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Abstract In recent years healthcare have been treated as business organizations.

The present paper proposes a conceptual model to measure the patient perceived service quality in healthcare. The proposed model contains 10 dimensions and is based on existing literature in healthcare services; and helps in improving our knowledge to identify the components that are important and can influence quality. Moreover, this research will improve our understanding of service quality and assists practitioners such that they are meet in their daily operations.

Acknowledgement At outset of this project we would like to thanks the Al-Mighty Allah, who has been gave us patient, skills and mainly sound health to complete this project. Without his help this is totally impossible to finish this project within time frame. We feel privileged to have had the opportunity to work with our Subject teacher and Lecturer Md. Rafiqul Islam on this project. His guidance and constant encouragement during the course of this eventful journey was critical for developing key insights. The numerous discussions on topics related to this research and other areas have allowed me to grow in many different ways. We would also like to thank also my course mate and fellows for preparing this project. Collecting information, sorting and finally prepare this output is huge task. I feel very much relief and satisfied to finish this project paper.

Introduction Healthcare is a rare service that people need but do not necessarily want but, remarkably healthcare is the fastest growing service in both developed and developing countries. The traditional services that once dominated the Service sector lodging, foodservice, and housecleaning have been increasingly supplemented by modern banking, insurance, computing, communication, and other business services; and the interest in the measurement of service quality is understandably high in addition to the delivery of higher levels of a service quality strategy being suggested as critical to service providers' efforts in positioning themselves more effectively in the marketplace. Service quality has been revealed as a key factor in search for sustainable competitive advantage, differentiation and excellence in the service sector. Besides, it has been recognized as highly important for satisfying and retaining customers. Accordingly the two questions firstly,

What is perceived service quality?

And secondly,

How must service quality be measured?

Have been debated by academics over the last three decades now and is of utmost interest. Moreover, the ongoing debate on the determinants of service quality and issue such as Is there a universal set of determinants that determine the service quality across a section of services? remains unanswered. Additionally, there is concern for the identification of determinants of service quality. In a consumer-oriented culture where healthcare delivery is patient-led and commoditized, the patient should be the intermediary of the quality of healthcare. Thus the purpose of the present paper is to develop a conceptual framework for measuring hospital service quality, expending the existing models and literature on healthcare services to benefit academicians, practitioners and researchers to enhance the understanding of patient perceived hospital service quality addressing this gap in literature as there are a few reliable and valid instruments available; and many service providers are implementing measures that are not aligned to the complexities of the health care setting. Consequently understanding of service quality assists practitioners to meet the requirements in their daily operations. SERVQUAL is designed to measure service quality as perceived by the customer. Relying on information from focus group interviews, Parasuraman et al. (1985) identified basic dimensions that reflect service attributes used by consumers in evaluating the quality of service provided by service businesses. As an example, among the dimensions were reliability and responsiveness, and the businesses included banking, credit cards and appliance repair. Consumers in the focus groups discussed service quality in terms of the extent to which service performance on the dimensions matched the level of performance that consumers thought a

service should provide. A high quality service would perform at a level that matched the level that the consumer felt should be provided. The level of performance that a high quality service should provide was termed consumer expectations. If performance was below expectations, consumers judged quality to be low. To illustrate, if a firms responsiveness was below consumer expectations of the responsiveness that a high quality firm should have, the firm would be evaluated as low in quality on responsiveness. Parasuraman et al.s (1985; 1988) basic model was that consumer perceptions of quality emerge from the gap between performance and expectations, as performance exceeds expectations, quality increases; and as performance decreases relative to expectations, quality decreases (Parasuraman et al., 1985; 1988). Thus, performance-to-expectations gaps on attributes that consumers use to evaluate the quality of a service form the theoretical foundation of SERVQUAL. The purpose of this paper is to provide a review of the SERVQUAL research on service quality in the following areas: (1) definition and measurement of service quality, and (2) Reliability and validity of SERVQUAL measures. The issues we address are of importance to both service managers and researchers. Service quality is important to marketers because a customers evaluation of service quality and the resulting level of satisfaction is thought to determine the likelihood of repurchase and ultimately affect bottom-line measures of business success (Iacobucci et al., 1994). It is important for management to understand what service quality consists of, its definition, and how it can be measured. If management is to take action to improve quality, a clear conception of quality is of great value. A vague exhortation to customer contact employees to improve quality may have each employee acting on his/her notion of what quality is. It is likely to be much more effective to tell a service contact employee what specific attributes service quality includes, such as responsiveness. Management can say, if we can improve our responsiveness, quality will increase. Valid and reliable measurement of service quality is vital to quality management. As an illustration, if employee training or a change in work procedures to enhance quality is undertaken, it would be important to measure customer perceptions of quality before and after the quality action was taken to see if the goal had been achieved. A reliable measure is one that is consistent, that is if quality did not change, the measure of quality would not change. A valid measure is a measure in which the score generated by the measurement process reflects the true value of the property that one is attempting to measure. As an example of the importance of reliability and validity, consider Jones whose weight was measured in a physicians office at 165 pounds and the physician said, You should be no more than 160 pounds. Jones tries to lose weight, but Jones scale at home is unreliable and poor Jones wonders why the diet works one week, but not the next. Next, suppose Jones scale was not valid, low by five pounds; Jones thinks the problem is solved, but it is not.

Definition and measurement of service quality (SQ) Definition of SQ Parasuraman et al. (1985) suggested three underlying themes after reviewing the previous writings on services: (1) service quality is more difficult for the consumer to evaluate than goods quality, (2) service quality perceptions result from a comparison of consumer expectations with actual service performance, and (3) Quality evaluations are not made solely on the outcome of service; they also involve evaluations of the process of service delivery. Parasuraman et al. (1988) defined perceived service quality as Global Judgment, or attitude, relating to the superiority of the service. Dimensions of Service Quality Dimensions of service quality (SERVQUAL) were originally introduced by Parasuraman, A, Valerie A Ziethaml and Leonard L Berry in 1955 in the area of service quality. SERVQUAL was developed based on the view of the customers assessment. This assessment has been conceptualized as a gap between the Customers expectations by way of SERVQUAL, from a class of service providers and their evaluation of the performance of particular service providers. Tangibles The hospital should have modern equipment. The hospital should have visually appealing facilities. Doctors and other employees should have a professional appearance. The hospital should have visually appealing materials associated with the service.

Reliability The hospital should provide services as promised. The hospital should maintain error-free records.

Responsiveness Doctors and other employees should offer prompt services to patients. Doctors and other employees should be willing to help patients.

Assurance The hospital is able to handle patients problems. Doctors and other employees are able to instill confidence in patients. Doctors and other employees must be courteous at all times. Doctors should have the knowledge to answer patients questions.

Empathy Patients should be given individual attention. The hospital should have convenient consultation hours. Doctors should deal with patients in a caring fashion.



Service Quality

Sutiational Factors


Empathy Product Quality Tangibles

Customer Satisfacti on

Customer Loyalty


Personal Factors

Customer Perception of Quality and Customer Satisfaction

SERVQUAL Model and Hospital Service quality is a focused evaluation that reflects the customers perception of elements of service. The SERVQUAL model has been used across various service industries including hospitals to assess and improve service quality. In todays world of fierce competition, rendering quality service has become managements top-most competitive priorities and a key determinant of return on investment as well as cost reduction. In healthcare organizations, the role that patients play in defining what quality means is now crucial. Owing to information asymmetry that characterizes patient-provider interactions, although the technical aspects which form the what of a medical service are difficult for patients to evaluate, the functional aspects about how services are delivered form important soft components of service delivery. Evidence suggests that functional quality is usually the primary determinant of patients quality perceptions and is the single most important variable influencing consumers value perceptions, which in turn, affect their intentions to purchase products or services. Service quality is a focused evaluation that reflects the customers perception of elements of service. Parasuraman, Zeithaml, and Berry (1988) developed a tool to measure service quality the SERVQUAL. The SERVQUAL has been tested across a number of service industries and its applicability to the hospital environment has also been assessed in the Western settings. However, such evidence from Indian hospital sector, and specifically medium sized hospitals, is sparse. Materials and Methods Study Context: This study has been conducted at a renowned private multi-specialty hospital. The hospital is functional since over few years and an established corporate group manages the business after its takeover for years. The hospital has a bed strength of 110 beds, employee strength of about 400 and average bed occupancy of over 70 per cent. The Hospital has all kind of modern diagnosis equipments and has experience doctors, nursing staffs and management team. Catering service and medicine facility is standard. It produces its patients foods in-house procurement. Specially most of the doctors and nursing staffs are experienced in abroad.

Questionnaire, Development and Structure The developers of SERVQUAL have suggested that it can be adapted or supplemented to fit the characteristics or specific research needs of a

particular organization. Hence, we subjected the scale to a preliminary evaluation. Inputs were received from senior management personnel and an academician. The decisions to modify the scale were based on relevancy of the questions to hospital services and ability of the patients to respond to those without undue frustration or confusion. The Gap model based on the SERVQUAL depicted in figure one defines service quality as the difference between perceptions and expectations. It advocates that as service providers perceptions are important in design and delivery of services while those of patients are important in the evaluation of services, the views of both parties are important if a thorough understanding of service quality is to be gained. Though the SERVQUAL model considers management in the provider side, which is characterized by mostly not very large hospitals with very small management teams, this study has also used staff members instead of only managers. (Henceforth, management and staff are together referred to as staffs). The questionnaire included a section on expectations and another on perceptions. Each section consisted 20 items. These were derived from the Yousseef et al modified version of the SERVQUAL. The instrument is added with a section three on demographics (gender, age, education and income) and a final question on overall service quality of the hospital to be rated on a five point scale. All questions were close ended. The scale used is a five point Likert scale with ends anchored strongly disagrees to strongly agree. Though the original SERVQUAL scale uses a seven point Liker scale, and 22 items this study has used a five point scale with 20 items as literature shows no association between the number of items, method of administration and sample size and the reliability of the instrument. The present ability of the questionnaire was given due attention. Considering that the scale has 20 statements related to expectations from excellent hospitals and another 20 about perceptions about the study hospital, common terms were used for statements. These terms were used

instead of repeating the term for each of those statements as has been done in previous research. In the expectation scale the term excellent hospitals will have and personnel at excellent hospitals will was printed as a common term for the 11 statements and nine statements following these respectively. Similarly, in the perception scale the common terms were this hospital has and personnel at this hospital. Another questionnaire was developed for staffs. It included the same statements as those in the questionnaire for patients, except that the respondents were asked to mark patients expectations and perceptions, as understood by them. The common terms, as described above, hence in the staffs questionnaire were patients expect excellent hospitals to and patients expect personnel at excellent hospitals to The questionnaires were made available in English language after pilot testing. A constant sum scale to determine relative importance of quality dimensions was put as a separate section as in the originally designed questionnaire. However, during the pilot testing it was realized that almost all respondents, in spite of explanation, marked the importance in percentages instead of from a total of 100 units as was desired. It was then decided to omit this section to avoid difficulty in response and also to reduce the length of the questionnaire and rather use regression analysis to reach the objective. Sample and data collection: A total of 100 patients who had a stay of at least two days were voluntarily enrolled in the study on the day of/evening prior to discharge from the hospital. Patients were requested to fill the responses on the bedside after ensuring that they were comfortable. Each patient took about 20 minutes to complete. Of the 100 forms filled, five were found to be incomplete, and were excluded from analysis. All participants were approached with respect and researcher followed ethical principles in research. Informed consent was obtained from each participant. The questionnaire for staff members was administered during their duty hours. Staff members included in the study was nurses, doctors- generalists

as well as specialists, front office staff, patient assistants and those from accounts, marketing, human resource and billing departments. Staffs who have worked for a minimum of three months at the study hospital were invited to participate in the study. Each staff member took about 12 minutes to complete the form. The data collection for staff and patients was carried out simultaneously during the first quarter of 2009. Results and Discussion Patients: Male respondents represented about 57 per cent of the patients surveyed. The study had 52 per cent patients aged below 40 years. The largest group (25 per cent) being in the 21-30 years age group, the smallest group (five per cent) was aged below 20 years while the elderly formed about 12 per cent of respondents. Majority of the patients were educated up to secondary school. Of all the survey questionnaires completed, 39 patients (41 per cent) did not state their income and were labeled 'Not Stated'. Excluding these, majority earned below Rs. 20,000 per month. The average length of stay of the patients as on the day of the study was four days Staffs: The staff members interviewed included 26 nurses, nine generalist and 14 specialist doctors, and 11others who were staff from other departments as mentioned above. The staff members surveyed included 65 per cent females and 35 per cent males. The higher number of female participants is representative of the hospital industry. Of the staffs interviewed most (81 per cent) were less than 40 years of age. Their average work experience in the hospital industry was 10.6 years while that at the study hospital was 7.8 years. Validity and Reliability of SERVQUAL Instrument Considering the objectives of the present study and the recognized instability of the dimensionality of SERVQUAL, it was considered necessary to address the construct validity of the scale. It is noteworthy that in the literature about SERVQUAL, there is no agreement as to which scores (expectation, perception or quality gap scores) should be factor analyzed

and indeed, all three types of scores have been used in previous research. In the present study the researcher has adopted Vogels et al (1989) view which suggests that the expectation scores should be factor analyzed to determine the items that should be included in the service quality dimensions because these scores are not influenced by possible flaws in the service rendered by various firms in the industry. Thus, in the present study, SERVQUAL scale was factor-analyzed by principal component analysis in the patients expectation scores. The Statistical package for Social Sciences (SPSS) was used for data analysis. A rotation procedure was applied to maximize the correlations of item on a factor. Assuming factors were uncorrelated, Varimax rotation was utilized and four factors with Eigen values above one were extracted. To measure the adequacy of the sample for extraction of the four factors the Kaiser-Mayer-Olkin (KMO) measure was computed. The KMO value (.890) indicates that the examined data set is highly adequate for factor analysis. Moreover, the data set was found to be multivariate normal and acceptable for factor analysis according to Bartletts test of sphericity (p = 0.000) The Bartletts test of Sphericity compared the correlation matrix to the identity matrix and showed clearly a significant relationship between the variables, approximately Chi-Square 990.33, df = 190, p < 0.0001. Total variance explained (63.039) by these four components exceeds the 60 per cent threshold usually accepted in social sciences to support the solution. The first factor, which explained 24.37 per cent of the total variance, was labeled - The human aspect of the service quality. Factor one contains nine items similar in nature to assurance and empathy and hence could be regarded as the soft dimension of quality. The second factor includes four items and explained 13.82 per cent of the total variation. It was labeled Responsiveness dimension of service quality. Factor three that includes five items explained 12.73 per cent of the total variance and was named 'Reliability dimension of service quality'. The fourth factor comprises three items and explained 12.1 per cent of the variance, it was named 'Tangible dimension of service quality'. The extracted factors with factor loadings are presented in table one.

The current research results highlighted that the structure proposed by Parasuraman et al., (1988) for the SERVQUAL scale was not confirmed. This finding is in line with previous relevant studies. Many of the items loaded heavily into different factors from the prior dimensions proposed by Parasuraman (1988). It was decided to keep these dimensions and analyze the data accordingly. The validity of the dimensionality of these groups supports the suggestions made by Babakus, Cronin and others that the dimensions of SERVQUAL may depend on the type of industry being studied. An internal consistency analysis was performed to assess the reliability aspect of the derived four dimensions. The value of the alpha coefficient ranged from .74 to .89 (alpha > .70 (Table two) indicating that the four dimensions are reliable measures of service quality. Reliability analysis was similarly conducted for the expectation scale and for the perception scale. Both scales were found to be reliable with Cronbachs alpha value of .92 and .93 respectively. Descriptive Statistics Patients expectations (PE): In terms of patients expectation, the mean ranged between 3.73 and 4.60. The lowest 'expectation score' was for the statement stating Excellent hospitals will have pamphlets and other communication material visually appealing, while the highest score was for that stating Excellent hospitals will have the patients best interest at heart. This suggests that patients are highly concerned about trust in the hospital. This could be explained by the mystified nature of medical services or simply that these are high in credence attributes and hence it is highly difficult for customers to evaluate them. Another reason for the high expectation could possibly also be news reports of growing incidences of unethical conduct and irrational practices in Indian hospitals. The fact that all the top five expectations are in the human aspect factor indicate that the management must ensure that the patients realize that

the hospital has patients best interest at heart. It is important that this is emphasized in communications to patients and also through staff behavior. Amongst the five items that received the lowest expectation scores, three are from the tangibles dimension while two are from the responsiveness dimension. Tangible dimension includes items stating about modern looking equipment, visually appealing physical facilities and visually appealing communication material. All the tangible dimensions receiving lowest scores indicate that patients do not go very much by the look of the hospital as is usually assumed. It is surprising that patients have one of the lowest expectations to staff never being too busy to respond to patients needs. Possibly patients perceive a hospital to have a large client base and hence likely to be offering good quality by noticing staff to be busy. Patients Perceptions Patients mean scores for 'perception of actual service' ranged between 3.65 and 4.32. The lowest perception score' was for This hospital has pamphlets and other communication material visually appealing. The highest 'perception score' was for the two statements stating The personnel in this hospital give prompt service to patients and The personnel in this hospital are always willing to help patients. The findings of high perceptions in the human factor dimension imply that the personnel are perceived to be serving well. The lowest perception is for the hospital has visually appealing communication material, and about meals being served hot and of good flavor indicating patients unhappiness about catering services. Indian hospital managers need to particularly consider this in view of the varied food habits in the country probably indicating need to give choice of food items to patients.

One item from the human factor that has scored low perceptions is about personnel telling patients exactly when services will be performed. Patients perceptions are low about two items from the tangible dimensions. As these items are also among the low expectation items, the implication is to include these items in areas of improvement but not in the highest priority category. A comparison of patients expectations and perceptions for the four factors is presented in figure one. Statistical analysis shows that the mean patient expectations for two of the factors- Factors one and three are significantly different (p<0.05) from the respective mean patient perceptions. Staffs Understanding of Patients Expectations and Perceptions The mean value for staffs understanding of patients expectations ranged from 3.87 to 4.70. The lowest score is for statement stating patients expect excellent hospitals to have visually appealing pamphlets and other communication material, while highest score was for the statement patients expect excellent hospitals to always be willing to help patients. Mean scores for staff understanding of patient perceptions ranged between 3.52 and 4.28, the lowest being for statement five which stated that patients perceive this hospital has pamphlets and other communication material visually appealing while highest was for statement which stated that patients perceive the personnel in this hospital understand the specific needs of their patients. The mean patient expectation and perception scores as perceived by staff for each factor are presented in figure two.
Gaps in Service Quality Gap five: The Customer Gap: This study finds differences between patients expectations from an excellent hospital and their perceptions of the service quality delivered at the study hospital. The SERVQUAL model labels this as gap five- the customer gap. This study finds that there exists gap five in the hospital analysis reveals that these gaps are significant (p<0.05) in the human factor and the reliability dimension.

Gap one: The Knowledge Gap: The SERVQUAL model defines gap one labeled Knowledge gap as the gap between the management/ staff understanding of patients expectations and perceptions and the actual expectations and perceptions of patients about service quality at the hospital. It is the first step by which hospitals can proceed to reaching patients expectations. This entails identifying areas where patients expectations and perceptions of service quality mismatch with the staff and management understanding of these. The figure three shows that staff members have largely overestimated patient expectations. As regards understanding of patient perceptions of service quality, the reverse is found- staff has underestimated the hospitals performance. Which Dimensions Matter Most? In order to examine the effect of the quality gaps - in the four dimensions - on the patients overall evaluation of the quality of the service provided by the hospitals (general question in the questionnaire), regression analysis was performed. The four quality gaps were used as the predictors of overall quality of the services provided. Considering the independent variables with statistically significant coefficients, it is evident that patients perceptions of service quality are attributed to the responsiveness gap as presented in Table three, which is in fact the predictor of overall service quality. The above research finding is worth reporting since it indicates that the quality of the service provided to patients in the study hospital depends heavily on improving the responsiveness (Factor two). Conclusion This study leads to the following conclusions which are particularly important for further use of the SERVQUAL model in Indian hospital settings. The SERVQUAL questionnaire can be modified to specific needs as recommended by Parasuraman et al. However, this raises concern about loss of the power of standardization. Although the scale is tested for reliability and validity, the process of evolution of the scale being subjective, the possibility of negligence of important items cannot be ruled out. The length of the questionnaire is another important consideration in using the SERVQUAL model. In view of the middle socio-economic class patients and their cultural contexts, this study has attempted to improve the present ability and the readability of the questionnaire which was found useful in keeping participants interest in it. Involvement of staffs directly interacting with patients instead of management alone as recommended by the original SERVQUAL model is a unique feature of this study. This has been found helpful in not only better identifying understanding of patients expectations and perceptions, but also in creating acceptance for subsequent service quality improvement strategies. This study concludes that the dimensional structure of SERVQUAL is unstable within the hospital industry and this finding is similar to that reported by Carman (1990) and Babakus and

Boller (1992). While the original study by Parsuraman et al 1988 proposed five (universal) dimensions which were supposed to measure the service quality in any sector, this study reports four dimensions for the hospital industry rather than five. This result supports the work of quality gurus who found that quality is a relative notion with respect to a given client segment. The regression analysis found the service quality gap in the responsiveness dimension to be the most strong predictor of overall service quality followed by reliability. However the model points that there are predictors of service quality other than the gaps in the four dimensions that this study finds.