Measuring Service Quality at Hospitals affiliated to Iran Medical Sciences

University

Zhaleh Abdi (Ph.D. candidate)

Health Services Administration , Iran University of Medical Sciences

Farbod Ebadi Fard Azar,

Associate Professor, Iran University of Medical Sciences,

Arezoo Khosravi,
Bachelor student in Health Services Administration, Iran

Abstract:

Introduction:
The issues surrounding the measurement and provision of service quality in health
care settings are becoming increasingly important to health care managers. This research
aims to investigate patients’ perceptions and expectations of service provided by
hospitals affiliated to Iran University of Medical Sciences (IUMS) by using a generic,
internationally used market research instrument called SERVQUAL which assesses the
service quality in five dimensions: tangibles, reliability, responsiveness, assurance and
empathy.

Methods :
This study involved adapting the SERVQUAL instrument (translated into
Persian), with additional items on patient potential loyalty or PPL( consists of overall
satisfaction , intent to return and recommend hospital to others) and asking a sample of
inpatients (n=620) in IUMS hospitals to complete it . Patient expectations of service were
obtained on first day of patients’ attendance in hospital and their perceptions of service
were obtained in the time of discharge. Then perceptions and expectations were
compared to identify where the largest service quality gaps exist.

Results:
Statistics analysis revealed that there was an overall service quality gap between
patients’ expectations and perceptions ( p< 0/001) in IUMS hospitals ,and also the service
quality gap or expectations minus perceptions in two dimensions : tangibles and
responsiveness were almost high. All service quality dimensions were significantly
positively associated with PPL, and of the five dimensions, reliability was the most
important predictor of PPL( r =0/77 ) .
Conclusion
: Although the study has a limited sample size, it does appear that the SERVQUAL
instrument has a useful diagnostic role to play in assessing and monitoring service quality
in hospitals . The study provides evidence of where specific service improvements are
needed from the patients’ perspective, hence the findings may help hospital mangers
seeking to assess and improve service quality in managerial decisions making and
resources allocation. The study has raised a number of issues which would form the basis
for useful further research
.
Keywords:

Health Services, Quality Measurement, SERVQUAL,

Introduction
One of the fastest growing industries in the service sector is health care and also
this rapid growth has been accompanied by dramatic changes in environment (1) . These
forces of changes include that growing demand for health care, rising costs, constrained
resources , competitive pressure and monitoring by public and private groups and a
markedly better informed client have begun to exert extra pressure on health care
managers to reassess their strategies(1,2). A major solution to respond to these challenges
received much attention by managers is service quality improvement (3) . In health care
settings , patient satisfaction is an important component of service quality(4) .In other
words, patient satisfaction provides information on the success of health care providers in
meeting and satisfying the patient needs and expectations(5) . Satisfaction, in turn, has a
positive relationship to customer loyalty and the patient’s future decision to return to a
facility for receiving service (6) .Hence , quality management has emerged not only as
the most significant and enduring strategy in ensuring the very survival of organizations
(7) , but also is a fundamental route to business excellence and extending market share of
health care organizations(8).
Although competing for patients may not be the objective of the heavy
subsidized health care hospitals and institutions run by the government , they have a
moral responsibility to be a completely accountable for the efficient use of public
resources(9). , The world health organization(WHO) in 2000 identified responsiveness to
patient as a key measure of health systems performance to achieve better health outcomes
since satisfied patients are more likely to utilize needed services (10). Only when we start
to recognize the patients as the customers will we really seek to find out about the
patients’ needs,and only when we find out about their needs will the quality of service be
improved (11) . In order to find out weather we are meeting the patients’ needs or not ,
the only possible way is obtaining feedback from the patients themselves(12). Health
service organizations in Iran are no different .
There are public hospitals and private hospitals in Iran of varying bed capacity in the
country , and the need to increase their competitive edge is becoming more intense.
Furthermore, one of the drastic changes in health care services in Iran , during recent
years( by increasing in number of young and educated population) is that customer who
used to be passive , now tend to ask actively for detailed or specific services which they
need and then evaluate the service provided . One possible way beyond the health care
managers in Iran is assessing the quality of services in eye of patients and trying to
improve the quality of services based on patients’ views.

Service Quality in Healthcare

The theoretical conceptualization of the service quality construct indicates that service
quality is a multidimensional concept (13), and different researchers (in the field of
market or health services) considered different dimensions for service quality (14) .
According to Grönroos, Health care quality has two distinct components: technical
quality and functional quality. Technical quality refers to the accuracy of medical
diagnoses and procedures, and is generally comprehensible to the professional
community, but not to patients (15).In health care environment, technical quality includes
factors such as outcome measures , average length of stay and readmission rates(3).
Patient can not judge the technical competence of the hospital and its staff. Hence the
patient makes a judgment on a hospital based on the functional quality which he receives,
the manner in which medical care is delivered to him (16). Including factor such as
health care professional’s attitudes toward patients, facility cleanliness and quality of
food (17). Functional quality perceptions may influence future decisions to return to
facility for service. Some empirical evidence suggests that patients’ quality judgment
may be positively associated with technical quality, as reflected in outcomes such as risk
– adjusted mortality among hospitalized patients for medical conditions (14). In health
care, high technical quality is generally attained through peer review and clinical audits
and addressing the functional attributes of the service tends to be low on the priority of
clinicians. This needs to be changed, as these functional attributes have a dominant effect
on patient’s perceptions of service quality. If patient – focused improvement is our ideal,
then awareness of these issues by clinicians is important (3).It is also becoming
increasingly important to measure quality of services provision so that resources can be
directed effectively and efficiently toward improvement (16).
Delivering poor quality service and having dissatisfied customers are
antecedents to a number of critical behaviors (18). These may be in the form of switching
service providers and influencing others in their perceptions of quality (19). Moreover a
dissatisfied customer is likely to ten times the number of people than will a satisfied
customer (20). As posited by Ovretveit (2000) the cost of unresolved complaints from
dissatisfied customers for a hospital with 88,000 discharges patients per a year was
estimated to be US$ 4 million (21). Therefore, it is not surprising that meeting customer
needs and efforts in retaining customers are priorities for healthcare organizations (14).
Several models for assessing the quality have been tested across a range of
services and industries. The most widely used instrument in assessing quality is
SERVQUAL which is designed by Parasurman and et al (22). Parasuraman et al defined
service quality as the extent discrepancy between customer’s expectations and their
perceptions. Expectations means the wants of the customers, That is, what they feel a
service provider should offer and perceptions refer to the customers’ evaluation of service
provider (23 ). Parasuraman et al formulated a service quality model and identified 10
original determinants using in – depth interviews of executives and focus group in
interviews of consumers in 1985. Further thet developed the SERVQUAL instrument to
measure service quality in 1988(24). The SERVQUAL instrument consists of five
dimensions of service quality: tangibles, reliability, responsiveness, assurance and
empathy (25 ).

• Tangibles include physical evidence of services , such as physical facilities , tools

or equipment, appearance of employees and other customers ,
• Reliability means that the promised service will be performed correctly and
dependably at the first time.
• Responsiveness concerns the willingness or readiness of employees to provide
service. It involves timeliness of service.
• Assurance involves knowledge, courtesy of employers and their ability to convey
trust and confidence.
• Empathy is the providing of caring and individual attention to customers by staff.

The basis behind SERVQUAL, is the assumption that the difference (gap) between a
patient’s expectations (prior the use of service) and a patient’s perceptions ( after the
actual use of the service) reflects the quality performance of the given service(24) .
Although here are some criticism over SERVQUAL, it has been used to assess service
quality in a range of services and industries (25). Numerous studies in the health domain
have used SERVQUAL to assess the quality of delivered service in US(26,27,28 ,29),
UK(3,16,30,31,32) , and other countries (23,33,34) The aim of this project is to
measure the functional quality of service of provided by the hospitals affiliated to Iran
Medial Sciences University (IUMS) located in Tehran:Rasoule- Akram , Firoozgar,
Hashemi nezhad , Akbar- Abadi , Shafayahyaeean and Hazrate – Fateme .further , since
patient perceptions are likely to influence future decisions to avail the hospital’s
services , a construct of patient potential loyalty is postulated, comparing global
satisfaction with the hospital , intent to return to hospital and recommend it to friends and
relatives. We also examined the association of perceived service quality with potential
patient loyalty (PPL) to examine the predictive validity of quality perceptions for intent
to return to the provider .

Methodology

Survey Instrument
In order to design pilot questionnaire, the 22 items in the SERVQUAL instrument
developed by Parasuraman et al were referred to. Some modifications and adoptions were
made to selected questions to make them more relevant to hospital services. The 22 items
used by youssef et al (1996) in the evaluation of health care quality in the NHS were also
referred to. The translated questionnaire was assessed by 7 managers/ supervisors in 4
hospital for its content validity and their invaluable feedback was used in designing final
questionnaire. To assure of its reliability , it also was pilot – tested on 40 patients across 4
hospitals, yielding high cronbach’s alpha for all 5 dimensions and PPL variable ranging
from 0/815-0/955( overall cronbach’s alpha = 0/9023)
 The final instrument comprised three parts : 1- Respondent demographic
information 2 – Perceived service quality items adapted from the SERVQUAL
instrument in two section : perceptions and expectations .Each section had 22 items
relating to the 5 dimensions of service quality there were :

1- 1-5 Tangibles (5 items)

2- 6-10 Reliability ( 5 items)
3 - 11- 14 Responsiveness ( 4 items)
4- 15- 18 Assurance ( 4 items)
5 - 19- 22 Empathy ( 4 items)

A five point likert scale was used for these items, 1 being “ strongly disagree” and
5 being “ strongly agree” . The mean score for each dimension was used to assess the
performance of IUH within each dimension . 3- Third part of questionnaire tapped into
PPL. This construct reflecting the potential for return to the hospital , is conceptualized
as the aggregate of cognitive satisfaction and behavioral intent to seek future services or
recommend the hospital to the others. PPL score is the mean of the sum of three item
scores : global satisfaction with the encounter , willingness to return to the hospital in
future , and willingness to recommend it to others. A 5 – point scale was used for the
scoring system of these items too, with 1 representing least important / very poor and 5
representing most important / very good.

Data and collection

Regarding the consistent of resources and time, it is often impossible to examine
the population of interest during a research project , so based on the pilot study , the
number of sample figured out about 620 and a random sampling procedure was
followed .The inclusion criteria were the following : adult IUH patients who were
admitted to general units excepting psychiatrist units , emergency rooms and intensive
care units . The survey was administrated during October – December 2007. The section
pertaining to patients’ expectations of service quality was given to the patient on
admission time prior to receiving any treatment and examination, and the section relating
to perceptions of service quality was given to the patient after the service was delivered
during at the time of discharge. The patients were made aware that participation was
entirely voluntary and confidentiality was assured. The questionnaire informed the
patient of the purpose of the study and ensured anonymity of responses.

Results
A total of 598 questionnaires out of 620 were returned . This represents a
response rate of 96 percent .The mean (SD) of age of the respondents was 40/5 (16/5) .Of
these, 42/5 percent were female and 57/5 percent were male; 61/4 of respondents
presented “This is their first time attendance in this hospital “and 38/6 percent of
respondents presented that “They had been in this hospital previously.” One of the
main objectives of this survey is to determine expectations of hospitals’ services in the
eyes of the patients. The expectations of patients along with the hospitals performance
(patients’ perceptions of services quality) were analyzed. The means of the perception
response for the 5 dimensions range from 2/05 to 4/05 and the expectation response for
them range from 4 to 4/68 . Table 1displays the information for each questionnaire item .
As shown in this table, perceptions fell short of expectations for every category,
indicating negative service gaps (perceptions minus expectations) and reveals that
patients’ expectations generally were not being met. However the legitimacy of using
means on ordinal data may not be precise since the intervals between points on the likert
scale have no meaning. Furthermore, the calculation of means from derived scores is
risky . Hence, the Wilcoxon test was used to test the hypothesis that there were no
differences between patients’ perceptions of service quality and their expectations of
services provided .
T-test results revealed that mean patients’ perceptions was significantly less than
patients’ perceptions of service quality in all five dimensions and in all 22 items( p-value
< 0/001).
Table 2 shows the means of perception and expectation response for the five
dimensions. The means of perception range from 3/17 to 3/94 and the means of
expectation range from 4/18 to 4/59 with the largest gaps for tangibles and assurance.

Table 1 - Perceived quality of service – Expected quality of service – Gap scores01

Perceptions Expectations
Items / Scales Mean SD Mean SD
Gap scores