EVS Coupled with the typically low retention rate of EVS employees and hospitals traditionally lacking systematised processes for this department. 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. “Cleanliness is an important part of the healing and caring environment”. “EVS is an important part of the patient’s experience in the hospital”. uncertainty and a feeling of scepticism about the people and services being provided. quietness. Assistant Administrator at McKee Medical Center in Loveland.
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. In response. Texas. comments Fortin.USA.Chief Operating Ofﬁcer at the 1. Colorado. Founded in 1979 and based in Englewood. and how nice the person was who cleaned their room – these are things they can easily quantify on a survey. “I believe each facility is unique. At that point. Colorado. many administrators and operating ofﬁcers are opting for quick solutions. Any hospital that wishes to remain in the running must act now to position itself as a leader among survey respondents. and EVS plays a key role in patient satisfaction. “Clean areas invoke a sense of conﬁdence and a positive feeling about the people and services. by virtue of the fact that they specialise only in healthcare EVS. so we work really well together”. EVS plays a crucial role in meeting the patient’s expectations of excellent patient care. “Patients can deﬁnitely assess how clean their room is. Typically. and upping the “cleanliness” factor is an effective means of enhancing the perception of competency. administrators at some hospitals are increasingly turning to management companies and consultants who. agrees Marilyn Schock. which encompasses 20 hospitals and other facilities that offer an array of medical services. Given such a short timeline. continues Schock. so housekeeping deﬁnitely has a role”. Arizona-based Banner Health organization. Medi-Dyn is a privately held corporation providing environmental and laundry management services exclusively to the healthcare industry.
000 per year while improving quality of service. When you have that. for example. where more than 99 percent of patient responses have ranked EVS services as good or excellent since 2001. Texas. both managers and all direct labor staff are employed by the contractor under a full-service option. The attainment of such successes hinges on proven quality control systems. Under the guidance of Medi-Dyn. Through such feedback mechanisms as: patient interviews. is phenomenal.
. so do HCAHPS surveys Early positive returns on patient surveys from hospitals that rely on EVS management experts prove hard to ignore. At the McKee Medical Center. “Typically. is the fact that it can yield a return on investment that is often superior to managing the department from within. the key is to get the right management person”. so effective training in meeting patients’ expectations must extend to all levels of the department. Fortin reiterates.1
In a management-only structure. “and housekeeping has blown all other departments off the map. Bill Walles. In other situations. where patient satisfaction scores for EVS are consistently above the 95th percentile. Natchez Community Hospital in Mississippi. you can’t fail”. That was up from the 70th percentile on courtesy and the 65th percentile on cleanliness when Medi-Dyn began the contract in June 2003. “The Medi-Dyn Director here. Gains in EVS management can even possibly inﬂuence capital outcomes. the contractor provides the on-site management needed to effectively lead daily operations. really believes in this and understands what we are trying to accomplish within our EVS department. “We only utilise Medi-Dyn for its management services – the employees are our own but they report directly to the Medi-Dyn manager”. Other hospitals that chose the same option as St Joseph and McKee include Memorial Hermann Hospital in The Woodlands. one particular hospital reduced its full-time-equivalent EVS staff from 72 to 46. Press Ganey scores in third quarter of 2006 for “courtesy” and “cleanliness” were in the 99th percentile.IJHCQA 21. When EVS “shines”. and. the level of quality can consistently improve over time. administrative reporting procedures and ﬁnancial accountability. One of the lesser-known beneﬁts of turning to an EVS management expert to help enhance HCAHPS results. and its managerial staff from eight to four. “We started a competition between departments: nursing competes against each other on scores each month. exposing new hires to our goal of improving the patient experience. saving over US$350.” “In the selection of any vendor. This allows hospital administration to concentrate on other facets of patient care and improving the facility’s ratings.” “Medi-Dyn’s expertise combined with our culture of excellence ensures a seamless teamwork approach. He is very involved in patient satisfaction. notes Schock. department head inspections. EVS staff represents a tough population for retention. maintaining EVS as the hospital’s top-scoring department. At the same time. says Fortin. physician questionnaires. so they are doing something right”. Intermediate levels of integration also exist. as well as ancillary departments”. it is the EVS worker who frequently comes into direct contact with patients.
St Joseph’s became a part of Hospital Partners of America. “The cleanliness deﬁnitely affected their overall impression of our facility”. and the ‘face’ that you want to put out there is one of cleanliness”.healthservicetalk. every person that came in that was interested in buying the hospital could not believe how clean it was”. but the customer-service gains you achieve. “Perception is everything. North Carolina based healthcare services company that owns and operates general acute care hospitals in partnership with leading physicians throughout the USA. “EVS plays a key role in how your hospital is rated. As of August 2006. a Charlotte.coml
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. For further information: www. it improves the possibility a patient will return or recommend your services”. recalls Fortin. agrees Schock.“When our hospital was up for sale. does not end with just good ‘H-caps’ scores.
Warne and S. Collins and S. . A long term affair. when individuals have become consumers of health care services. Patient-centred.IJHCQA 21. McAndrew. J. McAndrew. They are descriptions of the books. Warne. ISBN 13 9781846191763 Keywords Patient experience. Methods and Practices of Experience-based Design Paul Bate and Glenn Robert Radcliffe Oxford ISBN 10 1 84619 176 9. McGregor. . J. Stronach . Using patients’ experiences in medical education: ﬁrst steps in inter-professional training?. . E. P. . and meets a growing demand for educational approaches that address the perspectives of patients and carers. A. Morris. E. Hepworth. S. the focus is usually on “after the event” accounts . D. Quality standards
Experience Based Design (EBD) is a new way to bring about improvements in healthcare services by being user-focussed. O’Neill. This book ﬁlls that gap. or in the training of health care practitioners. Nursing. Skidmore. Professional education
Current health policy places an emphasis on the greater involvement of health service users and carers in all aspects of their care.
Bringing User Experience to Healthcare Improvement: The Concepts. S. Kilminster. based on information provided by the publishers. Stark and I. Nursing policy paradoxes and education implications. There is little patient involvement in “before the event” experiences such as planning to meet health care needs. Horne. G. . provision and evaluation.stepping forward. Contents include: . Thislethwaite and B.i.
. Costello and M. Ewart. J. .
Using Patient Experience in Nurse Education Edited by Tony Warne and Susan McAndrew Palgrave Macmillan ISBN 9781403934017 Keywords Healthcare policy. However. Patient involvement. Beyond the tick box: providing a strategic direction to patient involvement in education. S. Healthcare improvement. A. . Canham. The person as a life expert: this is not a love song. student-centred learning in community and primary care nursing. F. carers. H. Patients as teachers: utilising patients in classroom teaching. education and professionalisation in a contemporary context. healthcare professionals. including planning.e. Facilities. McAndrew. these are not reviews of titles given. Simpson. Looking back. Samociuk and S.1
Please note that unless expressly stated.
Using stories and storytelling to reveal the users’-eye view of the landscape Patterns-based design: the concept of “design principles”. and quality improvement and organisational development specialists in healthcare. It offers recommendations for the future and many interesting points for discussion. patient satisfaction is a big part of that evaluation.family and friends are all involved in the patient experience and systems and policies need to adapt to take this into consideration.” Lynne Maher. Methods: becoming a disciple of experience. By exploring the underlying concepts. it’s need to know! It gives you action steps in all areas of the practice. Through anecdotes and real-life examples from practicing physicians. 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. this exciting guide offers a unique approach to healthcare customer satisfaction. Bringing the user experience to health care. Patient satisfaction
In today’s health care environment. the very people who are experiencing them. Experience-based design: tools for diagnosis and intervention. This compelling book illustrates a new approach to redesigning health systems so that they truly meet the needs of patients and staff. .). Patient expectations. . “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. . too will ﬁnd the book inspirational. Contents include: . methods and practices of EBD. . . It will be of great interest to health and social care management. you will learn
. The intellectual roots of experience design. having satisﬁed patients just is not enough you are now being judged by payers and compared to other providers. Future directions for experience-based design and user-centred improvement and innovation. Concepts: a quiet revolution in design. So what’s different? . This is a must for all health care staff. health and social care policy makers and shapers. particularly directors of service improvement in hospitals and directors of nursing. Patient groups and national organisations. Improving Patient Satisfaction Now: How to Earn Patient and Payer Loyalty explains why understanding and meeting patient expectations is not only nice to know.
Improving Patient Satisfaction Now: How to Earn Patient and Payer Loyalty Anne-Marie Nelson Jones & Bartlett ISBN 0834209225 Keywords Healthcare evaluation. . . .
and practical techniques to increase patient satisfaction in this updated edition. How to earn raves from patients and payers. Making wrongs right. .
. Some things change. Lighting and leading the way. . Winning practices for loyal patients. a more productive and committed staff. Set standards for a great ﬁrst and last impression. .1
how to develop higher patient satisfaction. Create a schedule that satisﬁes everyone! . . . . Want compliant patients? Communicate and educate. The telephone connection. Contents include: . but patient expectations remain the same. . Empower your patients with knowledge. Empowerment? It’s just plain old trust! . . Want to communicate better? Listen well. . Motivation: it takes more than a paycheck. The diversity imperative hits health care. . . . Now is the time to create loyal patients and winning practices. more compliant patients.IJHCQA 21. Where does clinical quality ﬁt in the picture? . For practice administrators and managers only: how to gain physician participation. Eighteen ways to learn what patients want. . . How do you rate when you’re face to face with your patient? . Success is a team effort. .