r.

I
t

.fl1|rr r.rl.,.lS,rrrrr.l l Zr)11: 1r,i. 2,

Contents lists available at ScieitebDirect w

Information Sciences
journal homdpage: www.elsevier.com/locate/ins

Fuzzy vll(oR method: A case study of the hospital

service
evaluation in Taiwan ffi c,orrlrl..t

Tsung-Han Chang"
Department of htformation Management, Koo-Yuan
university. 1821, Jllongshan nooajirl,1n, District, Kaohsiung
city 821, Taiwon

ARTICLE INFO ABSTRACT

Art[cle history:
Received 25 March Z01Z
This study proposes . fr ;,ilry *d ,l* VIt oR
Received in revised form 5 method to provide a rational' scientific and systematic process
June 20,l3 lor evaluating the hospital
Accepted 15 February 2014 service quality under a fuzzy environm"nt *h"r"
the uncertainty, subjectivity and vague_
Available online 25 February 2014 ness are addressed with linguistic variabres parameterized
oy triangutar ruzrf-nu*u.rs.
This study applies the fuzzy multi-criteria decision
making appr.oach to determine the
Ikywords: importance weights of evaluation criteria and the
vll(oR method is taken to consolidate
Fuzzy sets theory the service quality performance ratings of the feasible alternatives.
an urpiri.ul ."r"
Compromise solution involving 33 evaluation criteria,2 public and 3 private
me<iical centres in Taiwan assessed
VII(OR by l8 evaluators from various fields ofmedical industry
Hcspitai service quality evaluation is solicited to demonstrate the
proposed approach. The analysis result reveals
Multi-criteria decision making that the selvice quality ofprivate hospitals
is better than public hospitals because the private hospitars
Trianguiar fuzzy number are rarely subsidized by
governmentar agencies. These private hospitals
have to fend themselves to retain existing
patients or attract new patients to ensue iustainable
survival.
@ 2014 Elsevrer Inc. All rights reserved.

1. Introduction

Delivering' building' understanding and maintaining better

service quality_ are the major concerns of every industry
today' service quality expectation has been used to eiplain
importance' and customers' evaluation on the service quality
.r p..oi.ril"s of service, an ideal standard, an attribute of
Ig)]. rne main purpose of evaruating service quality is to
measure service performance' diagnose seryice problems,
*rnag. seryice delivery, and provide the optimal service for
all customers [64]' A considerable number of studies have
been cJnducted to evaluite the service quality of various
which include retail [5,4N8 !)3],. p-ublic agency fields,
I39i, bank l4sj, web service 114.25,.].J.45,67.1371, airline and airport
ll9'20'2$'56'57'6s'69'90i, h-otel i6,13,43:)1:96f iralfic and transportation
care f 1'10'17'46'62'79'Il1]' service quality assessment {7,s3,72l,supermarker f 661, hospitat and health-
and control in hospital and healthcare date back to the
century' At the end of 2010, there have been 513 public and private mid-19th
hospitals in Taiwan. Faced with continuous compet-
itive pressure' a growing numtler of medical providers have
realized that being able to provide good healthcare seryice
quality is the most important factor for ensuring the
future success gi:1. ro, patients, quality and effbctiveness of
pitals are two major concerns when seeking he-althcare the hos-
services. If the'patients are not satlsfied with the service quality
which the hospital provides' they will seel< the healthcare
services elsewhere, Hospitals, therefore, have to enhance
their

* Tel.: +886 7 6077940i fax: +886 7 60777g8.

E-mail addresses: tll00B2(0r:t:.kVLr.e tlu.lw, rh{hnng05 )6itli:;s1;r.,r;,1"r,rru.r.

iril rl,.rlr)r.or^. lr' :',to ..,,,..2U14 Lt/. I lq

':
0020-0255|tc- 2014 Elsevier Inc. All rights reserved.
 A. Meesala. J. patil

rou'/nalorRetaitinsandconsumerse
;:i::.fi:itH :':::.::]11:o to..qualirv manasement
u*ur"tv. ii,l shn,,,. Nordicschoor
and sho.ld
rRY-!Yx\
view((iriii,u,,< .., ,;,.,
rrearthcare,no,T-I?"
",loi^-.T''rasement ilH::HlJ"i;"ffii:irl;xi;ii ,:;:^^,-*'*'*'*'-/
. ;tr!;:t:i;i,,ri;J**ffii{i:i::"ilifi#iiil# f;.tf.ilj;n..i[:t"fi,1|1!il".11;fii::,';H:':'iT'$:::i
in ,r,i" ron!.,*'"sr'"' '"iil,-"*1ffi.ffiL:;m*ll.-:.,1g
i;r'**i'luaivservcehas,w.
*
11re
wiierr.:,",-:"p,".9 service
qtrarity (sERVouAr.) _""
dimensio.s
o'n'?*,ti,i."*"1i"l:#-i*;il;H;"il:'1f",
dime'sions of qualitv
seMce' rhev are: (1) rrrere are rive
langibiliry, reliability, .".oonriu".:*vQuAl) ^:^-:, - tl'uot';;i:'1 tansibilitv
",r.,pu,ny.
be sttrdied to understani tnr'i'''";
outcomes.r.n .lnj^":,o:,t tr,"i. ,il;""',nff[|'',i:u*'":::::
i.;;;;'i:',.i"a*.r."*"'-"",,1a 1t;i1i1t*'
_*j:l,i 8ii:Y'::JJ:I'-:T,ll;,,1:1T:*
i;;11;;,;;:;:ff11"T.1_appearance or p"*onn.r); (2) reliabiritv
lfr*m'I'*;lg :'Y*-u'l'"0"i'' l"i "'",.",-,,!1
:::i::1:,,*."T:-.*. t,::*;ilr'-lT:
:"il*j.*ffiJil1;;:1mffilififi:pii$a*xff: ,tfrii1ft:il-t'H*il*t"t,"""rr"'nplmxir,d*
;::#::,j,jrT,*{iliii:t*1ffi***l}#jl:l;;'tr
,r.r* ,rr.i *i,"i '&(vIIv ,{11;i#."r,'}*!;iii{1it''i"n:;:i"',"ill1;i*#}#
ir ,**"r" i"".,t'"J"o1tll"t"
functional
a quality system
suDsrdrzed' Inrportarttlv.
*" potentialiv
rmprove trra
concomitanr ,o*tol Iitetaq' anJl';;,;i;' rr'"
ouali
p'ti""t';::l:fl::i t;';o;;;;-un"'Jt
porenrialrv ,.u"1 T"tntss' there t''l"a-r*
advice on .ho,.*
t"ll"
patienrs 0"0""a"""'T"'""^ "*ttto' iil,' -
;i:ffi:JT m;,.t"i:.*-iifuT"il'"ij,:ffi,,'":ffi il;:'#ffi$,","""T#,:t:{f$'":'ffi:li$:1ry*;li
*J:lt*H*.T,t,'#:.-ir;;:' nj ff,rf i*5tn*#,lJ]p"i""
jl;'*: tfui:
rTilffi
":trtfr ruril r*i4.i;n:
'J;".r"'""'ls survcvgl'
ffi3tr[',::;,,.i3ly j]ii!!:"1""i','Jm:*'ixi;;t'.*l*[:T ::f:"]:: jr'l.t':i::
tty governments' antl
'"*'ai";;
t"a"iry on-.ar*.r\l
prorrder. ou.,".J1ptv,i"iun, io.'ffiJT"il:';f;,i:T;:ll::
mn
,-J.'ffi#*:fui;i::6fmmilT::i"[]1:J:;i
a n,"n..n.' upt'+titliifiilx-l.;;;t:::TffJ:T:::,?#
patients. In nutshel
on the consum..'t;ff"iljYrj d" ;.;ililervice eualiry variabres
iitryi"tf;;jffi'{{.,-,'Jii,?lx:{fril:,ffiil$li
mostimportan; f"';;'""
Notablv' phvsician's
decision i. tr'. .".oni
Isik et al
a"""r"o'"r .",,;;;, T::"'"t':n arnong patiel ;;#;
(2011) studied
the appricabiiity oi
stucry urrcove'rs;;:l':-,:l i"ili SERVQUAL dimen-
generar ,.*i.. o.juniz;;,;;;;;.:-JJiffilJ";;lli;",f
can be useru'o;._r,'1. ,,.-.ii,,,i ..'"i,1"1 .oa.iing
**:ii3:'::::J.il::"throulir
lflluring'".,.,,""i^'r"'::::::,j:,,"j:e
sERve'UAL is a usetui
2. Lirerature review
and hypothesis ffffi:"".-",;r*;.':.""1;"yiil::",Til1',J*.?,J1, ':::r:::I-

' The foundation for the sriprrnrr^ '

:J,hiinT*r";Td:Hi:L'"#;:'';;',1"i;iil:ili;fiTi ffJ$l;T:il:t*;;iH::,i:iii'[:T"lTfi:J,",*,,"":-n',ri':t{
:T:ot"t satisfaction are re'
' vr r'stalrce' qttality service and

;j"ijfl;"ffi ;';;;:
;;ffi *j}i1ii,,il"' uw;;yirfu::u i"1ffi[':]:l,TJ: ::il ;:*;;
tt'' t'o'piiur o"a it, i.plii"ti"", :.
ft:tiff'""X,"J"#i;,fitiiliii ,ln: I:*l:::,:;::,1lXl'"Ti i. ii*"",.d in the

*}"i*:::Ts,'T;i'ii"."'*loo""f,';J':x1#il:; i*
-r;* t 2 consume,1s sahs/acrrbn

sanuo'nrl;";i"fi;t"?::i:#J'"'"t;J:."J"r:"i:i:*,:',t$ satisraction is.trre key

Serwice quality is n pu*!l',,,-".'. ractor that drives whe'
the

i,l?Tff;iit:Trtf #fiTiTi,#:gg,gqp*m ;i:li#,';',":l;,,iffl,l,'-* ***#:ri,;::':*;:

L{i{18). World Health (

'.u,r,,v.,".im;,ilr:rc#''i:i1T'il'iJill"J":*{;lij m;,;ir,l#[Jt+i$il$**kTih:T:J':';:
f"lii":',ffij19-:1;n::il**','."y.11:,::liH ffl"il: ;11:fi:''""' '"J 6i;;;,;;ii'J#[}lT["Jn{i],Iil:':l':.1:'lhf
waste), (3) accessibilit
;;;;;;;;,;il#i:""1': ancr'avoid ;t"Sf:i,i-,:il]!-:l,T i:';q ;ii ti:,f.:,ii3-;[tT:.".:;
acceprance/par,.n,-."nI -(-'1':lv
(takes with a product;;
ences).. (5/ ecuirabir;ry lled ii;11,",11'lil{1] ilfTll"'"" ;.,*:- after severar pur.l,ur.,
asgender;"i;;;ttoes '","-T.J"r"i"t
not var.v in quaritv o1;_1" blg'" ,: "";;;",;;i,r. and rheir
1".,"*.,,"r, ;ffi1[J;:#.J,fii;"].,#1" ono,r,",

;'lilm:;ilxTr:T:Tf:15:li"fiT*ryrulrr
i":ru **",:*;,J:"i-1::
de very *".'. ttt *
:fiilf::t3#H*:ii:ff::rTr;:'"?,'"r.:#*ii;m;:x
fi;Jiili*; ;J:;Tfr:ilii!,ii,li*;#'fl.ffi17
1_ quarirv ;;,;;-,,",
.'UruiU[ritJ,T[.ll$:i':T:lJ..""l"it"i:,service iz,i,, :i,' ,j f;;ilIT:H;,:.1;,"Ti;*1",f"trffiilj
cusrome*nti,ro.,ion
-u;ix*m"ilitg**::ilff"f recomm";;';;;;;;::;*' rovartv'
r*r,,,, ,'.'", . ,uuo; purchase
i20J l)
Resarding service qualiry
ctinensions, there 2.2. Patient's ktyatty to
(1) Nordic school view }l.ltt#""1t^Jj-il:: hospitat
""i lzja-"ffi':ilT;ff'H:::t:it:; rheco'sumerwhoreturnsseverartinrestobuytheservicerromthe

2
 A. Meesala, J, paul

Table I Journal oJ Retailing and

Consumer Seruices rt (ltrr) lrtr_rrrr
Relatd Studies on Impa(:t
of Sepi ce euality on
_ Customer satisfaction.
Author and year
Purpose / Objective
Method
|,ril,nlkv ettla). Findings
To nreasure quality of
Service euality in seryice ip Using Parasuranan et al.
selEct hoslitals in Krishla District
Healthcare Sector: Demographic factors and
oi Andhra pradesh, Inciia SERVQUAL morlel (19g8)
An Exploratory and that
qragnose measures seruice quality_ socioeconomic status have
a
Study on Hospitals. taps deep intpact on patients,
IUp JoLo.ncil Of satisfaction.
Mo*ettng
Manugement,
13(1), 7_28.
l,iri;rri.trr rrrij,{l.rbltr A new model to gauge
i:lill.1). Bevond the Based, on the patieDt
organizational and ntarket ratings f.om
seryice process: The factors Physician ownership,
that inpad rustomer,s experirnce therHn5pilsl Consumer
effects of sPecialization, and ntarket
both directl)' and indirectjv Assessnent of IJealtlicare
organizational and competition significantly
through their inlluence Providers ancl S)6tems afli:ct
markeI factors on on the aud the
seryice process. Americat Hospital Association Patrent ratings DimensioIs of
cnstomel the scruice process a(t
Annual Suruey rvas empJol a5 a
perceptions of ed to
deternrine organizational anrl rrediator between organizational
health care services. and market factors and patient
market factoii,
Journal of Service rattngs,
Research, 17(4),
399_414.
trVongmkmit, p., and
A complrative inrl)sis
Thawesaengskulth_ to show lhc
(lrtl(rrllces in lhe perceived Both a nrodified SERVeUAL
ai. N. (2014), seruice scaie
qualjty among paticnts flnd thc Kano mq(lel to The ieveJ of quaiitu attributes
llospital seruice li.onr catcgorize
ano pnontize a hospital was clil rent lbr difterent
dihereDt natignalitjes (Jxp2a. s seruic"
qualif, preferences qual jty attributes. nationalities.
M1'anmar, Ar abic Srates. Varjance
among culture ;ncl
Thuiland ). analysis to differentiate marl<et
diversitl. fotdl segmentation based on nationality,
eLnlity
Ltatngement &
Blslnsss
Excellence,2S(7/
8),908_922.
t.,ittt 's.',:\ t', A. iLlt):t).
To itvestigate the various
Configural 645 self-administered
sufflciencv conditions influencins
algorithnts of questio|naires fron patients Patient satisiartion, patieri
patient loyalry to a hospitrl. of all
patient satisfaction, pafticipation in the process
c4tegories in a ntajor medical of
pafticipation iD diagnosis, and patient
center jn Taiwan and applied
diagnostics, and fuzzv participatioD in treatment
set qualitatj!r comparative
tratment anaiysis (fsleCA) to it. decision-making combined
decisions, together suffice for high patient
influences on loyalty to the hospjtal;
hospital lovalty,
JoLu-nal of Serutces
Marketing, 27(2),
91_103.
1)r,)ll i2{il tii. Relating
To investigate if patient
Patient Satisfaction 870{) participants (61% American,
satisfaction with healthcare
to Insuralce varier Patient satisfastior varied
by different Rpe of insurance 39"" Canatiian) infornration, which
Coverage: A thev Drade avajlable rvith greatll rvith the t)?eofinsurance
coverage heid by the patient.
Comparison of Also informatjon. A comParrson thev held. Also, Arnerican
to determine whether overall
Market Based and between Medicare ancl, Medicaid, patients with employer-basecl
satisfaction is higher within
Govelanlsnl employer based insurance, lnsurance report higher levels
nrarket-based health chre and the of
Sponsorecl Health systems satisfactioD as cgmpared to the
as tound in the United Statcs National Health Insurance
Care. Acadenul OJ.
of nationaJ Canadian system.
Canada.
Busines.s Research
Journal,26_16.
i.fi.i2l I JJ. The impact
To study the inrpact of high-
of high- The rcsearch model was tested
pedonnaitce work systerrrs
performance work using structural equation tnodelins Hospitais can indeeci improve
(HPWS) on employee
systems in the attjtude, custonter satisfaction and Ioyaltv
for hrootheses uring anto t
health-care
seruice quality, customer o, i 9; through effi cient operations,
satisfaction, and customer pairs of employee-customer
industry; ernployee lovaltv empioyee engagement, and
ia various healthcare rdsnofidents spread among
four better senice quality.
reactions, seryice selectrd hospitals with more
organizations. than
quality, customer 500 beds.
satisfactjon, and
customer loyalty.
Seruice lndu.stries
Journal,32(1), 17_
36.
I lr,rl;r' rrri !!",;I ritr
T0 determine the association
i:l{} i t, l. Addressing A sample of 4,1 12 adults aged
between a patient,s spiritual 65 Highlights the importance of
Older Adults' needs
and their overall perception of Years and older and who were
Spiritual Need.s in consecuti\'(ly discharged tlrrring addressing a patient,s spiritual
satistactiou with care. a n^eds by conducting
l2-nonth ncrjod (July 2007 ;rroler and
ethctent spiritual assessment.
(cotttimretl on next page)
 A. Meesalo, J. Paul

Table 1 iconhnueCl

Purpose.'OLjectile

-::.:i -:l: through June 200S) from hospitals

:.__::: -- in three geographically diverse
regions of tie US: California,

.'''.'-.'.' Texas, and New Engiand.

i! Lr--1!S
l{l::l'lr. H., Xrro:tri.<
.::. R. J.. and
Chunxiao, lf.
{2f108). Sen'ice
L0\alt\: An
iitegratjve Model
and E\amination
Tc cier.:lop a nodel that links
dimensions of customer ioyalty
such as cogniti!e, affective,
inteDtion, and behavioral with a
cohesive and sound system of
determinants.
The data comprises 3500
customers across China from
various senices such as airlines,
banks. beauty salons, hospitals,
hutel:. mobile telephone.
This research added a new aspect
of customer loyaltv to the
literature that of-commerciai
friendsri:. The kev loy-alty
ia(:,:: c:i ! i:it-,ner satisfaction,
C:.r:.:::1: S::. ia! i:i:neSS.

a!-rcss Senice
Cantefs./ournol
O,r.r-cn ice
,R.se(r rl. / i(1J.

To investigate quality conte\1, Surti o:re':f i:: :\ir:i:r as l: r

- . The impact market orietrtation ald their eftect 7{0 hcs;:::.Lr rr.a,s-i:.r:e ::t-: : ::
oi qualih context on organization perfornani*. cential L'S. l.:. r..;:. i:-:.::
ancl nrarket
betltrer. !at::--i, :,i .^:::
orientation oD or gan:ZatiCnrl :.::t:i:::.: n::,:.:
0rganizatj0nal the hospltal r.j:-.::-, -:: : ;
performance in a
structural eq:::L::s :.: ::..:.:
senice
en\ironment.
Journctl Of Seruice
Research, 4(2),
140-1,54.
l. l)ar rrr(i \llirliirl To cr:,rrlLe ::e pi:<-. jsr ::i: B;oad range of p.r:-.::: y:- {! r:'
trlr! l. CaptunDg : :i ": t::::tire
i t: in:: ll la,ll:i:llii:::1 :t:t:::::i ntale. -1.1 iertal: !:,: :i: :::(i tf,- r : "::: :: :: ::ll:aCted b)'
-: - 1 :
the dynamics of in- lrn.rta:i:E paj:::\e :::c -:a:aa:L:: prcre:s los:t:fr a:i ::;::: : ::,-! :1: ::ir- :l l::-:rOCeSS
Process nr!;tilr) iinJ :.:l:siii.tt,,: , :ra:: sii:j:t.tctiun anJ =r. ,:- -:' ;::ir-3 :::,::.:: I l:.-:t ;uere
consumption hiSh ir-prciess pls:t:re er.t:tols tire:: ei:rre ::;r
emotions and on)r') could be mcielec r,i:h
=:;.:-.: .t:xl :l
s::r ri 5 da'.s)::; rl:t:: :r.::':-: .le" lh starus) iactors
satisfaction in s:alistical confidence and the r::a:5!enl\ e.rl::-e::s ;i :ire .r:1,::r:::: :t;:t:ent trenCs in
extended senice model shorved a good abilir io sili .3riab-es r:iEn cepafiure. e:::t::r: .1 sle:; increaing
transacti0ns. predict retrospectile globa) l:lrls rrere resi:3 .rsing a tieni rr -re enotions \1as
lnterrntiona[ judgments. Cr il:,4 :la.irsrI :!del noiiced for men as conpared t:
Jou'na[ Of r\ omen
Research In
Markctirtg , 1 5(4),
309-320.

same firm is a loyal customer. But customer defection is not the
opposite of customer loyalty and vice versa for several reasons like
availability or lack of choice. According to Lrve,squ( irtrl )l. ir ..r.1
r,,1r ii, approximately half of the consumers stay with the firm er.en
when their problem is not solved with firm's service. A \.ariet\- of
reasons such as high switching costs, non-availability of truly. differ-
2.-i. S.,-. :.'p qLo1iry and cotlsutner sotl-yoctlon
)1et:cro-cqicalli', the SERVPERF tiamervork marked an inprove-
ment or e: the SERVQUAL (Jairr lrr\i (;ul)lii. 200:1). Horrevrr.
SERVQL.{L framervork has been used to assess serdce qualitv in :
variefl of sectors such as banking (.lrhigir'. 2iX]6; liell irt ll.. r .

entiated alternatives, choice constrained by the loeation, mone)'and
time. and inertia or habit make a customer staywith the firm (l-trtr:er'.
. - .' . . :rntrv and ljinhs, l!!)6).
' r r.ri :,]{XXi) argues that patient's loyalty can be measured on
::-.::c components (tri-component model); they are: (a) using the
::r\-.lers again for the same treatment (UPAS), (b) using the proriders
.,:...r: tor different treatments (UPAD), and (c) referring the pro\iders
: -ii.ers (RPO). This research shows that service qualih', which is
:.::j-:ied on these three components, can predict patient lor,alq and
::.:--:rstrates how to measure the service quality on three constructs.
:r:::r.... (1) physician's performance, (2) nursing pedormance. and (3)
::::i:-rnal quality. This is premised more un the performance of
rr'. r..:ils but not the total systern of delivery. SER\-QL-{L that
::::::s .l cielivery system better suits the purpose of our papcr.
hospitalil- ()r.,.t ir and llLr-csain. 20{)5), internet marketing (l , -
\lL]1. ': -: rr), insurance ('l sor.r);;rl.os irn(l llilnd,2{XXr), and resti.';-
rants (t.r ' .: 1.. 2{}lo) as measudng performance could be ditficult to
implement in many organizations due to inherent and stmcru:al
problems relating to consent for collecting sensitive data etc.
,' Sr''jnr:hrrrt (2{)0 ll observed a strong relationshiLr be-
lrreen qLralih ofproduct or service and satisfaction ofconsumers. Tjle)
fuund that consumer's perception of the quality is an inrpr::.:.:
verl.rble rleternrining the satisfaetion level. Similarll. (:.,.. ..
based on the study of customers of Malta's banks, found that
custorner's satisfaction plavs a mediating role in sen'ice qualitr' driurg
customer loyalty; importantly, senice qLrality is an important driler oi
c,,lstonrer satisfaction whrch explains 53% of vadance. Srmilar.r'.
'r :'-'. ri i2il0.jt confirmed the direct relation between each oi-th< tive
cimensions of sen'ice quality and bank's reputation; bank's reputai jon,
i:r turn, inrpacts customers'repeated purchases and lo)alt]'.
,\:rlrlli el al. {2(}lo) exanrined the relationship of qualin. senice

, :r:.eived quzrliq'senice Ci:';=s ..'-::"::,:-,- :.--:--:.r .:
" ., .: .: ,rl ilo{.t(.lJ; .\llt;t.,. . .:::..';....
-,.-::. ihe researchby Lrlrlbrrl.,1 , .::1.-\':* t rr..-, ::t...i
' i.: ::::: and indirect effects on behaliorai inlen:r:,::.
- ' ., . r r,f rl. i:{)l4l l-ras tested the framer,.,rrk :f P:rasur;rr:a:r
:: a.. s SERVQUAI var-iables using the data coilectei tlom 350 patients
and found that empathy and assurance dimensions are positilelv
related to customer's satisfaction but not others: customer's satisfac-
tion has a significant effect on repurchase intention and rr'ord-of-mouth
communication. Contrary to general trend in research findings on
qualit)'service dirnension and patient loyalq', tt.,.-': ,.:: ii.. : r..
i-(rl r ) has shown that the essential service attributes do not relate to
customer's satisfaction in Taiwan's medical sen.ices: similarlr'. custo-
mer lo1'alty does not depend on clrstomer satisfaction and clrstomer
con-iplaints since barriers set up do not allorv the customer to change
the service provider. ltl;rrrl]a t,20121, based on the data from 210
patients of a private hospital in H1'derabad. in India. estimated a
customer satisfaction iudex score and the values u'ere coruputed as-
75.87 (out of a maxirnum of 100). The factors cn rrhich the r:lcier ri'as
computed are: (1) reliability, (2) knorrledge. t'-ir atritude. ({l ccmmu-
nication, (5) availability, (6) safet)'. (-) l:-;str,-::riness. tE) ccnsis-
tency, (9) equipment and facrlities. and i.1['] p-c:ptness. The facrors.
lr'hich got relatively low scores indrcat:ng the ne--essii; of in::re,liate
improvement, are: (1) communrcation. (2) pro::rpl:ess. anC a3) arail-
abiiiq'. The above-mentioned studv did nc: c.-:r :l--e i::--.=:s: :s of
SERVQUAL and so could not establrsh the cont:rlutrr: o: e:.c]: if rhe
drnrensions to the overall qualitl senice nor the i:rpact
"t;-r.1itr
senice on satisfaction, Further, there *'as no attempt naCe lc unie:-
stand how age, gender or marital status of patients influer:ces t:e
ratings.
In cleveloping coltntries like India, the gorernment p:.r 5 1--.s
healthcare costs of poor patients in the belor*the-pove$ rBPl
categories in public hospitals and approved prir-ate I-.o-';it'is.
Secondly, the doctor who first treats them and lvho is;c:.e.;-.r
affiliated to a private corporate hospital chooses the hospital ic: i;:e
patient. As our main purpose of this study is to examine the factcrs r:.al
affect patient satisfaction and loyalty in hospitals in a develcli:3
country, rve believe that SERVQUAL dimensions are more relelart
than that of SERVPERF constructs.
So this research has to establish which of the SERVQLI-{ irmen-
sions most impact the patient satisfaction and the mediating re-ation-
.hip of the latter n'ith the patient's loyalty to hospital.
Thus, rve derive our first hlpothesis.
Hlpothesis 1. AIi the SERVQUAL dimensions equal)f impact the
-::ient satisfaction in a populous developing country.
-: Pattent satisfaction and age
l;.iients ofolder age are more satisfied with healthcare service than
' . :: cf t't rr1.. 20{)2: .k'nki:rsun cl ill.' 2l}01). \'cnn
)'ounger age ('l'hi
. r:, l2il{)5) reported that patient satisfaction vary with age.
:: . :-. employment status ancl marital statlts' Ilrttn'tt tt ii1 (11){)$)
' -:: :.ler. male, less educated and healthier patients shorved the
':r.r:.-.-r to rate the care provided by the hospital higher than female'
-. r ::: nore edr,rcated and comparatively sicker patients Shlrbiri:
: .:rd that demographic variables stlch as edltcation. income.
.: - -:: ::.1 ilge have a significant impact on patient satisfaction On the
'.- ::.1. il,rtiirrin rild Snh:ri (20():l) found llo signrficant effect oi
-' --,,',=: xnd location as moderating variables betrveen qualin and-
. i ' .: :. i:"lrel ittrtl ;\rl*ms (2{}i}l ) had also shol:r tll:'i t:e
::lrl::ll:la:lrll .'
Journal oJ' Retoi!;t: ::: i; -,.: -: - -:,: - : r -
C.en:rg:a;hic variables snch as ag. SEia:: ::,: ::,.-:
nl:i:al status have no moderating efrect a: s::::::::. -:
Based on an intenielv-based studr, or 3-i- :.:.:.
' ...., show that young prtt.n,a.-.i:-: ::.-'.: .. -
Itr'.] h.igher than rvhat the.v receive at present. \ot;i.r .r:..
5i leiirs of age are more satisfied with sen'ice qualil ::.-,-. -:. : -, . :
aiher age groups. Overall, the findings of the studf ini:c;:= ::,:: : :::
narriecl, less eclucated persons rate the seruice clualiq'of i.l-^e:,:.; :. .
higher than )'ounger, single and more educated patients. H:,iu':',=-
there are no studies on the healthcare services that particuiarll-s;r:-rt
the relationship of age, gender and marital status ofthe patients x'r:h
therr evaluation of satisfaction with services. Therefore, we tbrmulate a
second hlpothesis.
Hlpothesis 2, Age, Gender, and Marital Status rmpact the
er-aluations of the patients in a tlpical developing country'.
2.5, Patient sahs/actlon and loyalty
,'.The healthcare industry in popr.rlous ier'=.:,:i:i :-,
india, is on the growth stage as seen tic,r:. :i:: r. ir i .-. .:
hospital construction projects are undc: i - :.::. -
tion and loyalS' are tire trso strar=g;: , ..=.r--: .-.: '
monitored and kept at'a higher peaes::.. s, ,-*.:: :
throughout the years. The hosp:rais.:.::.: ,--
between specific dimensions of q::..:. .--:,.-.,-"
satisfactio' , and patient lovaln. C:::::.- l-::: -,
identified so that thev rrill be focuseC r: E:-: --.. I :- r r. .^,..r:-'.:.-
istrcs of the healthcare industn'take:i :.: -*-.: !:-: :.=
depending on the recommendations .: ;
patient's choice of private corporate hcs;... :-, - .. ::.:'.::-: s
reimbursement of healthcare costs to BP- :" i-'.: '-.. :-r'.:-:::.::e a
significant proportion of patients being ti.al=: :: :-ri.3:: ;-;r.rare
hospitals. A hospital's principal goal is buriCi--.:::::::t lrli-:: ioes it
relate to the level of patient satisfactic;r? \l'i.:: is :i.e rlle lf patient
satisfaction in bnnging about custfmer i:r'al:,? Easec. on these
qriestions rve arrive at the third hrpolhesis.
Hlpothesis 3. Patient satisfaction has a inediating rolt in tntrtasing
;::rent loyalq'.
:1-.e
3l Research methodology ancl meastrres
i. -i:i:-:!ric
l:e s:,rCv rvas conducted on 180 res;.':J.:-:: i'h' r.i . . :itrso:.
tre;:;:.::.is in,10 different hospitals in ilic=:,--,: :-:'.:: :'-rl-1 T:''
sanp,. c:r.;iises 55% rnel1, and 45': r'.:::'.t:, ^ .'= r:::'. :- -:.1:! - :
of -2', i::,t::le,l persons and 28% si:u.:s T:-. i.:-:..
roung ;?::cns. 42% middle-aged pe:s::.i. -::-: --
Respr:.:::rts rr'ere selected on a ranCe:. :;=:. : ::'.:-:.a :- :.::'-:
hosprtal.,:nlr' -l-5 patients (*'ho rece:r:: ::-: ::: ::'t:: " =':=:: :o
ensu:e :anlrmization, only the firs: -t:..: ---: :- :--::::.: u-':--' c'jd
identiicatron numbers only rvere ci:sei-, -,-. - :-: :- : ;: l::- : -: .- :: : :li\t
hospital. onl. those rvith et'en nurr.l---:: ::.:.. - -
3.2. Re-.eorch tnslnrment
SER\-QUAf scitle \\'l1s s-:g:tt.i :::: ll:-.. :- .::t ::r::- pe:teptions
Itens ,:f each li:rensicn cf nrc:fr:a
q:3r'-]--{ aie lr ' ' - : The
it.:rs r,ere r--:li:.ec ir acr:::::r= 1"-"h the icea c'f:he industry-
\'::i--r-.:. F,:.'.:--:... ---:::c:-.--..:: :I:e :en rtla::rg to iriorma-
t!1 l:: prri'-r:'--. ar.: i;:i,:..a:tr n:: l::'portant -'incc the costs are
:=.:r::::.ej ':r: S: -:t::-:s:=.=:r:: s-:ilarlr', atmoSphere and C6cor
'r;ere :rt : -r-: -t.-r:1,-." :-.'r-: :';:: items like risualiv appealing
p.-rs.:a. :r-..-:..t::s :ri
:=:-.::e.s :i.:rlplolees are found to be adequate
t, =.at-..,- --.. ::.:.::!:.::r'
i:r-::sicn. Similar treatment \\'as given to
 Journalo-tR'::: -. :-: --

'
3i - ' --'';-'-' _'::i ':'
people reqr.llring about
iuriril o.or"a iz.ooo L.t-' :-:-::'j-':-' -i::r 1 r : : .
I

:-. :i '-: t,-

hospitals, 165 pnr-::e:-s::::s
centers. \"Aile aro'.it lS': -: :='-'l':--' ':. :- -::l ' l
to.pit.ils. ul::ih:.rlc;. -l ::- -=:' : -

-.::e hospital has j:-':--: ' llcaimentrnp:ir';re:oS;]:].Slt|.1'1;'1la.l;5;;..''1

:';=;]t-= - :- -
equipment ,r.agotarnnra,t,['r:;1'r l:r':.:-:- : ":
2. Hospital's PhYsical i:.cr-:i:t: ::: antl-reliable. e-thougil :h?i ::: :r'::::"
: -iS il:'l:l'i-
:: :::l:' -':=;:::tn--s ': --:-:'
r'isually aPPealing non-availabill:' ofbei-' l: ''' - -l
3. Hospital's employees apPear ie;r
anv dav,ri:a-a \'?ilr' G-r=::'-"t:: s;::i1's v;rich a:e i:'-":
2 ReilabiliQ l. The hospital providFs its <en--ei : are preferri: '
the patients at the time it promis<s l-' ittt.t" ::.1 srln:nt :: ':;: ' '::':;';ties - --
do so. pool 't..-!i-::-:-p:1.- ::: :::!--ls But m-an]'people :1r: --: -
2. When Patiqnts have Problems' ,..: \--:i -ii:.:
.LL-1.---: -:'.-= : l::ralehospitalsrsrelativelv z''-:-"
hospital's employees are s)'mpathetjc
Ii' -.:.::r: i0il'.-r: ': : -':'': :::ieS Of lndia
and rtassuting. 3 The husPrtal r' health ': ' -';- ' -
accurate in its billing.
I: H. Je::--:.-. :.''' e ls a unique communitygolern:t- :--
by the
1. Hospital employees tell Patienls
-.1t)
s:hixe cel-.a i:-.:'' -1 -'J a Sree' offered
..
:r': ::.
3. Responsivelless premium palrrneni -
exactly when senices will be i"aa*a pat,aa.rs: i: d',es :lot involve any
for a grat.itous financial assrs:;: :
performed.
2, Patients receive Prompt senice lrrn-'
;;:;;;i,ihi. ,.h.-. iro\ides to Below Pole;i - -
lNR 200,000 (USS31-5) to a patient belonging
the employees.
is more than enough for treating anr': ' :
r':rl'r: (BPL) group. this assistance
3. Flospital emplo)ees are aluar s
scheme' the patient cilli r'- :
to helP Patients expcnsive surgicirl treatl.Ilelrts Untler this
1. Patients feel safe in their irii::'": :-'
-6! *ith the eligibilitl card anddoes nothave tc:'r'
4, Assurance i",'" p.i."."ftospital
scherne is ha's':
with emPlol ees. ^
anrtlting at all. Obtaillirlg arl eligibilitl card for-this
2. Enplolees are knlul':l:":'' obtain an eligibility carcl with son-
frbb;'even ineligible persons can
3. EmPlovees are Poi:'-e
rvhrch is not at all uncommon here' Generally' a phlsician
4. ErrrPl r-c: ;.' . ' bribing.
also sen'es as -''
lhem.r.i: : _ ;;;"; who is treating the patient in his private clinic
_

Llrei. ':: j
consultant doctor in a big irivate hospital;
when itis forlld that
5. Empathv
treate<1 ii a big hospital' he refers
the patienis :' l::
i:'i
-l O",i.lt, fl"t to be
i.^ pt"'^a. hospital in rihich he is already a consultant

b PIieni
S3listactLon .1. Findings and discussion

i l. -''i.'i;l :::.-'-r

- . - :::r:-:! ;sa:ie ser:;<s;l lf:_'

:::: :: :.i::se I am salisfied arc
::: j::::.t-i. ltrth
the hospitai
1r.1. 'rsc rhis h"spital in spi:e
- I
:

conPetitors deals' r'--:--r-'-: -'- .

?:l -'l--s
I roul<t to use adiit o:al l:-:=:,: .--:Fi ;. Sir,r. shich is lrss r.f
.
3. Prefer
products and sewices (such as ].:]....'-.l.cCFl..^re'9-.1''91-.an'].9S.res;='::l''l...';.
::'-;'- "- ' :'
soccialist adrices, treatments , ., - .t :.: R-"lSLi of the model is il- b:: ': :' i
Jragnnsis an'l othqr ttrcdical ''n
in this hosPitai.
':'
,--- . ', .,;,,..n tCtOtt, rrhich is 015 ir:::':s::-:i:. rrhici
': -: '- : :'
::'r':i::e
fert indices
4. I prefer this hospital to othe;s -'.i. ...,.. :L..: 05 But for these
- . .:;: ..:r. J.:l ntness is good' l'1" - 'r si-.i: :-:
"-
,*t ;alr illagram (f'tth l)llglrrrr l) and of reliab;-r' :l
be irrelevant ani ::i'-:'1---: ,-..-..... ".i;htl (with their significance levels)
other items also if they were found to strd':r'::"
Path analy.sis was run with SPSS AMOS 20 Fir.e :';--=:=: :-s -: ..r ,..r-,,.U.lness ('160) (on patient satisfaction)' -'''
to h'' s:
responsiveness', relia':":q" ::-'i']r-' patient's lo1'alw
service quality, nameiy, tangibility' '.," -' rsilent satisfaction
r ('666) on
taierl as exogenous variables rii-:'t i"::::'l '' ,iot'= dir'ect, indirect arld total effects of T::':: '-
ance, and empathy were
t:-:':L;'. -\-'surance, Responsiveness' and Reliability on Pa:r::: '':: '
:-
was taken as an enclogenous variable Patiei-: s l-''t;ir' :-'
satisfaction and total :':
;;-;i;;". taken as the second endogenous variable ::.i:r ,n .'.:.f aiso the clirect effects, inclirect 1ftect'
Post-d'eta ?r':" : :
..,,.;.,,,0n on patient's loyalty to hospital
were contacted to tttl. -- t--:
;;;t.;;. not iniuclecl in the sr'rrvey of tangibility' ein:r:r-" : '-
3.3. Backgrouncl of the sfitdy locatiot'L ;;;i;*, particulariy the irrelevance
They all agreed that ther. sr : il :.'':
niliion ;;".;;..'," patient satisfaction'
Hyclerabacl metropolitan area has
a popuiation of about 6 5 what kind of inf;:s::--::":=
in-t, tti-t.t* has aclviseci them no matter
and siaff the hospital had' ('lab[: 5)'
( 550) only have di:er: .:'- ':i
n.rponriu"ness (.160) ancl Reliability ''
puti""t like it was for'rnd by the studl' of '
o. satisfaction
rrl a1 {lt}l1)' Patient's satisia'::
1-1ri,L' and, also of llsiLr-Yriatt liit
:--

has clirect effects on Patienis'

Loyalty to Hospital ( 660) lnterest:rglv'
li tttt anl researi:' or
this research giu", u t't'u in'igl't it'oi T"1l coul.:f satisfa'trcn
patient
kind is to identifl'the factors that underlie t\e
ate tedttndant' sirrce barel1' trr'o of
hve
SERVQUAL dinensions
climensions of sERVQUAL are relevant.
It bears repetltion here that
are have no relevance in this
kind
inlluencing patient setrsl:ctrfi
tdngibility, empathy, una o"u'ont"
Path Diagram L Motlel shoring factors
 Standardized estimate

.550 i;S
i.i::i:i:\ eless .160
.089
.092 t-
.o27 - if
::l
:,: :-: Saiisfaction .666

- : - : : --- ::.-::- '.': :: 'is:i'\-QUALiftheconterl Table 5

-:r- :: - ;-; I - -:' ::-:l-:lrtiollaslmmetry'and

-'-
--:, ;-'-' ;-.- :': :l: ::-r-:'--r:ls edviceforcl-roiceof
En'rpath1" :\:1-\
' ! '-:': -:' - :: r: ::':-': ci Tlngibilin" Lolalw to
D:

--::.'-- i ":1: =ili:::i: ":-: ;':':'--:iit1.on Patient's

:I-
: , . .- !.,-.: : -..:..-=ss .-:- ;':': Re'labilin' ( 481) have t]ld]:"tl :;;t
(mediating)
.-=:- :-:r:,=.:s l.:,r'4.:; tc Hospital. The inten'eningwith those of \..FI

:: F:::e:! sahsiaction These findings are in iine

:1::.--.:
TLI
CFI
: :1. -
T:( total eftects of responsiveness and reliabiliry on patient Hl:?
satisfaction are .160 and '550'
on patients, loyalty
The total effects of responsiveness and reliability
indirect effects tnediated by patient Table 6
to fforpiuf, whicli are otviously on
are.160 ancl .366, respectively. Tl-re total effects of Critical ratios for regression coefficients based
age
.",i.r*i"", are 666 The
O"t*ft satisfaction on Patients' Loyalq' to Hospital Young Middle age
'mediating patient satisfaction is very high since the indirect
role of
effects oiresponsiveness ancl reliability
rnthrence it' Young 00(.)

as per our findings' are: (1) 1.3.15 .000

to focus on' Midtlle Age
The most important aspects
1.624 .605
(3) bil]ing accuracy,. old
timely clelivery of ,.rvi..,, (2) caring emplol'ees,
about the time of service delivery' (5)
ioi *"0"t communications
(6) rn'illingness to help employ-
;;;;$;-t of services, ancl emplol'ees' to$'arcls patients' their commn-
Table 7
i".. In ..r.r,.", employees' attitucle Critical rattos i : :e:::::
critical to
and accurate clelivery of senices are .highly
"i."i"t, rrith that of llitrrrrLllrr
i;;;ilift ..,.""r. These lindinis cc.rrroborates

Single
is more critical to
Further, we fin'l that women patients' satisfaction l\l r rried
they are more inclined to visit the hospital again
buiidlng loyalty since
high As regards the influence of
if tt.i.-rotota.tion with the service is ('l'iiblt (r) are
(CRs) for
J"*"g.upftl" variables, Critical Ratios .age Table 8
within the threshold limits of -1 96 and
+1'96 There is no evidence for Critical ratios lor

variables taken for this study' The critical ratios

f-p"* age on the ('l'ebltr 7) are within the
"f
for coefficients based on marital status
antl +1 96' Hence marital stahrs has no 000
i}rr*rhold limits of -1 96 N]
2.65 5
variables' F
i-pu.t or', patient's ratings on selected
is outside the threshold
The critical ratio for coefflcients of female
it be surely inferrecl that gender impacts the the nale gr::: I 1-: - :
5); to the Hospital rvhile it is not so with
li"rrtr^i-i,,i,1,' can
i'e', patient satisfaction.and loyalty' These iveights o: :L:'-:--: -' '
lualiq'sen'ice evaluations, {21){r)l and Shabbir ;;J;*; hut. no impact on regression
;;;i";t are in line nith those oi vi:ttn end l'oir{r
but gender does. :':l
1-:
et al. (2010).
with Patients' Loyalty- iu..d on the results of the research' we cons:it:
The regression weight of patient's satisfaction hwotheses as follows'
is significantll' bigger tl.ran "rr--
to uorpitit is .185 foi f"-ol" g.o.,p; this
1lr, t;. '1 1 trrsuL'\v:".': -
'sincealltheSERVQU'\Ici::':-'':rr
lsreJecteoslnucarr -
*tight fot male group ('l'ablt: :r)' Women's reliabill:' ;:": ::::. :
.1 t 3, rvhich is the regression equally ilnpa{jt patient's satisfaction Only
satrsfaction with service quality ias greater impact on Patients' Loyalty

Table {
l:ie.i. indirect and total effects'
Reliabilit.Y Patreii s:l:!
nce Responsiveness
Tantibilit) EmpnthY ^!<s u ra

.55{J OLIU
089 160
.o27 .000 666
Pr:ient Sntisfaction(Direct Effects) 000 000
.000 .000 .000
P3iient Loyalty To Hospital(Direct Effects) 000 .000
.000 .481 .000
Parienr Satisfactior (Indirect effects) .068 .t47
.035 .550 .000
Pi:isnt Lo"valty To Hospital(Indircct Eficcts) 089 ,160
.666
.027 .JOO
Patient Satisfaction (Total eff ects) .060 106
.018
P3iient LoYaltv To Hospital(Total Etfects)
 istir:le E,.::
L)'I:lel 1i::

'-'...
- : :::::-:r:i!::
Tansibilitv r ?1.

:, -:- -i:::::::lill
:::,-:: :::r.taction ?::
i:: ::: S:trstacti0n 1-:
::::::: lo|hlq To I i;
H::prtal

l able 10
l:.-:: :: :ritthesrs based on trre findings

Hrn,rthesis Statu: ahe: rereailh

l'..:.:,.:.-']-:,:!:':.:::::::.::r'ienpath\..l:1::J]::'':
..S:::-r:-:a:-,:-' :: .r:: r:-.:::1:::-:.t. Patient'S Satisfacttcn :.--:. -
: : i\'\.L.\L paiier:is .:i i.., : : ::t:: :-.=,:rb,litr- and responsl\'nsj . ::
- ::j .: :j, ... 1:_:.:.: -::., :::t:l:cSi{titi]Cant]r'to mediaiea b: :,::..i:: :i::.::t-::,: i:r influencing the loyaltr' .: :.--
:,.:.ir: !-rt:si:attor bui the other
patients to hospita,. Ti=::--,.r .r.roftant aspects to focus on, RS p:: :. .:
:a:a: :Lr:a:
: -:::, research, are: (1) tjnelr ct,tr3n ef senices, (2) caring emplovee:. j
:-a: :::::. ::: ).:::-:-.- Cr::::: ::.la;:r elaluatiOnS but billing accuracy, (4) proper communications about the time of srr-....
i'_- i --_.--- :i: r:, i'.n:r:d- Slarus do not. deliven, (5) promptness of senices, and (6) employees'willingness :-
:i----::-::i it tle pattexts help emplolees. In other \1ords, employees'attitucle towarcls patie:::.
;;:r.nt sJt:sfaction has a F:i:::: -.:rsi:ction nediates the
medirting role in increasing :: .:: : -:: : of reliabilitv irnd their proper communication with patients, and accurate cleliven r:
the patient Io) alt) ::!:::i. -::-i:s nith patient senices are highli'critical to hospital's success. Simply stated. Attit:r-lt.
Cortmunication. and Delivery (ACD Model) are the key to rr-.ri:.
patients return to the same hospital.
An important interence that can be made from this studr'.. :-
ness do impact.
assFlar)ce, empath\'. and tangibility nlatter little to the patri .: - -
llt'plrhi:sis 2 is rejected since onl)'gender intpacrs the evalr:ations
he/she depen:s hearill' on the treating phvsrcian in c.. '
but other factors do not as h)?othesized.
countries. In a \ri), SER\"QUAL is not fully relevant io th:: -. :-
llvpr,llrcr'lr :'i is fully accepted since there is an errdence for the since onh'tr'r c,i:,e corstnlcts were found to hale llnks r. :- :: :-'
mediating role of patient satisfaction on lovaltv
satisfactron. It :a: re ir::e:red frcm this that par:::.:: nt:-- : ,,-:
For ease of visual checking, the hlpotheses and their status after thrt th<.r f.li..,:j . ,. ..:.":. i ..i .': . :,--:.. :. .. ,
research are set out in the 'l':rblr.: 10.
empllhV T.:::c:-r.-.::, -- ..--,: r'.
\\-FJO ltams\v, rk -. . ...:. -. : -: ... .. , - . .. " -..
5" Directions for future research ac((pt3bl( I r:lr1:- :-:-.-. - -:.: :. :-

We provide sor.ne directions for other res.;:.iers to carn out and

extencl this line of research. For instance. ::.: sanple. a)thcugh large,
could be larger than this to get 1009'o re;:.sr:.:attcn of:ie population.
Importantly, the reliabilitv coelIiric::j,: Tangi'b.ili:.. "-{ssurance,
Empathy should be much larger a.l::,r:..-. --:\'.-.:e Er:aier than.7.
Fntnre research shor-lld foctts on i.-.t :::;l':.----e , i :::::ing,/treating
ph1'sician on the choice of hc:;:t=l i . ::.: ;.r.:-:.:. .t rtrer question
that should be examined is rrhet|t: : , s:,l::.! : - ::: l ti.::r image from
tire referring phYsrcians. It is po..;:.=:--::::-:.:ts:::st u'hat the
Fhlsician chooses for the p;:;e::s T:.t! sr-.,:-i be eramined. An
erclusi.e study'rith phvsicra:s as res:orde;:s ar.l rheir satisfaction
rritr each oithe dimensions of SER\-O'.AL shou.d be conducted for a
bettrr irrsight into the issne.
-{:rother sr-rggestion for those researchers l'ho are interested in this
?.rca is to conduct studies using framervorks other than sen.ice qualit)'-
n:del. For instance, researchers could use either i) llr:!:r,It lLnr]
-. , - 'i :, r (\\)\i4) framework of Serv'ice Profit Chain or ii)
,.: :.',rrr; {2{){)6)'s Relational Third Place theon iii) Compler
Orgarrizational Problems and Solutions (COPS) frameri ork pro- '".r1''1I ,:! l

pounded by laLrl anrl S;.rhrrlcv (2{}lbl in the conte$ uf l:,,s!:::.-s. ' " :

According to Service Profit Chain model, the senice qual.:. :..,:.:-ej

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b1'a senice provider is the consequence of a chain of::-;.-=::ct ' I lrfi ,r.,.,i1 ::
relationships. Sirnilarly, Rosenbanm's theory sr.lggests tha: : :::: c,rn- 1. l). sri,lr,.

sumers rely upon third places to satisfy not only their.r-,-:.:r.ron i j rti l\ illrlri:r I .
:r1) 1:l), !rl:l- 1,r I.
needs but also their needs fbr conpanionship and emci.:.r. :.:;port. il ,i rs 1{.1,..2{)1,1 ii .'
Furllter. the context of developing countries uhere tl.e :,:::.is get llrruin(lriljrg. t,
( iif,.n11r. A.,2(1r):.1. !..r'
healthcare iree ofcost cor.rld be the backdrop ofthe res:..::. -: such a

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sadsiirrt:'-::.f,:j Jtrnli{)ral intenlion..l, }le:rltlr (:are JiJ.. il ill :---
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influer-..: .n --.,ni reputatiol: q\:idtlci: fronl tbc barking ir.til::tr:' tr. i: :
.- ., :- :-: --,:--.Tii::..L<,j r:.ri- sr'nice qualib- g[ l'Lrt: Se*'. {i'!::. li :i). 72-8:j.
Zail'i, Il . 2, ,-l 11.{niilinil (rstorner stli$l;l(iti(tnr s best Plilctite PersPei i-r' : '

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