Understanding quality of care

UNDERSTANDING DIMENSIONALITY IN HEALTH CARE

Abstract In recent years, the quality of non-clinical elements of health care has been challenged in the UK. While elements such as communications, empathy, environment etc. all contribute hugely to care of patients, they often fall short of what they should be. This paper considers how these are currently evaluated operationally before a review of extant literature on dimensionality in services generally. It goes on to describe the methodology behind the exploratory phase of a larger project to generate a greater understanding of the dimensionality of health care with the ultimate aim of devising an evaluation model designed specifically for the health sector. Key words: quality, health, service, SERVQUAL, dimensionality 1. Aim To understand the dimensionality of quality in health services Objectives I. II. III. 2. Review existing means of evaluating the quality of non-clinical elements of care in health services Critique the SERVQUAL model with particular reference to health services Identify what dimensions are important to service users. Introduction Aim and Objectives

The service sector is an important part of the UK economy with a workforce of 25.76m out of a total UK workforce of 31.26m. Of this the public sector represents 21% of the overall UK workforce (Office for National Statistics, 2011). Economically, the NHS alone accounts for a budget of 114bn (Department of Health, 2010). With one million people accessing health services every 36 hours (Triggle, 2012), health services is a major contributor to both social and economic influences, yet despite ongoing debate, service quality in this sector remains an enigmatic element and has attracted little academic progression in its measurement since the development of SERVQUAL 25 years ago.

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3.

Review of the Evaluation of Health Care

Health care organisations are facing pressures from a variety of directions, one of which is the introduction of competition in the sector. This new phenomenon is pushing hospitals and community services to take a hard look at the quality of the services they offer as they face increasing demands to meet or exceed patient expectations (Dougall et al., 1999). This is a difficult aspiration, especially in an environment where some elements of patient dissatisfaction may be out of their control (Vukmir, 2006), such as the needs of different demographic groups, the involvement of partner agencies, government intervention, etc. The quality of health care remains a problem (Gummesson, 2001) and in the UK, where the National Health Service (NHS) has an almost monopolistic place in the sector, the challenges it faces are many and varied and have been categorised as: (O'Connor et al., 1988) i. Service elusiveness the nature of health care often means that the patient does not know what to expect; it is difficult for them to assimilate what the service means (Berry et al., 1988). ii. Employee diversity health care is dependent on a huge diversity of employees with different skills and personalities who have to work together (Bellou, 2007). Each plays a crucial role contributing to the patients perception of quality. iii. Interrelatedness patients require education to help them to understand the service and thus help them in their evaluation (O'Connor et al., 1988). The complexities of delivering health care means that its evaluation is challenging with a lack of resources, resistance by staff to data collection and inexperience and poor training for managers and staff (Eiriz & Figueiredo, 2005). Often those who are delegated the responsibility of managing quality are given the role as an add on to their main job (Desombre & Eccles, 1998). While numerous attempts are made to measure quality in health care, they are often complex in nature, are usually national and based on political issues such as targets rather than elements of care based on qualitative work with patients (Goodrich & Cornwell, 2008). The NHS has been said to be awash with data but short on information (Dr. Foster, 2009). It measures performance rather than quality. Of the plethora of measures used to monitor health care, the four key ones are through Dr. Foster, Care Quality Commission (CQC), National Patient Survey and Quality and Outcomes Framework (QOF). None of these have strong local ownership or are designed with local priorities in mind.

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2.1

Dr Foster

Dr Foster is an independent organisation which provides comparative records for every hospital in the country, on-line tools for the public to complete and records data in consumer guides allowing prospective patients to make informed decisions on which hospital they wish to attend. Data is used to benchmark trusts against national trends in quality, safety and efficiency. An on-line tool allows the public to prioritise six pre-selected elements that are important to them by use of a Likert scale. 2.2. Cleanliness Comfort Right information, participation in decisions, confident and in control Timely and well co-ordinated care Respect and honesty Treated with compassion

Care Quality Commission

This Commission monitors care offered by all health care providers to ensure they meet government standards of quality and safety. The Care Quality Commission (CQC) offers integrated regulation for health and social care in England. Its aim is to ensure better care for everyone in hospital, in a care home and at home. (Care Quality Commission, 2011a). All NHS trusts are required to register with the CQC, which in turn monitors their performance through annual self completion assessments, visits, surveys, MPs, local authorities, LINks (Local Involvement Networks), Patient Advice Liaison Services (PALS), comments from the public etc. The Commission has the power to remove registration from any trust failing to comply with essential standards. Nevertheless there have been concerns that the organisation is toothless after reports of poor care following visits. Trusts are measured against a number of essential standards which they state are based on the type of care provided rather than systems and processes. Patients can expect to be involved and told what is happening at every stage of their care Patients can expect care, treatment and support which meets their needs Patients can expect to be safe Patients can expect to be cared for by qualified staff Patients can expect their hospital to constantly check the quality of its services

(Care Quality Commission, 2011b).

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The dimensions are limited in some aspects of overall patient experience, particularly around empathy and the complexities of communications. 2.3. Patient surveys on behalf of the Department of Health (DoH)

Patient surveys are underpinned by research to determine priorities that the public place on service elements. Since 1997 hospitals in the UK have been required to carry out a survey annually. The CQC determines the core questions which fall into seven categories: admission to hospital; hospital and ward; staff; care and treatment; operations and procedures; leaving hospital and overall. These can be augmented at local level though this opportunity is treated with caution since the core questionnaire is unduly long. Unfortunately, more recently there has been a tendency to incorporate questions of a political essence such as waiting times, cleanliness and mixed sex wards going against the spirit of the original framework (Goodrich & Cornwell, 2008). The survey is annual through which longitudinal trends can be extracted at each trust. One of the major challenges of the survey is that a patient merely registers dissatisfaction with an element rather than being able to explain what they were unhappy about (Coulter et al., 2009; Goodrich & Cornwell, 2008; Richards & Coulter, 2007). Vigilance is also recommended since studies have indicated that even where a patient has perceived their care as excellent they have often experienced a number of problems (Goodrich & Cornwell, 2008). This may be because of the inherent trust that patients have in the medical profession (Richards & Coulter, 2007) and do not feel in a position to be critical. 2.4. Quality Outcomes Framework.

This process assesses general practice on behalf of the Department of Health. It is carried out by panels of clinicians and lay people who visit each general practice on an annual basis. It provides the basis for an incentive programme through scoring management of common chronic diseases; practice organisation, how patients view their experience and extra services offered. The QOF accounts for up to 20% of the income of participating practices. The process has been criticized for removing the autonomy of general practitioners; micromanagement by the state; ignoring elements patients value such as trust and results in coercing patients to accept specific treatments (Mangin & Toop, 2007).

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4.

Critique of SERVQUAL

Until the development of SERVQUAL in 1985 by Parasuraman et al. the measurement of service quality traditionally came from theory around the marketing of goods. The SERVQUAL model employs the theoretical framework of expectation versus satisfaction and measures five gaps: 1. 2. 3. 4. Management perceptions of customer expectation and actual customer expectation Management perceptions of customer expectations and company stated service specification Company stated service specification and service delivery Company stated service specification and the external communication of this Customer expectation and customer experience. This gap is influenced by gaps 1-4 (Parasuraman et al., 1985)

It comprises first a set of 22 questions which asks the respondent the extent to which the firm delivering the service should possess each feature followed by a similar series of 22 questions, this time asking the extent to which the respondent feels the firm possesses each item. It does not, however, ask respondents to place the priority they would place on each item. With almost 200 questions to answer, the process is lengthy and potentially unwieldy. The first model comprised 10 factors (Table 1) In either model, with almost 200 questions to answer, the process was lengthy and potentially unwieldy.

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Table 1 SERVQUAL Determinants of service quality (Ten dimensions)

DIMENSION Reliability DEFINITION Consistency of performance and dependability. It means that the firm performs the service right for the first time. It also means that the firm honours its promises. Specifically, it involves: - Accuracy in billing; - Keeping records correctly - Performing the service at the designated time. Responsiveness Willingness or readiness of employees to provide service. It involves timeliness of service: - Mailing a transaction slip immediately; - Calling the customer back quickly; - Giving prompt service (e.g. setting up appointments quickly). Competence Possession of the required skills and knowledge to perform the service. It involves: - Knowledge and skill of the contact personnel; - Knowledge and skill of operational support personnel; - Research capability of the organisation, e.g. securities brokerage firm. Access Approachability and ease of contact. It means: - The service is easily accessible by telephone (lines are not busy and they dont put you on hold); - Waiting time to receive service (e.g. at a bank) is not excessive; - Convenience hours of operation; - Convenient location of service facility. Courtesy Politeness, respect, consideration and friendliness of contact personnel (including receptionists, telephone operators etc.). It includes: - Consideration or the consumers property (e.g. no muddy shoes on the carpet) - Clean and neat appearance of public contact personnel. Communication Keeping customers informed in language they can understand and listening to them. It may mean that the company has to adjust its language for different consumers increasing the level of sophistication with a well-educated customer and speaking simply and plainly with a novice. It involves: - Explaining the service itself; - Explaining how much the service will cost; - Explaining the trade-offs between service and costly; - Assuring the consumer that a problem will be handled. Credibility Trustworthiness, believability, honesty. It involves having the customers best interests at heart. Contributing the credibility are: - Company name; - Company reputation; - Personal characteristics of the contact personnel; - The degree of hard sell involved in interactions with the customer. Security Freedom from danger, risk or doubt. It involves: - Physical safety (Will I get mugged at the automatic teller machine?); - Financial security (Does the company know where my documents are?); - Confidentiality. (Are my dealings with the company private? Making the effort to understand the customers needs. It involves: Understanding/ - Learning the customers specific requirements; Knowing the - Providing individualised attention; customer - Recognising the regular customer. Tangibles Physical evidence of the service: - Physical facilities; - Appearance of personnel; - Tools or equipment used to provide the service; - Physical representations of the service - plastic credit card or a bank statement; - Other customers in the service facility. (Parasuraman et al., 1985)

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A later piece of work refined these to five dimensions (Table 2). This was based on a study of 200 respondents, each of whom had used one of the five sectors included in the research appliance repair/maintenance, retail banking, long-distance telephone, securities brokerage and credit cards.

Table 2 SERVQUAL Determinants of service quality (five dimensions)

DIMENSION Tangibles: DEFINITION up-to-date equipment physical facilities visually appealing staff well dressed and neat polite appearance of facilities in keeping with the service staff should be sympathetic if customer experiences problems when firm promises something by a certain time it is achieved dependability provide service at time they promise records kept accurately provide prompt service tell customers when to expect service willing to help customers staff not too busy to provide prompt service DIMENSION Assurance: DEFINITION customers can trust staff customers feel safe polite staff staff get support from firm

Reliability:

Empathy:

staff know what needs of customer are staff have customers best interests at heart staff give personal attention staff give individual attention convenient opening hours

Responsiveness:

4.1.

Challenging the Model

SERVQUAL is widely accepted as having made an enormous contribution to theory around the measurement of service quality with claims that service quality has become SERVQUAL. (Woodall, 2001, pg 596). It has, nevertheless, received considerable critical analysis over the years. A review of extent literature raises a number of concerns as described in Table 3. Omitted from these are a number of potential methodological flaws. 4.1.1. Sectors Used - The authors state the firms they used represented both high and low contact services; a debatable claim since high contact services are those where transactions involve consumers and staff in complex interactions as contextualised by the theory of co-creation (Vargo & Lusch, 2004). None of those selected acknowledge the true complexities of professional services such as health
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care where human elements such as courtesy, empathy or the communication skills which are so important, especially where services are tailored to individual needs. 4.1.2 Sample - the sample of participants used in the work was limited. Fourteen senior executives were interviewed across the four sectors. No front of house staff were included. This risks losing rich and valuable data gleaned from their working relationships with consumers. The later work to refine the model in 1988 targeted just 200 respondents across the sectors collectively. For such a seminal piece of work, this was a modest sample 4.1.3. Dimensions Dimensionality is a pragmatic way of measuring service quality but a question lies in the nature of the dimensions. The influence of SERVQUAL is diminished since sector specific dimensions were omitted from the research, only general dimensions being deemed relevant (Parasuraman et al., 1985). While this ensures a more flexible model across services, it misses some key components relevant to specific sector contexts where items are not transferable from one sector to another. 4.1.4. Validity of Expectations - Fundamental to the model is the gap between expectations and perceptions, a concept which has attracted debate over its validity (Robinson, 1999; Buttle, 1996; Cronin & Taylor, 1994; Babakus & Boller, 1992). Problems arise around what people base their expectations on, when they form them or whether these can be carried across sectors. Expectations can change with familiarity (Rosen et al., 2003) which will alter perceived level of quality and affect the validity of the disconfirmation model on which SERVQUAL is based. Experience is also polysemic with a variety of meanings and using the concept alone is too simplistic. An alternative model is SERVPERF (Cronin & Taylor, 1994) which, while based on the same 22 attributes as SERVQUAL,questions the concept of comparing experience with expectation (Cronin & Taylor, 1994). The model is more parsimonious, removing expectation and relying on data around performance only. This pragmatic advantage over SERVQUAL cannot be ignored since only one questionnaire is required (Jain & Gupta, 2004).

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Table 3
AUTHORS

Validity of SERVQUAL
LIMITATIONS SERVQUAL limitations: scoring, reliability, validity, emphasis on process rather than outcome, hierarchical service quality constructs, reflective scales, use of generic scale for all sectors, applicability for online use and culturally. It can be useful if adapted for specific industry use and it is validated through reliability and validity analysis. SERVQUAL does not explore the validity of its constructs in the public sector where service issues are more complex and there is a greater diversity of stakeholders. SERVQUAL and SERVPERF are of equal validity for diagnostic purposes, although SERVQUAL required more adaptation for different sectors. The choice between the two should be based on if the tool is to be used for diagnostic uses and operationalisation taking into consideration the length of the SERQUAL model. SERVPERF is simpler to use and explains variations in overall quality service, SERVQUAL is better diagnostically. SERVPERF is preferable for assessing overall service quality; SERVQUAL is superior in identifying quality shortfalls. The use of SERVQUAL in care homes across the USA identified limitations in the original version Some items were irrelevant. They conclude that SERVQUAL is convenient and reliable in measuring quality across countries, but more work is needed in cross national reliability in healthcare. SERVQUAL model overlooks key factors of service quality: the core service, systemization/standardization of service delivery (non-human) and social responsibility of the provider SERVQUAL doesnt ask what consumers want service providers to do; constructs are predetermined; service literature is still confused about the meanings of some of SERVQUAL constructs; it is not as effective as service specific models While SERVQUAL has been the preferred method of measuring service quality since the 1980s, too many questions arise concerning its efficacy for it to retain its prime position. Concerns include: generalisability across sectors; the measurement of customer satisfaction rather than service quality; the wording of questions, the relevance of measuring expectation. SERVQUAL has a major impact on business. But there are limitations around validity of constructs; doubts consumers assess quality as perception v expectations (hey do not consider expectations); dimensions are not universal; moments of truth can vary from event to event; use of two questionnaires causes confusion. There is little evidence of the validity of customers evaluating service quality based on expectation versus performance. Concern is also raised about the global use of the dimensions across sectors. Published SERVPERF model as an alternative to SERVQUAL. Saw the SERVQUAL model as too subjective relying on the transitory element of customer satisfaction rather than long term service quality. SERVPERF is superior as predictive tool and looks at weighting performance items. They question the inclusion of SERVQUALS expectations in health care where expectations are high across all dimensions; they also consider it the more useful as a diagnostic tool for managers.

(Ladhari, 2009)

(Rhee & Rha, 2009) (Carrillat et al., 2007)

(Jain & Gupta, 2004) (Kilbourne et al., 2004)

(G.S. Sureshchandar et al., 2002b) (Winsted, 2000) (Robinson, 1999)

(Buttle, 1996)

(Cronin & Taylor, 1994) (McAlexander et al., 1994)

(Carman, 1990)

The dimensions of SERVQUAL cannot be applied cross industry.

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5.

Dimensionality

Understanding dimensionality underpins everything else in evaluating service quality. This section explores the dimensions identified by literature and their relation to functional and technical elements of service. It also reflects on the importance of relationships in the process. Table 4 Service quality dimensions an overview
AUTHORS (Wright et al., 2011) (Rhee & Rha, 2009) (Sanchez-Hernandez et al., 2009) (Howden & Pressey, 2008) ELEMENTS Service Process quality, Outcome quality Functional efficiency Relational - empathy Know-how (technical expertise) Trust Personal interaction Interpersonal quality interaction, relationship Technical quality outcome, expertise Environmental quality atmosphere, tangibles Process Core service/service product Human element Systematisation of service delivery: nonhuman element Outcome Interaction Technical (processes, procedures) Intrinsic reliability responsiveness assurance empathy Customer-employee interaction (function or process quality) Interactive quality Corporate quality Technical Reliability Responsiveness Assurance Responsiveness Reliability Competence Access Courtesy

Interpersonal Design quality Relationship quality Tangibles Service fulfillment Location Direct/indirect costs Administrative quality timeliness, operation, support

(Dagger et al., 2007)

(Kang, 2006) (G.S. Sureshchandar et al., 2002a)

Outcome Tangibles of service servicescapes Social responsibility

(Brady & Cronin, 2001) (Daley, 2001) (Mels et al., 1997)

Environment Service (interpersonal) Extrinsic tangibles technical

(Rust & Oliver, 1994)

Service environment Outcome (technical quality Physical quality Functional Tangibles Empathy Communication Credibility Security Understanding Tangibles

(Lehtinen, 1991) (Gronroos, 1990) (Parasuraman et al., 1988)

(Parasuraman et al., 1985)

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5.2.

Defining Dimensions

Theorists have come up with numerous variations of these core dimensions, (Table 4) and while similarities do exist, there is no overall consensus about them, or whether they can be generalised across sectors (Brady & Cronin, 2001). Some have attempted to categorise dimensions into the Nordic approach, technical and functional, or the US school of thought as in SERVQUAL, but this is an oversimplification where neither fully define the service quality construct (Brady & Cronin, 2001). Dimensions often comprise a number of items, each of which may influence more than one dimension. While these offer a more detailed and well defined construct, they do not overcome the complexities of use across sectors. While authors present a variety of sets of dimensions they see as relevant (Table 5), there is some consensus that the technical and functional dimensions come together to contribute to the overall experience in health care (Dagger et al., 2007; Zineldin, 2006; Lytle & Mokwa, 1992). These have been described as care and cure (Conway & Huffcutt, 2003) where care is conceptualised as the functional elements such as the environment, interactions, comfort etc and are deemed as contributing to the overall concept of service quality (McAlexander et al., 1994). Being at ease with an employee can reduce anxiety as well as make the customer feel respected (Lloyd, 2009; Macintosh, 2009). This is particularly relevant in the case of health care where dignity and respect are high on the agenda and often quoted in official guidelines and regulations. Where comfort or intimacy exists, it is more likely that the customer will provide the necessary information to help the provider deliver the most appropriate service (Lloyd, 2009) especially in health care where patients are anxious and may feel uneasy in confiding everything or fail to identify important snippets of information. Dimensionality in health care is difficult to contextualise as it is such a complex service. It can be delivered from a range of environments including hospitals, clinics, and surgeries and even from the home. It includes every citizen since everyone is a potential patient and it covers a huge range of services and professionals. WHO use the word responsiveness to express a patients experience of health care in its widest context, defining this as including: dignity, autonomy, confidentiality, information, prompt attention, access to social support, quality of amenities and choice (Gostin et al., 2003). Key to health care are respect and dignity, each of which features surprisingly infrequently in extent academic models. Together, these allow patients to feel in control, valued, confident, comfortable and able to make decisions for themselves (Scrivener, 2011). These omissions need addressing to reflect the priority most UK Government papers referring to health care place on them. Nor is privacy mentioned which is a basic human right and is an antecedent of dignity (Tabak & Ozon, 2004).
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5.2.

Relationships rapport, respect and trust

The nature of services makes the proposition of value and quality especially unpredictable. There are many opportunities for something to go wrong when the service provider and the customer interact, when both parties experience and respond to each others mannerisms, attitude, competence, mood, dress, language, and so forth. (Berry et al., 1988 p.38). Service is based on the interaction between two parties to create value and the importance of them, especially in professional and high contact services is clear (Lehtinen, 1991; G.S. Sureshchandar et al., 2002), since interactions help build professional relationships which should ultimately lead to trust. Drawing on literature suggests a basic hierarchy of constructs (Fig 1) although these will vary according to the nature of the service. Fig 1 Hierarchy of Constructs
Trust

Relationships

Interactions/Human elements

Rapport respect

reliability

responsiveness

assurance

empathy

Compiled by the author 5.2.1. Respect and Rapport Of the five dimensions central to SERVQUAL, four of these are based on the human element of service: responsiveness, reliability, assurance and empathy of which responsiveness and reliability have been seen to be especially crucial (Rhee & Rha, 2009; Angelopoulou et al., 1998; Berry et al., 1988; Parasuraman et al., 1988). Missing from the model, however, are rapport and respect which, although may be implicit within assurance or empathy (polite staff and understanding/knowing the client), they should be first order constructs in their own right (Macintosh, 2009) and explicit as dimensions. Respect is giving attention to a person and valuing them, understanding the individual, responsibility, an interest in humanity and acceptance of differences in people beyond tolerance (Abbott, 1991). Rapport goes much further than polite staff and understanding or knowing the client as defined by SERVQUAL. It has been
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deconstructed to include mutual self-disclosure (shared information and open communications); extras (responses to simple requests for customisation or exemplary behaviours) civility/courtesy (Macintosh, 2009) and interaction (Gremler & Gwinner, 2000). It creates a bond and cohesiveness which in turn generates trust and can help consumers relax (Macintosh, 2009). To ignore the significance of either respect or rapport leaves the organisation vulnerable to poor relationships with the customer/client, potentially breaking down levels of trust. 5.2.2. Credence and Trust Trust is a construct that should be inherent in all professional services but is one that does not appear as a dimension in its own right in much of the literature. This may be because it is assumed that the customer has a right to be able to trust the integrity, knowledge, experience, skills and expertise of the professional providing the service. Confidence in expertise, dependability of staff and familiarity are each antecedents to trust (Macintosh, 2009). The fact that rofessionals are bound by regulations set by governing bodies such as the UK Law Society, General Medical Council, and Royal Colleges helps in building confidence for customers/clients. Perhaps more than any other sector, health care is one sector that is highly specialised and personal demanding immense trust leading to an assumption that this construct should be reflected in dimensionality. Quality in health care has been conceptualised as the provision of appropriate and technically sound care that produces the anticipated effect. (McAlexander et al., 1994 p.34). The clinical procedures and outcomes are the shared aims of the patient and physician and are seen as an implicit rather than explicit element of services which patients feel they are not qualified to evaluate (Rashid & Jusoff, 2009; Conway & Huffcutt, 2003). They, therefore, depend on being able to have a trust in the expertise of the professional. They seek other prompts such as the soft elements, which although subjective are easier to assess. Much literature has been based on these peripheral (functional) items (Lytle & Mokwa, 1992), but debate continues around how they are defined (table 5) and their subjectivity compared with technical processes and outcomes which are reported through performance indicators and used for accountability, regulation and accreditation (Rubin et al., 2001).

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Table 5 Dimensions in health care

Author (Angelopoulou et al., 1998) Dimensions Physicians manner Quality of information sources Physicians professional/technical competence Interpersonal relations/skills Empathy Autonomy Respect Information Dignity Communications Technical Amenities Interpersonal Responsiveness: Dignity, autonomy, confidentiality, information, prompt attention, access to social support, quality of amenities, choice Tangibles Security Accessibility Credibility Understanding Responsiveness Courtesy Communication Reliability Competence Cost Communication Cleanliness Responsiveness Courtesy Respect for People: Dignity, autonomy, confidentiality, information Client Orientation Prompt attention, provision of basic amenities, social support networks, choice Convenience Security Economy Performance Reliability Aesthetics Object (Technical) Interaction Processes (Functional) Atmosphere Infrastructure Technical care Patient amenities Service personalisation Accessibility Price Catering Environment Competence Communication Demeanour Cost Facility Food Empathy Physical environment Understanding illness Religious needs Mutual respect Dignity Core Benefit Condition/treatment/outcome Intangibles Reliability, empathy, assurance, responsiveness Tangible Appearance of personnel, decor of facilities, location of facilities, appearance of facilities Expressive aspects the art of care Instrumental aspects quality of care, efficacy of treatment, continuity of care Access /cost aspects e.g. cost and convenience

(Pajinkihar, 2008)

(Dagger et al., 2007) (Gostin et al., 2003)

(Jabnoun & Chaker, 2003)

(Hasin et al., 2001)

(Murray et al., 2001)

(Walters & Jones, 2001)

(Zineldin, 2000)

(Camilleri & O'Callaghan, 1998)

(Andaleeb, 1995)

(Tomes & Ng, 1995)

(Lytle & Mokwa, 1992)

(Smith et al., 1986)

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6.

Methodology

The research uses multiple methods to exploit the advantages of both qualitative and quantitative techniques (Johnson & Onwuegbuzie, 2007). It is the approach favoured by pragmatists where all that matters is whether a strategy works satisfactorily. There is no distinction between theory and practice. This epistemology is gaining increasing amounts of attention in social sciences which is becoming more complex and dynamic with an increasing need for a more pluralistic approach. It uses the most appropriate means to understand the question and solve the problem and is ideally suited to the health care sector where structures, processes and patterns are complex (Lowe et al., 2005). Qualitative techniques were used to generate in-depth data about the meaning of quality to both service users and providers. This data was then be used as the basis of a questionnaire distributed across a wide demographic sample. 6.1. Qualitative Process

6.1.1. Interviews A literature review was followed by a series of interviews to understand how quality is currently measured and what issues staff believe are important to patients/carers. These were carried out with representatives from stakeholders, managers and clinicians including: the chair of large teaching hospital trust director of facilities of a large teaching hospital trust the regional director of the Care Quality Commission a local MP a local authority representative medical director of a district general hospital matron of a hospice accident and emergency receptionist a senior nurse with responsibility for cancer patients a director of nursing a physiotherapist

Each interview was semi-structured and lasted approximately one hour in length. The aim was to understand what priorities organisations place on service quality elements and to understand measures taken to evaluate these qualities 6.1.2. Focus groups A series of eight focus groups comprising patients, carers and general members of the public was held. These included groups comprising people with multiple needs, young mothers, elderly, a user group at a local surgery and general members of the
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public and represented a wide age range from early 20s upwards. Members were selected from personal contacts and recommendations from organisations comprising the health economy in Greater Manchester. The objective was to discuss participants own ideas about the priorities they would apply to elements of quality (Cohen & Mallon, 2001). 6.1.3. Analysis The interviews and group discussions were digitally recorded and later transcribed. Copies were sent to the interviewees and to at least one member of each focus group to ensure that they were an accurate reflection of what had taken place. In the case of the groups which comprised participants with multiple and complex needs and the elderly, escorts who were present were asked to check for reliability on behalf of the group members. The transcripts were then coded via open coding and against SERVQUAL to draw out themes and items which were then used in the design of a questionnaire. This was an iterative process as the complexity of data required revisits in order to ensure reliability and effectiveness in the coding. This was especially the case when transcribing groups comprising participants who had complex needs and for whom communication was difficult. An earlier career in the NHS equipped the researcher with experience in communicating with staff at all levels and in dealing with sensitive issues among a wide cross-section patients and carers. 6.2. Quantitative Process

6.2.1. Distribution of Questionnaires A self-administered questionnaire was designed comprising seven themes with a total of 104 items derived from the qualitative data. Respondents were asked to rate the importance they placed on each item on a seven point Likert scale ranging from not so important to very important. The questionnaire was designed with the support of two senior academics and then piloted twice among personal contacts. As health care is relevant to everyone it was important the sample for distribution comprised a wide demographic. Anyone over the age of 18 was deemed relevant. This age was chosen as a cut off as approaching anyone under 18 would create ethical issues. Distribution was via a number of channels: Snowballing techniques through personal contacts Convenience sampling using personal contacts of the researcher A database 950 from the voluntary sector based in the north east of Manchester
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A national database of 5,500 taken from mail order customers and representing all socio-economic groups and demographics

More than 1,100 responses were received. 6.2.2. Analysis At the time of writing analysis of the quantitative work had not been completed. SPSS will be used to complete a factor analysis and produce regression tables. The data will ultimately confirm or falsify dimensions currently used in the evaluation of service quality in health care and will lead to the development of an instrument which can be adapted for use in clinics, local doctors surgeries or hospitals. 7. Results

The results discussed here are interim since only data from the qualitative work are available. The dimension that featured most prominently was aligned with SERVQUALs empathy. When deconstructed into items to reflect comments made by participants, the open coding suggested the factor was far more complex than suggested by either SERVQUALs original model of ten elements, or the later model of five. The open coding broke the dimension down into five distinct items: attitude, reception, empathy, respect and privacy. The last two of these reflect the importance literature places on each as dimensions important to professional services. Neither is made distinct in the SERVQUAL model. Assurance also received high scores and was easier to assimilate with both SERVQUAL versions, although the inclusion of polite staff and staff getting support in the refined model of five dimensions did not fit with the open coding which focused mainly on trust and safety. The most apparent omission within either SERVQUAL model was communications. This appeared as a factor in its own right within open coding, featuring third in priority. It proved to be a complex factor breaking down into 15 individual items. See Appendix 2. Access to services was yet another factor which didnt easily fit within the refined SERVQUAL model where it was represented as simply convenient hours are in place within the empathy factor, although it did appear independently in the original model. Yet again, open coding revealed it to be a dimension high on respondents agendas and one which comprised several individual items (appendix 2). There was some synergy with tangibles, although health care raises an extra item with the provision of food. Responsiveness and reliability were also aligned fairly closely with SERVQUAL.
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Table 6 compares the dimensionality of each model. Appendix 2 sets out the breakdown of each dimension into items. Table 6
SERVQUAL 10 Tangibles Reliability Access Responsiveness Understanding the customer Courtesy Security Competence Credibility Communications

SERVQUAL vs OPEN CODING

SERVQUAL 5 Tangibles Reliability Responsiveness Empathy Assurance Open Coding Environment Food Ease of access and reliability of services Responding to needs Caring approach Having trust in my care

Communications/involvement in my own care

These interim results suggest a degree of synergy between the original SERVQUAL model with 10 dimensions. They do not, however, reflect the complexity of each with reference to health care. 8. Limitations

It is likely that everyone has contact with health services at some part of their lives which means that it is not viable to reach every potential user group. Some groups were over represented, while others lacked representation. In the qualitative work, focus groups were, in the main, from north east Manchester and despite the high levels of black and minority ethnic (BME) groups in the area, these were not included, largely due to potential language difficulties and access problems where community members are less likely to participate in mainstream projects. Surprisingly few were included in the national database or the local voluntary sector for the quantitative work. 9. Ethics

The nature of the work was very sensitive where a number of respondents were reflecting on the circumstances of serious illness, or even death. Ethical approval was obtained from the National Research Ethics Committee North West for generic coverage across all sites. Focus group participants were asked to sign a form setting out the purpose of the study and where it is likely to be published. A similar explanation was included with the questionnaire the completion of which signified permission for inclusion in the study. All data has been treated confidentially and in the case of the qualitative work, anonymously.

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10.

Contribution to Knowledge

There has been little work done in developing new concepts for the measurement of service quality since the development of SERVQUAL 25 years ago. Evidence supports the view that the model is not ideal for general cross-sector usage and a gap exists, particularly in the provision of a service specific framework bespoke to health care. This is an area of immense topical relevance of which every member of the population is a stakeholder. The aim of the study is to overcome this anomaly by contextualising service quality in a health care setting, thus adding to the theoretical debate. It marries local strategic decision making with contemporary Government policy which clearly sets out a direction where patients are central to service delivery, focus is placed on quality and competition is likely to become a feature. The aim of the project is to tackle the miscellany of methods currently used in the sector by developing a fresh diagnostic framework to evaluate quality and tailored to local needs. In achieving this, it will help health care providers to identify failings and set strategy in accordance with Government policy aspirations to improve patient experience and in so doing establish themselves as a place of patient choice. 11. Conclusion

The evaluation of quality in health care is extremely complex and over recent years, has become high on the Government agenda in the UK. Despite this, there remain concerns about the overall issue of quality in this sector. While there is an abundance of work carried out nationally, much of it is performance which, although important, leaves room for more priority to be placed on the human elements of quality. As the most widely used operational model, SERVQUAL claims to be suitable for cross sector application, although further investigation suggests otherwise. It omits some key dimensions and items which contribute towards overall patient experience within health care, especially around professional relationships and communications both of which are multifaceted with a number of second level items. It also ignores basic constructs such as privacy, dignity and respect, each of which can be seen as human rights (Gostin et al., 2003). While recognising the effectiveness of using dimensionality in evaluating health care, findings from the qualitative part of this project support the need for service specific models to reflect the unique needs of the health care sector. 12. Future Research

More extensive research over if or how dimensions vary according to different user groups would create an opportunity to develop evaluation instruments for individual specialities. The principles of this research can also be extended to other sectors in order to create sector specific tools for service evaluation.
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There are also openings for further research into the relevance of customer service versus service quality in a sector where patients (especially older ones) often experience services in the long term giving them more experience allowing them to judge long term quality more effectively rather than transactional and short term customer service.

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Ladhari, R. (2009) 'A review of twenty years of SERVQUAL research.' International Journal of Quality and Service Sciences, 1(2) pp. 172-198. Lehtinen, U., Lehtinen, J.R. (1991) 'Two Approaches to Service Quality Dimensions.' The Service Industries Journal, 11(3) pp. 287-303. Lloyd, A. E. a. L., S.T.K. (2009) 'Interaction behaviors leading to comfort in the service encountere.' Journal of Services Marketing, 25(3) pp. 176-189. Lowe, S., Carr, A. N., Thomas, M. and Watkins-Mathys, L. (2005) 'The fourth hermeneutic in marketing theory.' Marketing Theory, 5 pp. 185-203. Lytle, R. S. and Mokwa, M. P. (1992) 'Evaluating Health Care Qualty: The Moderating Role of Outcomes.' Journal of Health Care Management, 12(1) pp. 4-14. Macintosh, G. (2009) 'Examining the antecedents of trust and rapport in services: Discovering new interrelationships.' Journal of Retailing and Consumer Services, 16 pp. 298-305. Mangin, D. and Toop, L. (2007) 'The Quality Outcomes Framework: what have you done to yourselves?' British Journal of General Practice, 57(539) pp. 435-437. McAlexander, J. H., Kaldenberg, D. O. and Koeng, H. F. (1994) 'Service Quality Measurement.' Journal of Health Care Marketing, 14(3) pp. 34-40. Mels, G., Boshoff, C. and Nel, D. (1997) 'The Dimensions of Service Quality: The Original European Perspective Revisited.' The Service Industries Journal, 17(1) pp. 173-189. Murray, C. J. L., Kawabata, K. and Valentine, N. (2001) 'People's Experience Versus People's Expectations.' Health Affairs, 20(3) pp. 21-24. O'Connor, S. J., Powers, T. L. and Bowers, M. R. (1988) 'Improving service quality in the health care setting.' Journal of Health Care Marketing, 8(4) pp. 63-66. Office for National Statistics. http://www.statistics.gov.uk (2011) London: [Online] [Accessed on 9 August]

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Appendix 1 QUESTIONNAIRE
There is currently much interest in the quality of health care and we are trying to understand more about what are the most important elements for patients, their family/friends or carers. We would appreciate your time in completing this questionnaire. It should take approximately 15 minutes to complete. Please place a cross in the most appropriate boxes that reflect your own opinion about the priorities you give to different elements of care. Your answers should reflect the type of care you would like to receive rather than the level of care you feel you do receive. Please return completed forms to healthstudy@hotmail.co.uk . Your replies are totally confidential. The information we gather from this questionnaire may be shared with appropriate health and associated professionals to help improve the services offered at NHS surgeries, clinics and hospitals. A version in larger print is available on request to healthstudy@hotmail.co.uk or 07847557672 All completed forms will be entered into a draw for 25 gift token for Marks and Spencer or Argos, depending on the choice of the winner. If you wish to enter the draw please give your contact details here. This may be an e-mail address, phone number or mailing address. These will be kept confidential. Name Contact details
THE ENVIRONMENT IN WHICH I AM CARED FOR
I want ... staff to be smart hospital signposting to be clear hospital waiting areas to have things to do staff to wear badges providing their name and job role decor in a hospital ward to be bright, cheerful and welcoming staff to wear uniforms which help identify their position and seniority local clinics/doctors surgeries to be bright and well decorated equipment to appear to be modern staff not to wear uniforms efforts to be made to make hospital environments as relaxing as possible good bedside entertainment such as TV/radio to be available if confined to hospital equipment to be undamaged and works first time there to be sufficient comfortable seating in waiting rooms
Not so Important 1 2 3 4 5 Very Important 6 7

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A CARING APPROACH
I want ... the receptionist to be friendly and courteous not to be asked for medical information by the receptionist to be asked what name I should be addressed by the professional to show interest in me as a person, not a set of symptoms the professional to show respect towards me the professional to help me to relax during a consultation the professional to be friendly and informal the doctor to understand me as a person and my needs all wards/departments to offer similar standards of service staff to have people skills
Not so Important 1 2 3 4 5 Very Important 6 7

COMMUNICATIONS/INVOLVEMENT IN MY OWN CARE knowing whats going on

I want ... to feel comfortable in asking questions to choose where I am treated professionals to have all the relevant information about me to hand information to always be given in simple, jargon-free terms to be given appropriate information at all times during my care to choose who treats me to receive important information face to face rather than by letter my records to be made available to me on request not to have to repeat information to different professionals professionals to ask if I understand what they have said in case of accents or terminology to feel my doctor or other health care professional listens to what I say to feel assured information is passed to other departments/agencies if necessary staff to refer to notes about concerns I have, my dislikes/likes etc information given by different staff/departments to be consistent to be given my options and involved in deciding the appropriate treatment to feel that I am an equal partner with the health care professional is important equipment to be available so I can take my own cholesterol and blood pressure staff to be aware of patients who are hard of hearing and speak accordingly staff not to speak to me in a patronising manner
Not so Important 1 2 3 4 5 Very Important 6 7

RESPONDING TO MY NEEDS
I want... not to feel a nuisance if I ask for help when in hospital nurses/assistants in hospital to answer calls for assistance in a timely manner complaints to be handled in a timely manner not to be moved from a ward with no notice someone to reassure me during uncomfortable/painful procedures any complaint I may make to be addressed appropriately staff to show a willingness to be helpful to know who to speak to if I have concerns to not be transferred between wards during the night or at meal times my needs to be assessed and appropriate action is taken if I have a problem nurses to be aware of my personal needs/concerns/fears not to feel uncomfortable if I have to make a complaint staff to have time to cater for my needs and to make me feel comfortable Not so Important 1 2 3 4 5 Very Important 6 7

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HAVING TRUST IN MY CARE

I want ... Not so Important 1 2 3 4 5 Very Important 6 7

to see the environment at the local doctor/clinic is clean to feel that the doctor trusts what I tell him/her the doctor to refer to a book/website if unsure about something the professional to take time to conduct an examination, treatment and/or tests to have trust in the clinical ability of the person treating me information about the professional history of my specialist to be available to me not to be asked for personal/medical information in a public area/waiting room where possible, to see the same professional the hospital to look clean the doctor to be sufficiently competent to not have to refer to a book/website the hospital I attend to have a good reputation/be free from public criticism to feel the professional knows me well enough to understand my needs there to be co-ordination between staff/departments providing my care In hospital to know my doctor the doctor to have my full medical history to hand the doctor to take into account my medical history where diagnosis is difficult to be sure my personal/medical history will not be passed on in error access to wards to be controlled there to be general agreement between professionals about my treatment to feel there is no danger of accidents when in hospital to know the doctor is competent even if he/she is not friendly strong leadership to be apparent and reflected in the level of care to see the hospitals record on cleanliness, e-coli and MRSA clearly displayed

EASE OF ACCESS TO AND RELIABILITY OF SERVICES

I want... Not so Important 1 2 3 4 5 Very Important 6 7

it to be easy to get timely appointments with my local doctor/clinic appointments not to run late to be able to easily get through on the phone to the local surgery or hospitals opening hours of local surgeries/clinics to extend beyond normal office hours the location of services to be convenient an explanation if appointment times are not kept to to have the option to see a GP who specialises in my needs not to have to spend lengthy periods in waiting rooms not to have to pay to get a faster or more convenient appointment physical access to premises to take account of people with disabilities home visits to be easily available when needed especially for children/elderly it to be easy to speak to the right person it to be easy to speak to a member of the ward staff if I am in hospital to feel unrushed when I see a doctor or other professional to have plenty of notice and reasons given if my appointment is cancelled to be able to discuss more than one problem at one appointment staff to do what they say they will when they say they will do it plenty of car parking to be available be able to get timely appointments for specialist services a choice of dates in the case of needing inpatient treatment car parking to be free of charge

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FOOD I want... volunteers to be on duty to help patients eat light snacks such as toast, teacakes, fruit, ice cream to be readily available no activities (except emergencies) to take place during meal time to allow staff to help patients not to have to decide the day before what I want to eat the following day food to be appetising and tasty Not so Important 1 2 Very Important 6 7

ABOUT ME Please place a cross by the appropriate category I am: (a) Retired (b) A homemaker (c) Not employed (d) In full time employment (e) In part time employment If (a) please state what your occupation was If (d) or (e), please state your occupation Do you have qualifications? Yes GCSE A level NVQ (or equivalent) No HND/HNC If so to what level? Post Graduate

Degree

Professional

Other (please state) Please place a cross by your age group I am aged: 18-35 36-50 51-65

66-75

76+

Please return your completed form to healthstudy@hotmail.co.uk.

THANK YOU VERY MUCH FOR YOUR TIME

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Appendix 2
SERVQUAL vs OPEN CODING BREAKDOWN OF ITEMS
SERVQUAL 10 Tangibles Appearance of physical facilities, equipment personnel and communication materials SERVQUAL 5 Tangibles up-to-date equipment physical facilities visually appealing staff well dressed and neat polite appearance of facilities in keeping with the service Reliability staff should be sympathetic if customer experiences problems when firm promises something by a certain time it is achieved dependability provide service at time they promise records kept accurately Responsiveness provide prompt service tell customers when to expect service willing to help customers staff not too busy to provide prompt service OPEN CODING Environment Modern looking equipment Light spacious environment Smart staff with ID badges Appealing waiting areas with seating Good signage Bedside entertainment Food Help with eating if needed Light snacks available Appetising food Ease of access and reliability of services Timely appointments available, not to run late Get through easily on the phone Convenient opening hours Convenient locations Specialist GPs Home visits Physical access for people with disabilities Easy to speak to right person Feel unrushed Staff do what they say when they say Car parking Flexibility on appointments Responding to needs In hospital to be able to get help when needed Not to be moved without notice Willing staff To know right person to speak to Nurses to be aware of my personal needs/concerns/fears Staff to have time to cater for my needs Complaints dealt with in timely manner Caring approach Friendly receptionists Privacy To be seen as a person, not set of symptoms Staff to have people skills

Reliability Ability to perform the promised service dependably and accurately Access Approachability and ease of contact

Responsiveness Willingness to help customers and provide prompt service

Understanding the customer Making the effort to know customers and their needs Courtesy Politeness, respect, consideration and friendliness of contact personnel

Empathy staff know the needs of customer staff have customers best interests at heart staff give personal attention staff give individual attention convenient opening hours

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Security Freedom from danger, risk or doubt Competence Possession of the required skills and knowledge to perform the service Credibility Trustworthiness, believability, honesty of the service provider Communications Keeping customers informed in language they can understand and listening to them

Assurance customers can trust staff customers feel safe polite staff staff get support from firm

Having trust in my care Clean environment Doctor trusts what I tell him/her Professional takes time Trust in the professional Information about professional is available Seeing the same person each time Co-ordination between departments and agencies Communications/involvement in my own care Feel comfortable asking questions Professional to have all relevant information about me to hand To be given appropriate information about my care My records made available on request Not to have to repeat information constantly Accents and terminology do not impede my understanding Professional listens to me Information passed on where necessary Staff dont patronise me Staff refer to notes about my concerns/preferences Consistent information given To choose where I am treated and by whom To feel an equal partner

The items within the open coding will be refined following a process of factor analysis.

Margaret Hyde