International Journal of Health Care Quality Assurance

Factors affecting dental service quality

Mohammadkarim Bahadori Mehdi Raadabadi Ramin Ravangard Donia Baldacchino
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IJHCQA
28,7
Factors affecting dental
service quality
Mohammadkarim Bahadori
678 Health Management Research Center,
Baqiyatallah University of Medical Sciences, Tehran, Iran
Received 10 December 2014 Mehdi Raadabadi
Revised 1 February 2015 Health Services Management Research Center,
12 April 2015
Accepted 10 May 2015 Institute for Futures Studies in Health,
Kerman University of Medical Sciences, Kerman, Iran
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Ramin Ravangard
Department of Health Services Management,
School of Management and Medical Information Sciences,
Shiraz University of Medical Sciences, Shiraz, Iran, and
Donia Baldacchino
Department of Nursing, Faculty of Health Sciences,
University of Malta, Malta

Abstract
Purpose – Measuring dental clinic service quality is the first and most important factor in improving
care. The quality provided plays an important role in patient satisfaction. The purpose of this paper is
to identify factors affecting dental service quality from the patients’ viewpoint.
Design/methodology/approach – This cross-sectional, descriptive-analytical study was conducted in
a dental clinic in Tehran between January and June 2014. A sample of 385 patients was selected from two
work shifts using stratified sampling proportional to size and simple random sampling methods. The
data were collected, a self-administered questionnaire designed for the purpose of the study, based on the
Parasuraman and Zeithaml’s model of service quality which consisted of two parts: the patients’
demographic characteristics and a 30-item questionnaire to measure the five dimensions of the service
quality. The collected data were analysed using SPSS 21.0 and Amos 18.0 through some descriptive
statistics such as mean, standard deviation, as well as analytical methods, including confirmatory factor.
Findings – Results showed that the correlation coefficients for all dimensions were higher than 0.5.
In this model, assurance (regression weight ¼ 0.99) and tangibility (regression weight ¼ 0.86) had,
respectively, the highest and lowest effects on dental service quality.
Practical implications – The Parasuraman and Zeithaml’s model is suitable to measure quality in
dental services. The variables related to dental services quality have been made according to the model.
Originality/value – This is a pioneering study that uses Parasuraman and Zeithaml’s model and CFA
in a dental setting. This study provides useful insights and guidance for dental service quality assurance.
Keywords Iran, Quality measures, Service quality, Measurement, Confirmatory factor analysis,
Quality improvement, Quality assessment, Dental
Paper type Research paper

Introduction
In today’s competitive world, quality has become increasingly important in all
International Journal of Health
Care Quality Assurance organizations and is considered an important, strategic lever (Brennan et al., 1991; Groene
Vol. 28 No. 7, 2015
pp. 678-689
et al., 2008), which plays a key role in gaining competitive advantages and achieving
© Emerald Group Publishing Limited
0952-6862
success (DeMoranville and Bienstock, 2003; Kong and Jogaratnam, 2007). Quality is
DOI 10.1108/IJHCQA-12-2014-0112 considered more in industries than in service sectors, whose main characteristics are
 production and consumption intangibility and inseparability (Murphy, 2007) while the Dental service
current service sectors can have a significant contribution to the economic growth and quality
quality of life (Büyüközkan et al., 2011). Measuring healthcare service quality is the first
and most important step to improving care (Davis et al., 2005; Lee and Yom, 2007) and the
quality provided plays an important role in patient satisfaction ( John et al., 2011).
Additionally, healthcare’s increasing complexity and the rising demand for improved
patient safety, monitoring health service quality has become essential (Manias, 2010). 679
The demand for quality is also increasing among health system stakeholders, such as
medical insurance organizations, healthcare providers and health policy makers (Beyer
et al., 2011; Davies, 2001; Rosenbaum, 2003). Consequently, providing high-quality
services in the health sector is considered a desirable goal that leads to development in
other areas (Andaleeb, 2000b; Karydis et al., 2001; Youssef, 1996).
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In hospitals, owing to the different services, quality can be used strategically to

create a distinct advantage that will be difficult for competitors to imitate (Lim and
Tang, 2000); promoting quality will increase patient satisfaction and loyalty (Arasli
et al., 2008; Dawn and Lee, 2004). Furthermore, quality has a great role in patient choice
or for future referrals (Jenkinson et al., 2005; Karassavidou et al., 2009; Merle et al., 2009).
In the past, goods or service characteristics were defined as the quality measuring
criteria. However, based on new methods and attitudes, quality is defined as customer
demands and desires (West, 2001). Today, measuring quality from the patient’s
perspective is accepted in healthcare and its use is increasing (Lin et al., 2009). The
information obtained by gathering patient perspectives is a successful method for
strategic evaluation and for improving health service quality (Saeed and Mohamed,
2002). In healthcare, different plans are made to improve and assure quality, especially
among dental service providers (Bader, 2009; Greenfield and Braithwaite, 2008; Kenny
et al., 1999; Mills and Batchelor, 2011). Patient perceptions, attitudes and satisfaction with
the dental services have been recognized as factors and are the main quality assurance
programme components (Butters and Willis, 2000; Saeed and Mohamed, 2002). Meeting
patients’ dental care needs and expectations may affect patient behaviour towards
increasing their utility, reducing cancelled appointments, pain and anxiety (Butters and
Willis, 2000; Newsome and Wright, 1999). Analysing service quality enables managers to
relate financial resources and performance improvement in areas that have greater effect
on customer perceptions (Raju and Lonial, 2002). Market-based mechanisms can reduce
dental service costs and another mechanism that has a strong effect on attracting
customers is meeting customer demands (Roberts, 1999).
Research shows that several factors, including performance (Schoenfelder et al., 2011),
environment, support/care and waiting time (Atinga et al., 2011), communication,
responsiveness, honesty (Hasin et al., 2001) nursing care, admission process,
environment, compassion for family and friends, physician care and discharge process
(Otani and Kurz, 2004), affect patient satisfaction. Furthermore, other factors affecting
patient satisfaction and dental service quality are technical competence, personal factors,
comfort, costs, facilities and equipment (Kress, 1988; Newsome and Wright, 1999),
assurance, provider empathy (John et al., 2011), responsiveness (Dewi et al., 2011),
communication, consideration, knowledge, abilities, skills (Dewi et al., 2011), high-quality
dental care, convenient appointment, friendly staff and modern dental clinics
(Al-Hussyeen, 2010). The literature shows that total dental service quality studies are
less than other specialties and that there is no clear and reliable information in this area.
Several people are referred daily to dental services, so identifying, measuring and
improving factors affecting dental service quality can prevent resource wastage
 IJHCQA and increase patient satisfaction. Therefore, this study aimed to identify factors
28,7 affecting dental service quality as perceived by the patients referred to a Tehran dental
clinic, using confirmatory factor analysis (CFA).

Method
Study design
680 The study population included all patients receiving dental services. This cross-sectional
and analytical study was conducted between January and June 2014. Inclusion criteria
were patients receiving clinic services at least once, who were familiar with its employees,
environment and dental clinic. A sample of 385 patients was determined (maximum CFA
size). This sample was selected from morning and evening work shifts across 15 working
days in May using the stratified sampling proportional to the size method. Therefore,
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each work shift was considered as a stratum in which patients were selected considering
the total patients in each shift using a random numbers table.

Data collection
Data were collected using a self-administered questionnaire, designed for the study,
based on Parasuraman and Zeithaml’s service quality model (Parasuraman et al., 1985).
This questionnaire had two parts: demographics, such as sex, age, marital status,
education level and insurance status, and a 30-item questionnaire to measure five
service quality dimensions, including tangibility (seven items), reliability (nine),
responsiveness (six), assurance (four) and empathy (four). A five-point Likert scale was
used to assess each dimension (1 ¼ strongly disagree and 5 ¼ strongly agree). In this
study, Parasuraman and Zeithaml’s dimensions did not change, however, their
respective items changed according to dental services. The modified questionnaire’s
validity was confirmed using six faculty members, including four dentists and two
health service management experts. Reliability was confirmed by Cronbach’s α
coefficient (α ¼ 0. 95). Data collection lasted 15 days. A researcher was stationed in the
clinic and distributed the questionnaire to patients. If patients were illiterate then
researchers asked questions and completed the document on their behalf.

Approval
Permission to conduct our study was obtained from university heads and authorities.
Informed consent was obtained from all participating patients and all were assured about
data confidentiality. Approval for conducting this study was obtained from Baqiyatallah
Medical Sciences University ethical committee (ethical code: CH/7018/100).

Data analysis
Data were analysed using SPSS 21. 0 and Amos 18. 0 using means, standard deviations
and CFA, which was used to determine consistency between patient responses and the
proposed structural model. Second-order factor analysis was used for data analysis.
The following indices were used in the CFA: comparative fit index (CFI), root-mean-
squared error of approximation (RMSEA), degrees of freedom (df), incremental fit index
(IFI), χ2 and normed χ2.

Findings
Most patients were male (53.2 per cent), married (79 per cent), 31-40 years
(32.5 per cent), had academic and university degrees (53.8 per cent) and insurance
coverage (83.1 per cent) (Table I).
 Variables Frequency (%)
Dental service
quality
Sex
Male 205 (53.2)
Female 180 (46.8)
Marital status
Single 81 (21) 681
Married 304 (79)
Having insurance coverage
Yes 320 (83.1)
No 65 (16.9)
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Education level
Less than high school diploma 48 (12.5)
Diploma 130 (33.8)
Academic and university degrees 207 (53.8)
Age (years)
o20 24 (6.2)
21-30 99 (25.7)
31-40 125 (32.5)
41-50 73 (19)
W50 64 (16.6) Table I.
Note: n ¼ 385 Demographics

The 30-item questionnaire means, standard deviations (sd) and Cronbach α are shown
in Table II. Cronbach’s α coefficient for each dimension was higher than 0.7.
The most important items were: tangibility: cleanliness, materials and supplies (4.87);
reliability: dentists’ attention to patient expectations (4.83); responsiveness: easy and
quick treatment (4.64); assurance: dental skills (4.83); and empathy: paying attention to
the patients’ needs and demands (4.64) (Table II).
According to the absolute χ2 index (797.9) and given that the model’s degrees of
freedom (270) moved away from zero, and had moved towards the independent model’s
degree of freedom (326), the proposed model was deemed appropriate. The normed χ2
index, which is a relative index, showed that if the value was between 1 and 3 then the
model would be more appropriate. Therefore, because normed χ2 ¼ 2.95, the proposed
model was appropriate and acceptable. Furthermore, because RMSEA ¼ 0.078, which
was lower than 0.08, the model was acceptable. Moreover, considering that CFI ¼ 0.930
and IFI ¼ 0.947, which were more than 0.08, the model had a good fit. Generally, the
model had a good fit and was acceptable. The results showed that assurance (regression
weight ¼ 0.99) and tangibility (regression weight ¼ 0.86) had, respectively, the highest
and lowest effects on dental service quality. Also, the results indicated that all variables
had acceptable loading factors for measuring latent variables (Figure 1).

Discussion
Given the healthcare system changes and the dental service providers’ key role in
maintaining oral health, our study plays an important part in improving dental services
and promoting oral health. Also, since patient satisfaction is closely related to service
quality (Alhashem et al., 2011), their perceptions can determine failures and gaps, and
 IJHCQA Quality dimensions and items Mean SD
28,7
Tangibility P1. In a good dental clinic, the equipment should be modern 4.81 0.44
(α ¼ 0.80) P2. The clinic employees should be clean, neat, tidy and
appropriate to their professions 4.75 0.43
P3. The waiting room, tables and chairs, bathrooms, toilets and
floors should be clean, beautiful, comfortable and desirable 4.71 0.54
682 P4. The card of patients’ chart numbers, pamphlets and
brochures should be appropriate and beautiful 4.28 0.77
P5. The cleanliness and quality of the materials and supplies
used for treatment should be appropriate 4.87 0.33
P6. The process of paying the bills should be easy and
comfortable 4.34 0.77
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P7. The car parking space for patients should be enough around
the clinic 4.37 0.90
Reliability P8. In a good dental clinic, the patients’ physical examinations
(α ¼ 0.81) and treatments should be provided at the time that has
previously been appointed and patients should not be
delayed too much on the day of physical examination
and treatment 4.72 0.56
P9. The dentist should consider the patients’ expectations and
needs and meet them completely 4.83 0.37
P10. When explaining the treatment procedures to the patients,
the dentist should speak clear and understandable so that
they fully understand him/her 4.74 0.43
P11. In addition to the assistants and secretary, the dentist should
also explain the treatment procedures to the patients 4.61 0.52
P12. The patients’ charts should be completed without any
mistakes and maintained accurately and can easily be
found when needed 4.53 0.57
P13. The dental care costs should not be high 4.55 0.61
P14. Everything should be done correctly and without
duplication and reworking at the first time 4.74 0.48
P15. The treatment provided should be of high quality and long-
term effectiveness 4.81 0.44
P16. The dentist should give patients useful and necessary
advice for preventing them from other diseases 4.74 0.48
Responsiveness P17. In a good dental clinic, there should not be a long time
(α ¼ 0.91) between patients’ physical examinations and their
treatment procedures 4.49 0.61
P18. The treatment process should be provided quickly and
conveniently 4.64 0.48
P19. The employees should behave towards patients such that
they can trust in the dental clinic and its employees 4.62 0.56
P20. A secretary should always be accountable for arranging
the time of treatment session by phone or in person 4.51 0.70
P21. The dentist should clearly explain the problems and
diseases to the patients during the first visit and physical
examination 4.63 0.52
P22. The employees should constantly be willing to help the
Table II.
patients referred to the clinic and be ready at any time to
Factors affecting
answer their questions 4.60 0.49
dental services from
the patients’
perspective (continued )
 Quality dimensions and items Mean SD
Dental service
quality
Assurance P23. In a good dental clinic, the employees should always
(α ¼ 0.71) behave towards patients with respect and courtesy and
ensure their privacy 4.74 0.43
P24. The dentist should be familiar with the newest treatment
methods, as well as the modern technologies 4.72 0.44
P25. The dentist should have sufficient skills and be good at his/ 683
her job 4.83 0.42
P26. A good dental clinic should have a good reputation among
the people so that they offer it to each other 4.53 0.57
Empathy P27. In a good dental clinic, the admission process for
(α ¼ 0.86) consultation and initial physical examination should be
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carried out quickly and easily 4.60 0.53

P28. The clinic employees should listen to the patients’
comments and opinions 4.57 0.57
P29. The clinic employees should understand and pay attention
to the patients’ needs 4.64 0.60
P30. The clinic employees should pay particular attention to
each patient’s costs of dental services and should be
assured that they are affordable for patients 4.57 0.53 Table II.

develop effective strategies to improve quality. Therefore, we aimed to identify factors

affecting dental service quality as perceived by patients referred to a Tehran dental
clinic. Based on CFA, all factors were highly correlated with service quality; assurance
had the highest correlation. The Wisniewski and Wisniewski (2005) and Karydis et al.
(2001) studies confirm our results. The assurance item, “The dentist should
have sufficient skills and be good at his/her job” had the highest mean, indicating
that dental skills and abilities, both technical and medical, are important according to
patients. A teaching hospital study in Ireland (McCabe, 2004) found that nursepatient-
centred communication training was poor so that the patients were dissatisfied
with improper communication and the nurses’ task-centred communication.
Thus, nurses’ poor communication appeared to contribute towards a decline in
nursing quality (McCabe, 2004). High assurance scores indicate that having an ability
to do things right, an updated knowledge, high competence and employee behaviour
are considered by patients as important, which increase their security and confidence.
These findings were consistent with studies conducted in Asian countries (Butt and de
Run, 2010; Lee and Yom, 2007; Lim and Tang, 2000). Generally, improved
technical skills may increase the service quality assurance dimension through
in-service training programmes and using qualified, experienced and motivated young
dentists. Healthcare organizations and hospital managers should attempt to inform
patients about employee knowledge and capabilities, so they can trust dental staff.
Like the Wisniewski and Wisniewski’s (2005) study, tangibility had the lowest
correlation in our study and includes facilities, equipment, employees and
communication. However, since tangibility has some effect on service recipients,
providing them with suitable physical conditions is important. Physical environment
has an important service quality role and an important reason why patients
choose a hospital (Arasli et al., 2008; Karydis et al., 2001; Andaleeb, 2000a; Camilleri
and O’Callaghan, 1998). Additionally, the “Cleanliness, appropriate materials and
supplies” element is an important item as it affected patient perceptions.
 Downloaded by Middle East Technical University At 02:39 01 February 2016 (PT)

28,7

684

Figure 1.
IJHCQA

service quality
model for dental
Confirmatory factor
 Responsiveness had a considerable influence on service quality. This dimension Dental service
is focused on care processes, whereby patients expect that employees are available quality
when needed and interested in quickly solving their problems (Choi et al., 2005).
An important item in the responsiveness dimension was the time between patient
examination and treatment; due mainly to the highly specialized clinic wards; i.e. if a
patient needs more than one dental service then s/he is referred to a ward to set an
examination date and time. Most patients tend to be referred to the clinic only once 685
or twice. This problem may be because most patients experience referrals to a
private dental office whereby they receive services in a non-separated and
non-specialized ward. Therefore, they usually compare their physical examinations
and treatments in the public dental clinics with the private dental office. Andaleeb
(2000b) showed that employees’ non-responsiveness and their unwillingness to
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provide the best services could waste patient time, money and energy. Therefore,
clinic managers should schedule and time service delivery appropriately. Also, they
should provide opportunities for employees to deliver services to the patient’s
satisfaction.
Reliability and empathy had relatively similar effects on service quality. In the
Anderson and Zwelling’s (1996) study , reliability had the greatest effect on service
quality. Reliability is the ability to provide services dependably and accurately so
that customer expectations are met. The clinic manager’s decision to cancel
the appointment for patients attending more than five minutes late, reduces to some
extent patient waiting times. However, most patients attend the clinic on time and
even earlier than the appointment, this decision has not helped to solve the patient
waiting time problem. Clinic staff should arrange patient appointments so that they
are assured that the previous patient’s physical examination and treatment is
completed before the next patient. Also, clinic admission unit staff or the ward
secretary should remind the dentist about the next patient’s appointment time as
each physical examination starts. Empathy effects service quality; i.e. it indicates
if clinic employees provide quick services and are sensitive to patient demands,
requests and complaints (Sultan and Wong, 2010). Poor empathy can lead to poor
communication between staff and patients. Therefore, improving employees-patient
communication is recommended. Increasing total specialists and diagnostic
equipment can improve patient admission for consultations and initial physical
examinations. If services are intangible then interpersonal interactions during
service delivery can significantly affect service quality perceptions (Brady and
Cronin, 2001). Studies that show the human element’s effects on patient perceptions
can demonstrate empathy’s importance (Mohd Suki et al., 2009; Padma et al., 2010;
Rose et al., 2004).
Our study has limitations, service quality in our study was measured only from
patient perspectives. Other stakeholders and interest groups’ views, including dentists,
managers and other service providers have not been considered.

Conclusions and recommendations

To improve dental service quality, paying attention to everyone’s needs and
demands plays a major role. Patient preferences should be considered fundamental
to providing good quality dental care. Therefore, given the positive effects on dental
service quality that we found, service delivery processes should carefully be
considered in all quality dimensions, especially assurance and responsiveness.
 IJHCQA Improving service quality requires administrators and managers to meet patients’
28,7 reasonable needs and to solve their problems. There are different conceptual
models for measuring health services quality; however, we recommend that all
models should be tested using CFA.

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Quality Assurance, Vol. 9 No. 1, pp. 15-28.

Corresponding author
Dr Mohammadkarim Bahadori can be contacted at: bahadorihealth@gmail.com; m.bahadori@
bmsu.ac.ir

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