The Dimensions of Service Quality For Hospitals: Development and Use of the KQCAH Scale Victor Sower, JoAnn Duffy, William. Kilbourne, Gerald Kohers, and Phyllis Jones Using a combination of qualitative and quantitative research methodologies, this study identifies the dimensions of hospital service quality, operationalizes the dimensions, and develops an instrument to measure patient satisfaction. This instrument, the Key Quality Characteristics Assessment ‘for Hospitals (KQCAH) scale, was developed using input from 12 hospital administrators, over 100 hospital employees, and 23 recent patients and family members. elt Care Manage Rev, 200,282), 47-59 ©2001 Aspen Publisher, In 47 Central to the process of continuous quality improve- ment (CQ) is the identification and measurement of the key quality characteristics (or service cues') that affect customer satisfaction. Identification of these key qual- ity characteristics (KQC) enables the organization to focus on specific areas for improvement. When an or- ganization has a valid and reliable instrument to meas- ure the KQCs associated with customer satisfaction, ‘management can identify areas of strength and weak- ness and track the results of the improvement efforts. However, hospitals do not have a reliable and valid in- strument for measuring service quality. This makes it difficult for hospitals to effectively improve quality. The intent of the study on which this article is based was to operationalize hospital service quality as a multidimensional construct sufficiently robust to cap- ture the perspectives of providers and patients, The primary objective was to develop a valid and reliable instrument that will support hospital management's strategic and operational decision making. In order to accomplish this it was necessary to determine the di- mensions of service quality for the hospital industry, to operationalize these dimensions in the form of measurable KQCs, and validate the instrument. The instrument developed from this study is the Key Quality Characteristics Assessment for Hospitals Key words: CQL, dimensions of quality, hospital, key quality characteristics, patient survey, quality management Victor Sower, Ph-D., CQLE, is Associate Professor of Manage iment, Department of Management & Marketing, Sam Houston State University, Huntswille, Texas JoAnn Duffy, Ph.D, is Professor of Management, Department of Management & Marketing, Sam Houston State University, Hluntscille, Texas. William Kilbourne, Ph.D, is Professor of Marketing, Depart ment of Management & Marketing, Sam Houston State Untiver- sity, Huntsville, Texas. Gerald Kohers, PhD, is Associate Professor of Management In- formation Systems, Department of Management & Marketing, ‘Sem Houston State University, Huntsville, Texas Phyllis Jones, R.N, C.P.Q.AAR, is Director of Quality Man- agement/Risk Management, Huntsville Memorial Hospital, Huntsville, Texas. Am ever version of theft hal ofthis paper was preset atthe Interna: inal Deion Sciences Institue Conference in Athens Greece on uly 7, 1999: NOTE: Cops o the KQCAH ave avaiable upon request othe eh sethor48 HEALTH CARE MANAGEMENT REVIEW/SPRING 2001 (KQCAH) scale designed to measure patient satisfac- tion using these KQCs. In order to accomplish these objectives a series of interconnected research strategies was employed using both qualitative and quantitative research methodologies (see Figure 1). The study began with (a) a review of literature ad- dressing the conceptualization of quality in general terms, within the service domain, and specifically in hospital settings, and (b) the selection of a theoretical framework (see Figure 1, Steps 1 & 2) Next the study identified the KQCs from the per spective of health care providers and patients using qualitative research methods. The KQCs were identi- fied through the use of focus groups conducted with recently discharged patients and their families, health care providers, midmanagement hospital employees, and upper-level hospital administrators. Like many studies of health care quality, this study incorporates the health care professionals’ perspectives but does not rely solely on their opinions of what constitutes quality care. The current approach to defining quality empha- sizes the need to include the customers’ perspectives? Nevers suggests that a general definition of health care quality starts with “the degree in which a product or service conforms to the needs, wants, and expectations of the customer.”*?-" An important focus of this study is to incorporate the patients’ perspectives in the defini- tion of quality health care in one specific health care set- ting: the hospital (see Figure 1, Step 3). Finally the study develops and validates an instru- ment to measure KQCs. The items for the instrument are drawn from the earlier qualitative analysis (Step 3). The KQCAH scale is developed and then empiri- cally tested on more than 600 recently discharged pa~ tients from 3 separate hospitals using factor analysis, regression, and estimation of Cronbach alphas (see Figure 1, Steps 4-10). CONCEPTUALIZATION OF QUALITY WITHIN HOSPITALS The review of the literature indicates that there is a ‘great deal of variability and confusion in how quality is conceptualized and operationalized. Variability in definitions of quality confounds the efforts of man- agers to assess and improve hospital quality during a time of mounting pressure to do so. Service quality often is difficult to define in terms that facilitate meas- urement. After an extensive review of the service quality literature, Reeves and Bednar observed that FIGURE1 ‘SUMMARY OF STEPS IN DEVELOPING THE, KQCAH INSTRUMENT Step 1: Definition of hospital service quality Step 2: Selection of JCAHO dimensions as theoretical framework Step 3: Collection of data from 125 participants in 12 focus groups ‘Step 4: Content analysis of focus group data to identify KQC Step 5: Construction of KQCAH instrument ‘Step 6: Collection of data from 663 recently discharged patients at 3 hospitals Step 7: Factor analysis to verily the dimensionality of the KQCAH instrument ‘Reassignment of items and n of dimensions where necessary ‘Step 9: Computation of Cronbach alpha {0 assess reliability of each dimension ‘Step 10: Assessment of KQCAH’s validity“The literature we summarized indicates that no uni- versal, parsimonious, or all-encompassing definition or model of quality exists.”5" * The difficulty in defining hospital service quality may account for the fact that no valid and reliable instrument exists. The general definition of quality according to the Ameri- can Society for Quality is “a subjective term for which each person has his or her own definition. In technical usage, quality can have two meanings: (a) the charac- teristics of a product or service that bear on its ability to satisfy stated or implied needs and (b) a product or service free of deficiencies.” ™ Reeves and Bednar identified the roots of quality as excellence, value, conformance to specifications, and meeting and /or exceeding customers’ expectations,*? ‘Quality is recognized as a multidimensional con- struct. Table 1 traces the development of the di- mensionality of quality. Garvin’ developed a list of 8 dimensions of product quality. Garvin and others (Stevenson*, Chakrapani*) suggest that these dimen- sions are applicable to both products and services However, difficulties arise when one tries to opera~ tionalize these dimensions in the service sector be- cause service characteristics differ from product characteristics. Services are defined as “social act(s) which take place in direct contact between the customer and representatives of the service company.” Service quality is more difficult to measure objectively than product quality because service characteristics in- The Dimensions of Service Quality for Hospitals 49 clude intangibility, heterogeneity, and inseparability of the production and consumption of services. These characteristics render service quality a more abstract and elusive construct than product quality."! Evans and Lindsay"? list 8 dimensions of service quality (Table 1). These represent an improvement over the application of Garvin's product dimensions to services; however, no empirical basis has been pro- vided for these dimensions. Parasuraman, Zeithaml, and Berry" developed five dimensions of service quality that have been em- pirically tested (Table 1) and incorporated into their SERVQUAL instrument. While a major step forward, these dimensions were developed and tested in indus- tries quite different from the health care industry (i.e, bank, credit card company, repair and maintenance company, long-distance telephone company). Other studies have identified potential difficulties related to the SERVQUAL instrument." Among the criticisms are questions about predictive and convergent valid- ity and unstable dimensionality. Chakrapani’ devel- oped a simpler service quality model consisting of three dimensions (Table 1). This model is intended to be simpler and more generalized than are those with more dimensions. Simplicity and generalizability re- duce the applicability of these dimensions to one spe- cific type of organization, ‘A number of researchers have attempted to address the problem of defining service quality within the hos- pital context and developing or adapting an instrument TABLE1 DIMENSIONS OF QUALITY —$ eS Garvin's Parasuraman et Product Evans & Lindsay's SERVQUAL Chakrapani’s —Coddington’s. JCAHO Dimensions Service Dimensions Dimensions Dimensions Dimensions Dimensions Performance Time Tangibles Service/Product | Warmth/Caring/ Efficacy Features ‘Timeliness Reliability Dependability/ Concern Appropriateness Reliability Completeness Responsiveness Support Medical Staff Efficiency Conformance Courtesy ‘Assurance Exceeding ‘Technology- Respect & Caring Durability Consistency Empathy Expectations ‘Equipment Safety Serviceability Accessibility & Specialization/ Continuity Aesthetics ‘Convenience Services Effectiveness Perceived Accuracy Available Timeliness quality Responsiveness ‘Outcome Availabil