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 scores

Perceptions Expectations
Items / Scales Mean SD Mean SD Gap scores
Tangibles
1-Staff /doctors are well dressed and appear neat 3/82 0/ 88 4/3 0/78 -0/ 48
2-physical facilities are visually appealing 3/27 1/05 4/2 0/66 - 0/ 93
3- have up to date equipment 3/1 1/06 4/2 0/64 - 1/ 1
4- Informative brochures about services 2/05 1/1 4 0/84 -1/ 95

5- privacy during treatment 3/62 1/02 4/2 0/64 - 0/ 58

Reliability
6- Inform patient precisely when services will be delivered 3/74 1/14 4/57 0/75 -0/ 83
7- Staff/doctors can be depend upon to do the right thing 3/78 1/06 4/56 0/81 -0/ 78
8-sincerity of staff/ doctors to try to solve patient’s problem 3/65 1/06 4/68 0/63 -1/ 03

9- Waiting time relative to appointment time or scheduled time for a service 3/69 1/16 4/57 0/66 -0/ 88
10- Keep accurate medical record 3/81 0/85 4/56 0/67 -0/ 75
Responsiveness
11-Maintain smooth flow of patients 3/32 1/14 4/67 0/55 -1/ 35

12- receive prompt service from the staff / doctors 3/19 1/25 4/53 0/63 -1/ 34

13- staff / doctors are always willing to help patient 3/58 1/16 4/33 0/63 -0/ 75
14- prompt response to patient’s request and problems 3/46 1/13 4/42 0/59 -0/ 96
Assurance
15- Staff/Doctors are Courteous & Friendly 4 0/97 4/5 0/64 -0/ 5
16- Staff/doctors possess a wide spectrum of knowledge 4/05 0/83 4/55 0/63 -0/ 5
17- staff/ doctors work together in the patient’s best interest 3/79 0/92 4/5 0/65 -0/ 71
18- explain thoroughly medical conditions to patient 3/93 1/08 4/51 0/59 -0/ 58
Empathy
19- 24 –hour service availability 3/71 1/07 4/56 0/63 -0/ 85
20- staff/ doctors give you personal attention 3/51 1/15 4/46 0/66 -0/ 95
21- staff/ doctors obtain feedback from patient 3/47 1/11 4/2 0/83 -0/ 73
22- staff/ doctors understand patient’s specific needs 3/33 1/15 4/41 0/75 -1/ 08
 Table 2 - Means of perception & expectation on five dimensions

Perceptions Expectations
Dimensions Mean SD Min-Max Mean SD Min-max Gap-Score

Tangibles 3/17 0.7 1-5 4/18 0/56 2-5 -1/01

Reliability 3/73 0/82 1/4-5 4/59 0/51 2/8-5 -0/86
Responsiveness 3/39 0/96 1-5 4/49 0/45 3-5 -1/1
Assurance 3/94 0/78 1/5-5 4/52 0/48 3-5 -0/58
Empathy 3/51 0/94 1-5 4/41 0/56 2/25-5 -0/9

More detailed analysis of the individual statements making up each dimension was undertaken. Four of the
highest expectations are E6 (Inform patient precisely when services will be delivered) , E9 (Waiting time
relative to appointment time or scheduled time for a service) and E8 (sincerity of staff/ doctors to try to solve
patient’s problem) in Reliability dimension , E11 ( maintain smooth flow of patients) in responsiveness
dimension. Four of the lowest expectations are E21 (staff and doctors obtain feedback from patient) in
empathy dimension , E 4 (Informative brochures about services) E3(have up to date equipment) and E2
(physical facilities are visually appealing )in tangibles dimension .
Four of the highest perception statements are P15 (doctors and staff are courteous and friendly) and P 16
(doctors and staff possess a wide spectrum of knowledge) and P18 ( explain thoroughly medical conditions to
patient) all in assurance dimension and P1 ( staff and doctors are well- dressed and appear neat) in tangibles
dimension. Four of the lowest perception statements are P4 ( Informative brochures about services) , P3
( having up to date equipment) , P2(physical facilities are visually appealing )all in tangibles dimension , P6
( inform patient precisely when services will be delivered) in reliability dimension and P12 ( receive prompt
services from doctor and staff ) in responsiveness dimension.
Table 3 shows the means of the responses to the three questions related to PPL dimensions. Sub sample
analysis of PPL by gender showed no significant difference in the PPL scores between male and female
respondents using the mann-whitney test ( p <0/001) . There were no significant differences in PPL responses
between those subjects who had been in a hospital for the first time compared to those who had been at the
same hospital before. There were also no significant differences between those with or without health
insurance cover.

Table 3- PPL scores

Items Mean SD Min- Max

Global satisfaction with hospital 3/51 1/04 1-5
Willingness to return to this hospital 3/32 1/23 1-5
Willingness to recommend the clinic to others 3/26 1/27 1-5
Mean score on potential patient loyalty 3/36 1/11 1-5
Sub sample analysis of PPL factor and educational level of respondents ( Kruskall – wallis test) showed
significant differences between subjects with different levels of education . Table 4 shows the result of the
test .

Table 4 : Comparison of means of PPL between educational levels

Group Mean SD P - value

Illiterate 3/55 1/1
Primary and Junior high school 3/67 0/91 P < 0/001
High school diploma 3/31 1/1
College degree and above 2/46 1/01

In order to reveal that which groups had significant differences a man –whitney test was conducted .
Based of the findings of it , there were significant differences in PPL level between patients who were
illiterate and patients who had college education and more than it , patients who had primary school or junior
high school education with patients who had college education and more , patients who had senior high
school diploma with patients who had primary school or junior high school . (p <0/001)
One of the most valuable elements of the SERVQUAL analysis is the ability to determine the relative
importance of the five dimensions in influencing patients’ overall quality perceptions. Past authors have
tapped into the relative importance of each dimension by asking respondents to split a total of 100 points
between the five dimensions. Due to the variable educational level of our patients, we avoided the complex
judgment process involved and chose instead the relative importance of each dimension by comparing their
relationship with PPL .The spearman correlation coefficient for the relationship between perception scores in
all five dimensions and the PPL was calculated (table 5) . Based of the results of this test, there is significant
correlation between all five dimensions and PPL, and also the correlation coefficients for reliability,
responsiveness and empathy and are significantly higher than the coefficients for tangibles and assurance.
Since reliability is the most influential all the quality dimensions, it suggests that timeliness and accuracy of
performance are the most desired service qualities , followed by responsiveness and assurance, which have
the next highest parameter estimates.

Table 5- Spearman rank correlation between perception scores

For the five quality dimensions and patient potential loyalty (PPL)

Correlation with PPL Spearman r p

Tangibles o/6 < 0/001
Reliability 0/77 < 0/001
Responsiveness 0/75 < 0/001
Assurance 0/73 < 0/001
Empathy 0/63 < 0/001
Discussion & conclusion
The Study compared patients’ perceptions and expectations of service quality in hospitals affiliated to Iran
Medical University (IUMS), and examined the relationship between service quality and PPL composing
cognitive satisfaction, behavioral intent to return and recommend the hospitals to others.
Notwithstanding the limitations of the current study, a number of areas for potential improvement in service
quality have been identified in the IUH . Importantly, These have identified in a situation where overall
satisfaction with the service is medium . As a diagnostic instrument, SERVQUAL has identified where the
largest service quality gaps , as perceived by patients , occur across five dimensions . The instrument also
allows managers and clinical staff to identify in further detail where such gaps are occurring by analyzing the
individual statements that make up each dimension. In addition, SERVQUAL is a useful instrument for
prioritization across five dimensions by assessing perceived importance of each dimension.
The highest expectations of the service quality in IUH is Reliability dimension while tangibles dimension
received the lowest expectations score so this study shows that the expectations of Iranian patients are similar
to those of Parasuraman(1985) and et al (35) , Youssef and et al in UK hospitals(1996) , O’conner et al
(2000) and Lee and Yom(2007) in Korean Hospitals (36).
In analyzing the distance (gap) between expectations and perceptions , assurance exhibits the smallest gap
and the gap for reliability and empathy are very close in size to it. The small gap of assurance indicates that
from the patients perspective, doctors and staff were polite, knowledgeable and treated them with dignity and
respect. While tangibles and responsiveness have the largest gap . Thus IUH performance with respect to
empathy, assurance and reliability is more closely in line with the patients’ expectations than that for tangibles
and responsiveness.
A meaningful input to managerial decision making is the comparison of these service gaps with the relative
importance of each dimension. In this study, by calculating correlation coefficient for the relationship
between perception scores in all five dimensions and the PPL, the importance of each dimension was
determined. According to this test , tangibles is the least important attribute with regard to patient overall
satisfaction and reliability is the most important . Researches like Anderson (1995) ,Youssef and et al (1996),
Curry (2002) Lin and et al(2004) and Wisniewski (2005) found reliability as the most important dimension ,
however researches like Lim & Tang (2000) found assurance as the most important dimension in Singapore
hospitals or Wong (2002) found empathy as the most important dimension in an imaging center .
Although tangibles has a large gap, it has the lowest level of patients’ expectations and also based on
correlation test , its impact on PPL factor (and also the overall patient satisfaction) are less than other
dimensions . So according this fact, it may not be the first priority in efforts taken by managers to improve the
service quality but the responsiveness dimension is different to tangibles . It has a large gap and also its effect
on PPL is considerable so in quality improvement programs managers should put more emphasis on this area.
Patients’ flows is an important indicator of responsiveness, so analyzing operating processes by hospital
managers and redesigning them in order to reduce waiting time may be a good solution to this problem.
In order to find areas need improvement, it is useful to examine particular questionnaire items. As shown in
table1, patients show high expectations for “ maintaining smooth flow of patients” , “Inform patient precisely
when services will be delivered” “Maintain smooth flow of patients” , “ sincerity of staff / doctor to try to
solve patient problem” but completely low expectations for “ physical facility are visual and appealing ” , “
staff and doctor are well- dressed and appear neat “ , “ having update equipment ”. Hence it can be inferred
that patients expect hospitals to deliver services on time ,inform them about the right time of delivering and
have responsible doctors and nurses who have a relationship of mutual respect with patients .
PPL is the criterion variable used in this study, may be a strategic service objective for hospitals to retain and /
or expand market share.
The finding of this research about the relationship between patients’ expectations and their potential
loyalty are consistent with the literature showing that quality perceptions drive health care institution selection
, weather it is recommended to others and patients’ overall satisfaction with service (37 ) . Other studies like
Reidenbach and Smallwood (1990) in US and Lin and et al(2004) in Taiwan hospitals have founded similar
findings.
 This study also revealed that there were no different in PPL level between men and women, between
patients who were hospitalized before compared to who were at the hospitals for the first time and between
who had insurance cover compared who had not it . This finding are consistent with the finding of those of
Wong (2002) , Lin and et al(2004),Wisniewski(2005) and Lee and Yom(2007), but there was a significant
difference between different educational groups of patients .This difference revealed patients with higher
education , were less satisfied . So by increasing of educational level of Iranians, delivering high quality
services by health care settings is becoming more important.
In conclusion, we have found the measurement of service quality to be important in evaluating the
effectiveness of the hospitals performance with regard to quality improvement initiatives. The SERVQUAL
questionnaire results demonstrate areas in which the IUH are close to meeting patients’ expectations, and
areas in which they fall far short of expectations. As managers goes through budgeting process yearly , they
should pay close attention to the allocation of quality improvement funds. In this way the IUH can improve
their level of quality in those areas which impact on patients’ perceptions of service quality the most. In order
to accomplish this goal ,hospitals should make a plan to administer SERVQUAL on a yearly basis.

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