SERVICE QUALITY IN BANGALORE HOSPITALS AN EMPIRICAL STUDY

R. Rohini B. Mahadevappa

In todays highly competitive environment, hospitals are increasingly realizing the need to focus on service quality as a measure to improve their competitive position. Customer based determinants and perceptions of service quality, therefore, play an important role when choosing a hospital. In this paper, we present a service quality perception study-undertaken in five hospitals in Bangalore city. The well-documented Service Quality Model was used as a conceptual framework for understanding service quality delivery in health care services. The measuring instrument used in this study was the SERVQUAL questionnaire for the measurement of Gap 5 and Gap 1. An analysis covering a sample of 500 patients revealed that there exists an overall service quality gap between patients perceptions and their expectations. An analysis covering a sample of 40 management personnel revealed that a gap between managements perception about patients expectations and patients expectations of service quality also exists. The study suggests improvements across all the five dimensions of service quality - tangibles, reliability, responsiveness, assurance and empathy.

INTRODUCTION

esearch evidence in both the manufacturing and services industries indicates that delivering high service quality produces measurable benefits in profit, cost savings and market share (Ziethaml, Berry and Parasuraman, 1988). In India, the past few years have witnessed an increasing concern regarding the quality of healthcare services. The globalisation and liberalisation policies have significantly changed the health care scenario in India. With increasing awareness, the patients, as consumers expect quality in healthcare services. Quality has been shown to be an important element in the consumers choice of hospitals (Lynch and Schuler, 1990). In the light of these changes, there is an emerging need to improve the quality of healthcare services. Researchers commonly divide service quality into two components: technical quality and functional quality (Gronroos, 1984: Parasuraman et al., 1985: Lewis and Mitchel, 1990: Lewis, 1991). Technical quality
Journal of Services Research, Volume 6, Number 1 (April 2006 - September 2006) 2006 by Institute for International Management and Technology. All Rights Reserved.

60 Service Quality in Bangalore Hospitals is defined primarily on the basis of technical accuracy and procedures. Functional quality refers to the manner in which service is delivered to the customer. In the health care setting, patients understandably tend to rely on functional attributes (eg., facilities, cleanliness, quality of hospital food, hospital personnels attitudes etc.,) rather than technical attributes when evaluating the service quality because they are unable to evaluate the technical quality due to lack of expertise (Babakus and Boller, 1991: Lanning and OConnor, 1990). This paper presents the results of a service quality perception study designed to measure the patients perceptions and expectations of service quality in five Bangalore based hospitals, using the multidimensional, generic, internationally used market research instrument called SERVQUAL (Parasuraman et al., 1988). The same instrument has been used to measure the managements perceptions about patients expectations and actual patients expectations across all the five hospitals. The SERVQUAL instrument has been widely used in many service industries, including hotels, dentistry, travel, higher education, real estate, hospitals and architecture. The advantages of SERVQUAL include the following (Buttle, 1994):
l l l l

It is accepted as a standard for assessing different dimensions of service quality. It has been shown to be valid for a number of service situations. It has been known to be reliable. The instrument is parsimonious in that it has a limited number of items. This means that customers and employers can fill it out quickly. It has a standardized analysis procedure to aid interpretation and results.

The present study covers a sample of five hospitals- a Super Specialty hospital (A), a Missionary hospital (B), a Government hospital (C), a Teaching hospital (D) and a Multi- Specialty hospital (E) based in Bangalore city, Karnataka, India. LITERATURE REVIEW The research literature on service quality has thrown numerous models by different researchers across the world. Health care service quality is
Journal of Services Research, Volume 6, Number 1 (April 2006 - September 2006)

61 Rohini, Mahadevappa multi dimensional. The multi - dimensionality of healthcare quality was supported by Griffith and Alexander (2002). Given the consumers propensity to switch service providers rather than complain, it is of paramount importance for hospitals to be acutely aware of what the general public looks for while evaluating the professional service of a particular hospital. Perception of hospital care is derived from a set of criteria based on perceptual cues that patients use. Lehtinen and Laitamaki (1985) present a holistic view on how to measure, monitor, and operationalise customer perceptions of service quality in health care organisations. John (1989) argues that there are four dimensions of health care service quality: the curing dimension, the caring dimension, the access dimension, and the physical environment dimension. However, most of the studies of health care quality are based on SERVQUAL, a generic, internationally used market research instrument. Reidenbach and Sandifer-Smallwood (1990) developed an instrument based on the original ten-dimension questionnaire developed by Parasuraman et al. (1985). They analysed patient service needs by examining the differing perceptions of service held by patients in three basic hospital settings: emergency room services; inpatient services; and outpatient services. Differential impacts were found in all the three hospital settings. Babakus and Mangold (1992) empirically evaluated SERVQUAL for its potential usefulness in a hospital service environment. The completed perceptions and expectations scales met various criteria for reliability and validity. Suggestions were provided for the managerial use of the scale and a number of future research issues were identified. An empirical study in a Belgian hospital by Vandamme and Leunis (1993) has been reported on the development of an appropriate multipleitem scale to measure hospital service quality. Discrepancies between SERVQUAL and the dimensions obtained from their study were discussed in some detail, along with the reliability and validity properties of the scale. Bowers et al. (1994) studied the five attributes of quality from SERVQUAL model. Their results from a quantitative analysis lend support to qualitative conclusions. Caring and communication were found to be significant. Three of the generic SERVQUAL dimensions
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62 Service Quality in Bangalore Hospitals were found to be related significantly to patient satisfaction: empathy, responsiveness and reliability. Anderson (1995) measured the quality of services provided by a public university health clinic, using a 15-item instrument representing the five dimensions of SERVQUAL. According to her findings, all the five dimensions measured negatively, assurance being most negatively measured. Based on these results, Anderson made some recommendations for budgeting future quality improvement projects. Youssef et al.(1995) measured service quality in West Midlands NHS hospital and in all the five dimensions of SERVQUAL that were measured found that patients perceptions failed to meet their expectations. Another study by Youssef (1996) revealed reliability as the most serious problem facing the NHS hospital providers involved in their study. A study by Sewell (1997) in the NHS hospitals showed reliability as the most important dimension, followed by assurance. Empathy and responsiveness were found to be of equal importance, while tangibles was found to be the least important dimension. Lim and Tang (2000) attempted to determine the expectations and perceptions of patients in Singapore hospitals through the use of modified SERVQUAL that included 25 items representing six dimensions; namely, tangibles, reliability, assurance, responsiveness, empathy, and accessibility and affordability. Their study revealed the existence of an overall service quality gap between patients perceptions and expectations. Jobnoun and Chaker (2003) compared the service quality rendered by private and public hospitals in the UAE. They used the ten-dimensions instruments developed by Parasuraman et al. (1985) namely, tangibles (7 items); accessibility (5 items); understanding (3 items); courtesy (3 items); reliability (2 items), security (2 items); credibility (2 items); responsiveness (7 items); communication (3 items) and competence (5 items). Their study revealed that there is a significant difference between private and public hospitals in overall service quality. The literature survey suggests a study for the existence of research gap in service quality of health care sector in India. To fill this research gap, a service quality perception study was undertaken in five Bangalore based hospitals.

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63 Rohini, Mahadevappa RESEARCH OBJECTIVES The specific objectives of the study were to determine: l how well the hospitals in Bangalore city were meeting the patients expectations on the service quality dimensions. l service quality scores by dimensions and overall service quality index. l the relative importance of the five dimensions to the customers. l managements perceptions of patients expectations. HYPOTHESES Two hypotheses were formulated for testing this study. They were: a) Patient Perceptions of Service Quality H0: There is no difference in patients perception of service quality among the five hospitals. H1: There is a difference in patients perception of service quality among the five hospitals. b) Managements Perceptions about Patients Expectations. H0: There is no difference in managements perception of patients expectations of service quality among the five hospitals. H1: There is a difference in managements perception of patients expectations of service quality among the five hospitals. METHODOLOGY A Conceptual Model of Service Quality The well-documented Service Quality model of Parasuraman et.al. (1985) was used as a conceptual framework for measuring service quality delivery in Health Care Services. The service quality model indicates that consumers quality perceptions are influenced by a series of four distinct gaps occurring in organisations. These gaps on the service providers side, which can impede delivery of services that consumers perceive to be of high quality, are: Gap 1: Differences between patient expectations and management perceptions of patient expectations. Gap 2: Difference between management perceptions of patient expectations and service quality specifications. Gap 3: Difference between service quality specifications and service actually delivered. Gap 4: Difference between service delivery and what is communicated about the service to patients.
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64 Service Quality in Bangalore Hospitals Perceived service quality (Gap 5) is defined in the model (fig. 1) as the difference between consumer expectations and perceptions, which in turn depends on the size and direction of the four gaps associated with the delivery of service quality on the marketers side.
Consumer
Word of mouth communications Personal needs Past Experience

Expected Service

GAP 5

Perceived Service

Marketer

Service delivery(including pre and postcontacts) GAP 3 Translation of perceptions into service quality specs GAP 2 Management perceptions of Consumer expectations

GAP 4

External communications to others

GAP 1

Figure 1: Conceptual Model of Service Quality

[Source: Parasuraman et al (1985)]

In the Service Quality Gaps Model, an underlying assumption is that service quality is critically determined by measuring the gap between

Journal of Services Research, Volume 6, Number 1 (April 2006 - September 2006)

65 Rohini, Mahadevappa customers expectations of a service and their perceptions of the service as actually experienced. Sample The present study was designed with the co-operation of five Bangalore based Hospitals. The management teams were up-to-date with the current literature and emphasised the pragmatic aspects of the research. Their active involvement helped in the assessment of reliability and ensured that the research instrument would be of practical significance. Hospitals were stratified on the basis of Specialty-Non Specialty, Government-Private and Missionary, ISO-9000 certified and ISO-9000 Non- certified. The sample hospitals consisted of A-a single specialty, ISO-certified, private hospital; B - a Missionary, ISO-9000 certified, general hospital; C - a Government, ISO9000 Non- certified hospital; D- a Medical college attached, ISO-9000 Noncertified, private hospital; E-a multi specialty, ISO9000 Non- certified, private hospital. In these five hospitals, a sample of 500 patients were randomly selected to measure Gap 5 and a sample of 40 hospital executives were randomly selected to measure Gap 1. The sample of hospitals, patients and hospital executives are presented in Table 1. Table 1: Sample of Hospitals, Patients and Hospital Executives
Hospital Type
Bed size Speciality Ownership Iso-9000 Single Private certified General Missionary certified General Government Non-certified General Private Non-certified Multi-specialty Private Non-certified Sample size

Patients
Sex Age / Education

Hospital Executives
Sample size Sex Age/ Education

100

100

M:72 F: 28

35-80yrs/ S.S.L.CPG 15-80yrs/ S.S.L.CPG 15-80yrs/ PrimaryGraduation 10-80 yrs PrimaryGraduation 10-80 yrs Primary-PG

M:5 F: 2

40-50yrs/ Graduation-PG 30-55yrs/ Graduation-PG

160

100

M:35 F:65

11

M:3 F:8

C 450 D 750

100

M:49 F: 51

M:3 F: 3

45-55yrs/ Graduation-PG 35-55yrs/ Graduation-PG 35-55yrs/ Graduation-PG

100

M:42 F: 58

M:3 F: 4

E 350

100

M:56 F: 44

M:6 F :3

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66 Service Quality in Bangalore Hospitals The Research Instrument The questionnaire used in this study followed the basic five dimensions of the SERVQUAL instrument developed by Parasuraman et al (1988). The instrument includes 22 items: four items belong to tangibles dimension; five items belong to reliability dimension; four items belong to responsiveness dimension; assurance dimension has four items and empathy dimension has five items. Respondents were asked to mark their extent of perception and expectation on a seven-point scale. The first section of the questionnaire contained the SERVQUAL scale, with 22 statements relating to patients expectations on the quality of service that the hospital should offer and 22 corresponding items relating to their perceptions of the quality of service actually delivered in a specified hospital. This simultaneous administration of expectations and perceptions statements is consistent with the methodology employed by the developers of SERVQUAL. Data collection and Analysis The primary data on 500 patients expectations and perceptions were collected in five hospitals using SERVQUAL research instrument to measure Gap 5. Personal interviews with the patients were also conducted. Out of the 75 distributed questionnaires among hospital executives, 40 responses were received to measure managements perceptions about patients expectations of hospital service (Gap 1). The response rate for patients sample was hundred percent, where as for hospital executives sample, it was 53.33 percent. Reliability was tested using the Cronbach alpha coefficient. Simple one-way ANOVA was used to test whether any significant difference exists in the perceptions of patients service quality among the hospitals (Hypothesis 1) and managements perceptions about patients expectations among the hospitals (Hypothesis 2). Averages were used to measure expectation and perception scores. Statistical Package for Social Sciences (SPSS) was used for data analyses. Reliability and Validity The internal consistency method (Nunnally, 1978) was chosen to assess the reliability of the research instrument used in this study. The internal consistency of a set of measurement items refers to the degree to which items in the set are homogeneous. Internal consistency can be estimated using a reliability coefficient such as Cronbachs alpha (Cronbach, 1951).
Journal of Services Research, Volume 6, Number 1 (April 2006 - September 2006)

67 Rohini, Mahadevappa Cronbachs alpha is computed for a scale based on a given set of items. Using the reliability programme, (Hull and Nic, 1981), an internal consistency analysis was performed separately for the items of each of the five dimensions of SERVQUAL. Table 2 presents the reliability co-efficient associated with the five dimensions of service quality. The reliability coefficient ranged from 0.887 to 0.934 for expectation scores and from 0.905 to 0.928 for perception scores. Typically, reliability co-efficient of 0.7 or more are considered adequate (Cronbach, 1951, Nunnally, 1978). Accordingly the scale used here was judged to be reliable. Table 2: Results of Reliability Analysis

Cronbachs Alpha SERVQUAL Dimensions No. of Items Expectation Score Tangibles Reliability Responsiveness Assurance Empathy Overall Score 4 5 4 0.934 0.934 0.887 0.884 0.893 0.950 Perception Score 0.923 0.928 0.915 0.905 0.912 0.906

4 5
22

The SERVQUAL questionnaire also fulfils the more practical requirements of validity as found in a number of studies (Vandamme, R. and Leunis,J 1993; Parasuraman et al, 1988). RESULTS AND DISCUSSION The results of the study include analyses of Gap 5 and gap 1.

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68 Service Quality in Bangalore Hospitals Gap - 5: Patient Perceptions of Service Quality In Table 3, the average expectation and perception scores are presented for each statement in the SERVQUAL questionnaire. The aggregated dimensional scores and overall service quality among the five hospitals are reported in Table 4. The comparative hospitals means of the five servqual dimensions and their overall service quality scores are presented in Table 5. Table 3: Average Scores on Expectations, Perceptions and Difference between Expectation and Perception: Gap-5 (n=500)
SERVQUAL Dimensions and their Items
P score E score (P-E) Score

Tangibles Excellent hospitals will have modern looking equipment. (eg., C.T. Scan, X-Ray, M.R.I. Scan, Tread mill etc.). The physical facilities at excellent hospitals are visually appealing. (eg., well maintained reception area, computerized billing and registration facilities, neat and clean pathology, biochemistry labs, hospital rooms, canteen etc.). Personnel at excellent hospitals will be neat in appearance (eg., staff with uniform and appropriate name badges, professional appearance of staff etc.). Materials associated with the services will be visually appealing in an excellent hospital. (eg., clean and comfortable environment with good directional signs, informative brochures about services, stretcher, wheel chairs, well maintained records etc.). Reliability When excellent hospitals promise to do something by a certain date, they do so. (eg., tests, follow up checks, surgeries etc.). When a patient has a problem, excellent hospitals will show a sincere interest in solving it. (eg., registration ,calling the concerned doctor to attend the case etc.). 5.42 Excellent hospitals will be dependable (eg., services provided at appointed time, errorfree and fast retrieval of documents, good communication, good treatment etc.). 5.59 Excellent hospitals will provide their services at the time they promise to do so.(eg., emergency care, casualty services etc.). 5.46 Excellent hospitals will get the things right the first time.(eg., correct diagnosis, prompt treatment etc.). 5.59 5.93 -0.34 5.94 -0.48 5.98 -0.39 5.89 -0.47 5.33 5.68 -0.35

5.32

5.73

-0.41

5.66

5.97

-0.31

5.46

5.86

-0.40

5.44

5.78

-0.34

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69 Rohini, Mahadevappa

Responsiveness Personnel in excellent hospitals will tell patients exactly when services are provided. (eg., adm issions, ward facilities, visiting hours etc.). Personnel in excellent hospitals will give prompt services to patients. (eg., good reception ,house keeping, nursing ,speed and ease of admission, speed and ease of discharge etc.). Personnel in excellent hospitals will always be willing to help patients. (eg., ever smiling, kind hearted staff). Personnel in e xcellent hospitals will never be too busy to respond to patients requests (eg., attending immediately whenever called). Assurance The behaviour of personnel in excellent hospitals will instill confidence in patients. (eg., convincing briefings by specialists, doctors, nurses etc.). Patients of excellent hospitals will feel safe in their dealings w ith the hospital. (eg., cost of treatment, medicines, trust with the personnel etc.). Personnel at excellent hospitals will be consistently courteous w ith their patients. (eg., patients treated with dignity and respect, impartial treatment, sympathetic approach etc.). Personnel of excellent hospitals will have the knowledge to answer patients questions. (eg., thoroughness of explanation of medical condition, proper advice in their respective areas etc.). Empathy Excellent hospitals will give patients individual attention. (eg., bed side care, proper diet r equirements , politeness of physicians, nurses and other staff etc.) Excellent hospitals will have operating hours convenient to all their patients. (eg., 24- hour service facility, fixing the operation timings according to the requirement etc.). Excelle nt hospitals will have the patients best interest at heart. (eg., good, sympathetic care, consistency of charges etc.). The personnel at excellent hospitals will understand the specific needs of their patients. (eg., receiving, investigating & sending th em to specific departments for treatment). Excellent hospitals will keep their patients informed and listen to them . (eg., operation details, explaining nutritional needs, pre-op & post-op care etc.). 5.67 5 .88 -0.21 6.16 6.30 6 .20 6 .34 -0.04 -0.04 5.40 5 .67 -0.27

5.58

5 .82

-0.24

5.74

6 .06

-0.32

5.80

6 .03

-0.21

6.40

6 .47

-0.08

6.18

6 .37

-0.19

5.06

5 .38

-0.32

5.45

5 .77

-0.32

5.47 5.68

5 .87 6 .01

-0.40 -0.33

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70 Service Quality in Bangalore Hospitals Table 4: Aggregated dimensional scores, and overall Service Quality Index (SQI): Gap 5 (n= 500)

SERVQUAL Dimensions Tangibles Reliability Responsiveness Assurance Empathy Overall Index Service

P score 5.44 5.50 5.63 6.26 5.47

E score 5.81 5.91 5.90 6.35 5.78 5.95

Difference (P-E) - 0.37 - 0.41 - 0.27 - 0.09 - 0.31 - 0.29

Quality 5.66

Tangibles Difference (P-E) E score Assurance P score -100% -50% 0% 50% 100% Empathy Overall Service Quality Index Reliability Responsiveness

In all the 22 items of the five dimensions of service quality (Table 3 and Table 4), patients expectations exceeded their perceptions. The most serious shortfalls (gaps on dimensions exceeding 0.25) are on dimensions-Tangibles (-0.37), Reliability (-0.41), Responsiveness (-0.27) and Empathy (-0.31). Obviously, these are the dimensions that will require most attention by hospital management if gap 5 is to be closed.
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71 Rohini, Mahadevappa The detailed findings of the study by SERVQUAL dimensions and by hospitals are presented in Table 5. Table 5: SERVQUAL Scores by Dimensions and by Hospitals
SERVQUAL SCORES DIMENSIONS A n=100 1.Tangibles 2.Reliability 3.Responsiveness 4.Assurance 5.Empathy Overall service Quality score -0.10 -0.14 -0.07 0.05 0.03 -0.046 B n=100 -0.48 -0.43 -0.36 -0.33 -0.57 -0.44 HOSPITAL MEANS C n=100 -0.79 -0.70 -0.55 -0.26 -0.55 -0.57 D n=100 -0.34 -0.36 -0.16 0.24 -0.12 -0.15 E n=100 -0.14 -0.42 -0.18 -0.15 -0.38 -0.25

1.Tangibles 2.Reliability Hospitals 3.Responsiveness 4.Assurance 5.Empathy -100% -50% 0% 50% Overall service Quality score *

Dimensions

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72 Service Quality in Bangalore Hospitals Table 6: ANOVA for Gap 5 of the five Hospitals
Dimensions Tangibles Groups Between Groups Within Groups Total Between Groups Within Groups Total Between Groups Within Groups Total Between Groups Within Groups Total Between Groups Within Groups Total Between Groups Within Groups Total Sum of Squares 1.591 .415 2.006 .800 .342 1.142 .504 .181 .685 .905 .209 1.114 1.392 .180 1.572 .904 .540 1.444 df 4 15 19 4 20 24 4 15 19 4 15 19 4 20 24 4 20 24 Mean square .398 2.770E-02 .200 1.711E-02 .126 1.206E-02 .226 1.391E-02 .348 9.000E-03 .226 2.701E-02 F 14.361* Sig. .000

Reliability

11.696*

.000

Responsiveness

10.450*

.000

Assurance

16.272*

.000

Empathy Overall Service Quality Index

38.656*

.000

8.362*

.000

Significant at .001 level

SURVEY FINDINGS The survey findings are summarised below: Tangibles In the personal interviews with the patients, it was brought to the notice of the researchers that most of the in-patients were extremely happy about the neat and clean house keeping facility, computerised billing and registration, modern looking equipments etc., (Hospitals A and E). However, some of the patients felt that even though the inside environment of the hospitals are conducive enough, there is disturbance due to the noise from the adjacent buildings which are under construction. Since most of the patients (generally in the age group 50-70 yrs) were admitted due to heart problems, they felt the toilet facility should have been inside the rooms rather than outside (Hospital A). Most of the patients felt that the hospital personnel (including
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73 Rohini, Mahadevappa physicians) should be provided with name and designation badges so that their identification could be made easier (Hospitals C, D and E). They also felt the need for a spacious visitor lounge, which would add to the hospitals reputation. Some patients felt the need for a professional counselor who would psychologically boost their morale (All five hospitals). Some of the male patients felt the need for a television set as an entertainment facility and a rest room for their attendants (Hospital B). Most of the new mothers were very much unhappy about the neonatal ICU being shifted to a farther place where in they find it difficult to walk often to feed their babies (Hospital B). With respect to Hospital C, in the personal interviews with the patients, it was brought to the notice of the researchers that most of the in-patients were extremely happy about the neat and clean rooms (both private and general wards) and registration, cost of service etc. However, majority of the patients felt that even though the inside environment of the hospital is conducive enough, there is disturbance due to the noise from the vehicles that are being parked just outside the VIP ward. Almost all the patients (generally in the age group 40-70 yrs) felt the need for western type of toilet facility (at least one in each general ward). Thus, an overall large negative score for Hospital C and least negative scores for hospitals A and E has been observed for tangibles (Table 5). Reliability Even though the patients expressed their satisfaction regarding the correct diagnosis and prompt treatment, error-free retrieval of records, good communication etc., (Hospital A), it seemed to the researchers that some of them were not very happy about the fast retrieval of documents, communication with the security personnel, follow up checks etc., (Hospitals D and E). The patients were also unhappy about the long waiting hours in the OPD and scanning, booking dates for surgeries and registration delays (hospital D). All these factors accounted for larger negative gaps for Hospital C and least negative gap for hospital A. However hospitals B and D showed equal negative gaps (Table 5). Responsiveness There were some patients who expressed their dissatisfaction as to not getting information on the type of service facilities that are provided for the costs incurred at the time of admission (Hospitals A, B, D and
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74 Service Quality in Bangalore Hospitals E). Most of the patients were unhappy with the delayed discharge procedure (Hospital E). Some of them felt the need for briefing regarding health insurance facilities and expected booking of rooms at the time of admission itself (Hospital B). However all the patients were happy about the quick response to the emergency attending of the hospital personnel (Hospital A, B, D and E). Thus an overall small negative gap with hospital A and large negative gap with hospital C and an in between negative scores for B has been observed. Hospitals D and E scored equal with respect to responsiveness dimension (Table 5). Assurance In the personal interviews with the patients, it was brought to the notice of the researchers that most of the in-patients were extremely happy about the excellent nursing care, assistance in the reception, neat and clean house keeping facility, very cordial and empathetic staff, ever smiling - ever ready helpers and the attitude of the physicians who would listen to their queries sympathetically (All Hospitals). Very few of the patients felt the hospital charges as high (Hospitals A and E), but some of them expressed that cost cannot be considered for the excellent quality of services offered by the hospitals. The patients were also convinced about the technical knowledge of the paramedical staff. All the patients were happy with respect to doctors treatments and briefings (All Hospitals). Still an overall small negative score has been observed (Hospitals A and E) which may be due to the patients expectations regarding the quality of nursing care, cleanliness and housekeeping being much higher than their experience in the hospital. Many patients from the economically poor background felt that even though the hospital charges are less, the cost of medicines, blood donation cost etc., as high and expected further reduction in these aspects (Hospital C), but some of them expressed that cost can not be considered for the sufficiently satisfactory quality of services offered by the hospitals (Hospitals A, D and E), thus accounting for a comparatively lower negative score for assurance dimension for hospital A and a higher negative score for hospital B. Empathy Even though the patients felt that there is excellent pre and post- operative care rendered by both doctors, nurses and dieticians, round the clock service
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75 Rohini, Mahadevappa facilities and good sympathetic care (All Hospitals), very few of them seemed to be confused about the individual attention given by the staff and the type of investigations carried out by the doctors (Hospitals B, D and E). Thus an overall small positive score has been observed for empathy for hospital A. During our personal interactions, it was brought to our notice that the patients were satisfied with the bedside care and concern shown by the hospital personnel. But, they expressed their dissatisfaction regarding discrimination in treatment by ward boys and some nursing staff between the general and private ward patients (Hospitals C and D), accounting for larger negative scores for hospitals B, C and D for empathy. Thus, Gap 5 is hypothesised to be related to positive patient evaluation because it measures the difference between patient perceptions and expectations, a standard approach to determining satisfaction and assessing an encounter. One way ANOVA results show that there are significant differences in all the five dimensions of service quality-Tangibles, Reliability, Responsiveness, Assurance and Empathy among the five hospitals in Bangalore city. There is also a significant difference in the Overall service quality among the five hospitals. The result of the ANOVA r e j ect sH 0 and accepts H1- there is a difference in the patients perception of service quality in the five hospitals and also in the Overall Service Quality Index. Gap 1: Management Perceptions about Patient Expectations Gap 1 is hypothesised to be related to positive patient evaluation because it reflects the difference between the managements perceptions about patients expectations of service quality provided and patients expectations of service quality. From a marketing perspective, the provider would design, develop and deliver the service offering on the basis of his or her perceptions of patient expectations. Likewise, modifications to the service offering would be affected by the service providers perceptions about patient expectations. Whether these perceptions of patient expectations exceed, match or measure below patient expectations can have a profound effect on future patienthospital relationship. Therefore, it can be argued that gaps in these areas can directly influence positive patient evaluation.

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76 Service Quality in Bangalore Hospitals Gap 1 scores by dimensions and by 22-Servqual items are shown in Table 7. Items for each subscale were subjected to reliability assessment. The Cronbachs alpha values for the managements perceptions about patients expectations were 0.941, 0.650, 0.958, 0.959 and 0.818 for tangibles, reliability, responsiveness, assurance and empathy respectively. Table 7: Average Scores of Management perceptions about patient expectations, patient expectations and their difference (M E): Gap 1 (n=40)
S e r v i c e Q u a lity D i m e n s i o n s M score E score (M - E ) Score

T a n g ibles E x c e l l e n t h o s p i t a l s w ill h a v e m o d e r n l o o k i n g e q u i p m e n t.(eg., C . T . S c a n , X -R a y , M . R . I . S c a n , T r e a d m ill etc.) . The physical facilities at excellent hospitals are v i s u a l l y a p p e a l i n g . (eg., w e l l m a i n t a i n e d r e c e p t i o n area, com p u terized billing and registration facilities, neat and clean pathology, biochem istry labs, hospital r o o m s etc.). Personnel at excellent hospitals will be neat in a p p e a r a n c e ( e g . , s t a f f w ith u n i f o r m a n d a p p r o p r i a t e name badges, professional appearance of staff etc.). M a t e r i a l s a s s o c i a t e d w ith th e s e r v i c e s w ill b e v i s u a l l y a p p e a l i n g i n a n e x c e l l e n t h o s p i t a l . ( e g ., c l e a n a n d c o m f o r t a b l e e n v i r o n m e n t w i t h g o o d d i r e c ti o n a l s i g n s , inform ative brochures about services, stretcher, w h e e l c h a i r s , w e ll m a i n t a i n e d r e c o r d s e t c . ) Reliability 6.53 W hen excellent hospitals prom ise to do something by a certain date, they do so. (eg., tests, follow up checks, surgeries etc.). W h e n a p a t i e n t h a s a p r o b l e m , e x c e l l e n t h o s p i t a l s w ill s h o w a s i n c e r e i n t e r e s t i n s o l v i n g i t . ( e g . , r e g i s t r a t i o n, calling the concerned doctor to attend the case etc.) E x c e l l e n t h o s p i t a l s w ill b e d e p e n d a b l e ( e g ., s e r v i c e s p r o v i d e d a t a p p o i n t e d t i m e , e r r o r-f r e e a n d f a s t r e t r i e v a l of docum ents, good com m u n ication, good treatm e n t etc.). E x c e l l e n t h o s p i t a l s w ill p r o v i d e t h e i r s e r v i c e s a t t h e tim e t h e y p r o m i s e t o d o s o . ( e g . , e m e r g e n c y c a r e , casualty services etc.). E x c e l l e n t h o s p i t a l s w ill g e t t h e t h i n g s r i g h t t h e first tim e . ( e g . , c o r r e c t d i a g n o s i s , p r o m p t treatm e n t etc.). 6.15 5 .89 5 .98 0 .6 3 0 .17 5.25 5 .68 -0 . 4 3

5.85

5 .73

0 .12

6.18 5.83

5 .97 5 .86

0 .21 -0 . 0 3

6.01

5 .78

0 .31

6.27 5.20

5 .94 5 .93

0 .33 -0 . 7 3

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77 Rohini, Mahadevappa

Responsiveness Personnel in excellent hospitals will tell patients exactly when services are provided. (eg., admissions, ward facilities, visiting hours etc.). Personnel in excellent hospitals will give prompt services to patients. (eg., good reception ,house keeping, nursing ,speed and ease of admission, speed and ease of discharge etc.). Personnel in excellent hospitals will always be willing to help patients. (eg., ever smiling, kind hearted staff). Personnel in excellent hospitals will never be too busy to respond to patients requests (eg., attending immediately whenever called). 5.88 Assurance The behaviour of personnel in excellent hospitals will instill confidence in patients. (eg., convincing briefings by specialists, doctors, nurses etc.). Patients of excellent hospitals will feel safe in their dealings with the hospital. (eg., cost of treatment, medicines, trust with the personnel etc.). Personnel at excellent hospitals will be consistently courteous with their patients. (eg., patients treated with dignity and respect, impartial treatment, sympathetic approach etc.). Personnel of excellent hospitals will have the knowledge to answer patients questions. (eg., thoroughness of explanation of medical condition, proper advice in their respective areas etc.). Empathy Excellent hospitals will give patients individual attention. (eg., bed side care, proper diet requirements , politeness of physicians, nurses and other staff etc.). 6.05 Excellent hospitals will have operating hours convenient to all their patients. (eg., 24- hour service facility, fixing the operation timings according to the requirement etc.). 5.25 Excellent hospitals will have the patients best interest at heart. (eg., good, sympathetic care, consistency of charges etc.). 6.20 The personnel at excellent hospitals will understand the specific needs of their patients. (eg., receiving, investigating & sending them to specific departments for treatment). 6.20 Excellent hospitals will keep their patients informed and listen to them. (eg., operation details, explaining nutritional needs, pre-op & post-op care etc.). 6.43 6.01 0.42 5.87 0.33 5.77 0.43 5.38 0.87 5.88 0.17 6.03 -0.15 6.03 5.67 0.36

6.23

5.82

0.41

6.40

6.06

0.34

6.43

6.20

0.23

6.48

6.34

0.14

6.28

6.47

-0.19

6.30

6.37

-0.07

Journal of Services Research, Volume 6, Number 1 (April 2006 - September 2006)

78 Service Quality in Bangalore Hospitals The Gap 1 scores for the study are reported in Table 7. It consists of managements average perceptions scores, customers average expectation scores and the difference between the two. As can be seen in Table 7, only six items on which managements underestimate customers expectations are- Q1(Excellent hospitals will have modern looking equipment), Q4 (Materials associated with the services will be visually appealing in an excellent hospital), Q9 (Excellent hospitals will get the things right the first time), Q13 (Personnel in excellent hospitals will never be too busy to respond to patients requests), Q16 (Personnel at excellent hospitals will be consistently courteous with their patients) and Q17 (Personnel of excellent hospitals will have the knowledge to answer patients questions). The more negative the score, the more serious the Gap. A negative score denotes managements lack of understanding of customers expectations. A positive score means that managements overestimate and are thus still out of touch with customers expectations (on all the remaining 16 items). The closer the scores are to zero, the more ideal they are. Table 8: Aggregated Dimensional Scores and Overall Score: Gap 1(n=40)

SERVQUAL Dimensions Tangibles Reliability Responsiveness Assurance Empathy Overall Gap 1 Score

M score 5.78 6.04 6.14 6.37 6.03 6.08

E score 5.81 5.91 5.90 6.35 5.78 5.95

Difference (M-E) - 0.03 0.13 0.24 0.02 0.25 0.13

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79 Rohini, Mahadevappa
Tangibles Difference (M-E) E score M score -50% 0% 50% 100% Empathy Overall Service Quality Index Reliability Responsiveness Assurance

Dimensions

The aggregated dimensional scores and overall Gap 1 score are reported in Table 8. It can be seen that only one dimensional score is negative and the rest are positive with the Overall Gap 1 score positive. This means that the managements enjoy reasonably a good understanding of customers expectations eventhough these tend to be overestimated in general. The Gap 1 score by dimensions among the hospitals-A,B,C,D and E and their overall Gap 1 score scores are presented in Table 9. Analysis of variance is shown in Table 10. Table 9: Overall Scores by Dimensions and by Hospitals
SERVQUAL SCORES HOSPITAL MEANS Hospitals Dimensions 1.Tangibles 2.Reliability 3.Responsiveness 4.Assurance 5.Empathy Overall score A n=7 -1.01 -0.07 -0.22 -0.28 -0.35 -0.39 B n = 11 -0.37 0.27 0.25 -0.11 -0.20 -0.03 C n= 6 0.23 0.41 0.32 -0.26 0.75 0.29 D n=7 0.61 0.22 0.37 0.22 0.68 0.42 E n=9 0.51 -0.22 0.41 0.21 0.42 0.30

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80 Service Quality in Bangalore Hospitals

Hospitals

1.Tangibles 2.Reliability 3.Responsiveness 4.Assurance 5.Empathy Overall score *

-100%

-50%

0%

50%

100%

Dimensions

Table 10: ANOVA for Gap 1 of the five Hospitals. ANOVA

Dimensions Groups Between Groups Within Groups Total Between Groups Within Groups Total Between Groups Within Groups Total Between Groups Within Groups Total Between Groups Within Groups Total Between Groups Within Groups Total Sum of Squares 7.350 3.862 11.212 1.115 8.120 9.235 1.069 1.690 2.759 .749 1.125 1.874 5.337 3.170 8.508 2.095 1.911 4.006 df 4 15 19 4 20 24 4 15 19 4 15 19 4 20 24 4 20 24 Mean square 1.837 .257 .279 .406 .267 .113 .187 7.500E-02 F Sig.

Tangibles

7.136*

.002

Reliability

0.687

.609

Responsiveness

2.372

.099

Assurance

2.495

.087

Empathy

1.334 .159 .524 9.556E-02

8.417*

.000

Overall Gap-1 Score

5.481*

.004

* significant at .001 level

Journal of Services Research, Volume 6, Number 1 (April 2006 - September 2006)

81 Rohini, Mahadevappa It can be seen that overall Gap 1 scores for hospitals A and B are negative and for hospitals C, D and E are positive (Table 9). The overall gap 1 score in hospital B is nearer to zero, though it is slightly negative. In this hospital, the management enjoys a good understanding of patients expectations. The overall Gap 1 score in hospital A is negative. It shows the lack of managements understanding of patients expectations. The overall Gap 1 scores for hospital C, D and E are positive. These scores show that management overestimates patients expectations in providing services. One-way ANOVA results (Table 10) show that there is a significant difference in the Overall Gap 1 Score among the five hospitals. The ANOVA r e s ul tr e j ect s H0 and accepts H1- there is a difference in managements perceptions about patients expectations of service quality among the five hospitals. An overall small negative SERVQUAL score in Gap 5 (-0.29) and a small positive score in Gap 1 (0.13) is a fairly typical result, because whatever be the quality of service provided by the management, the expectations of patients on the service quality of the hospital will be higher than that of the managements perceptions, because patients always compare quality to the cost incurred to get the services, which is very difficult to assess. CONCLUSION The importance and the human touch involved in the health care encourage patients to seek the highest possible quality. As patients are unable to assess the technical quality of health care, the quality attributes associated with the delivery of health care has been utilised by the patients. Results from this study suggest that patients define health care quality in terms of tangibles, reliability, responsiveness, assurance and empathy. In the present study based on the data from the five hospitals in Bangalore, SERVQUAL appears to be a consistent and reliable instrument to measure health care service quality. The results pinpoint areas for attention to improve upon health care service quality. The negative SERVQUAL score (Gap 5) across all the dimensions clearly shows that there is room for service quality improvement in Bangalore hospitals especially in Reliability (Hospital A), Empathy
Journal of Services Research, Volume 6, Number 1 (April 2006 - September 2006)

82 Service Quality in Bangalore Hospitals (Hospital B), Tangibles and Reliability (Hospitals C and D), Reliability and Empathy (Hospital E). Assurance dimension scored least negative in all the five hospitals. This indicates that the hospitals are performing satisfactorily on the assurance aspect of health care services that are most critical to patients. Timely, professional and competent service is what the patients expect from health care providers, and although hospitals in Bangalore are generally providing good services in these areas, improvements are still needed to meet patients expectations. Health care managers should focus more on training the paramedical staff in order to build confidence in the patients mind regarding the service delivery. Physicians should be involved in continuous learning programmes to further improve their knowledge in professional subject matters. Our study shows that gap analysis is a straightforward and appropriate way to identify inconsistencies between management and patient expectations of service performance. Addressing these gaps seems to be a logical basis for formulating strategies and tactics to ensure consistent expectations and experiences, thus increasing the likelihood of satisfaction and a positive quality evaluation. More consistent expectations and perceptions can be achieved in one or both of the following ways-(1). Altering the professional behaviors and expectations; (2). Altering patients expectations and perceptions. Examination of the perceptions of both the management and the patients in an exchange is a way to identify gaps in expectations and experiences. Once inconsistencies have been identified, strategies and tactics for achieving more congruent expectations and experiences can be initiated. Greater consistency, in turn, leads to a more positive service encounter and enhances the likelihood that the experience will evolve into a longer-term patient-hospital relationship. REFERENCES
Anderson,E.(1995) Measuring service quality in a University health clinic, International Journal of Health Care Quality Assurance, 8:2, 32-37. Babakus, E. and Glynn M.W. (1992) Adapting the SERVQUAL Scale to Hospital Services: An Empirical Investigation, Health Services Research, 26:6, 767-786. Babakus, E.and Boller, G.W. (1991) An empirical assessment of the servqual scale, Journal of Business Research, 7, 34-46.

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83 Rohini, Mahadevappa
Bowers, M.R, Swan, J.E., Koehler, and William F. (1994) What attributes determine quality and satisfaction with health care services?, Health Care Management Review, 19:4, 49. Buttle, F. (1994) Whats wrong with SERVQUAL?, Working Paper No. 277, Manchester Business School, Manchester. Cronbach, L.J. (1951) Coefficient alpha and the internal structure of test, Psycometrica, 16, 297-334. Griffith, J. and Alexander, J. (2002) Measuring comparative hospital performance/ practitioner response, Journal of Health care Management, 47:1, 41-57. Gronroos, C. (1984) A Service Quality Model and Its Marketing Implications, European Journal of Marketing, 18:4, 36-44. Hall, C.H. and Nie, N.H.(1981) SPSS Update, NewYork, McGraw- Hill. John, Joby. (1989) Perceived quality in Health Care Service Consumption: What are the Structural Dimensions?, Developments In Marketing Science, 12, Jon M. Hawes and John Thanopoulos (eds.), Orlando, FL, Academy of Marketing Science, 518-521. Lanning, J.A. and OConnor, S.J. (1990) The health care quality quagmire: some sign posts, Hospital and Health Services Administration, 35:1, 39-54. Lehtinen, J.R. and Jukka, M.L. (1985) Applications of Service Quality and Services Marketing in Healthcare Organizations, Building Marketing Effectiveness in HealthCare, Academy for Health Sciences Marketing, D. Terry Paul (ed.), 45-48. Lewis, B.R. (1991) Customer care in service organizations, Management Decision, 29:1, 31-34. Lewis, B.R. and Mitchell, W. (1990) Defining and measuring the quality of customer service, Marketing Intelligence Planning, 8:6, 11-17. Lim, P. and Tang, N. (2000) Study of patients expectations and satisfaction in Singapore hospitals, International Journal of Health Care Quality Assurance, 13:7, 290-9. Lynch, J. and Schuler, D. (1990) Consumer evaluation of the quality of hospital services from an economics of information perspective, Journal of Health Care Marketing, 10:2, 16-22. Nauceur, J. and Mohammed, C., (2003) Comparing the quality of private and public hospitals, Managing Service Quality, 13:4, 290-299. Nunnally,(1978), Psycometrica, McGraw Hill, New York. Parasuraman, A., Zeithaml, V.A. and Berry, L.L. (1988) SERVQUAL: a multiple - item scale for measuring customer perceptions of service quality, Journal of Retailing, 64:Spring, 12-40. 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, 49:4, 41-50. Reidenbach, E. and Sandifer, S.,B. (1990) Exploring perceptions of hospital operations by a modified SERVQUAL approach, Journal of Health Care Marketing, 10:4, 47-55. Sewell, N. (1997) Continuous quality improvement in acute health care: creating a holistic and integrated approach, International Journal of Health Care Quality Assurance, 10:1, 20-26. Vandamme, R. and Leunis, J. (1993) Development of a multiple-item scale for measuring Hospital Service Quality, International Journal of Service Industry Management, 4:3, 30-49.
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84 Service Quality in Bangalore Hospitals

Youssef, F., Nel, D., and Bovaird, T. (1995) Service quality in NHS hospitals, Journal of Management in Medicine, 9:1, 66-74. Youssef, F., and Nel, D. (1996) Health care quality in NHS hospitals, International Journal of Health Care Quality Assurance, 9:1, 15-28. Zeithaml, A., Leonard L.B. and Parasuraman, A. (1988) Communication and Control Processes in the Delivery of Service Quality, Journal of Marketing, 52: April, 35-48.

R. Rohini, M.Sc, M.B.A, is a Research Scholar in the Department of Studies in Commerce, University of Mysore, Post Graduate Centre, Hemagangotri,Hassan, Karnataka, India. Dr. B. Mahadevappa, M.Com, Ph.D, Lecturer (Senior Scale) in the Department of Studies in Commerce, University of Mysore, Post Graduate Centre, Hemagangotri, Hassan, Karnataka, India.

Journal of Services Research, Volume 6, Number 1 (April 2006 - September 2006)