Quality Assurance

ISSN 0952-6862
Volume 21 Number 1 2008
Health Care Quality Assurance

Addressing the issues of management and quality
Patient satisfaction structures, processes and outcomes
International Journal of
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International Journal of Health Care Quality Assurance

Patient satisfaction structures, processes and outcomes
Editors Keith Hurst and Kay Downey-Ennis
ISSN 0952-6862 Volume 21 Number 1 2008
Access this journal online ______________________________ Editorial advisory board ________________________________ Editorial __________________________________________________ Gearing service quality into public and private hospitals in small islands: empirical evidence from Cyprus
Huseyin Arasli, Erdogan Haktan Ekiz and Salih Turan Katircioglu ______
3 4 5
CONTENTS
Measuring the three process segments of a customers service experience for an out-patient surgery center
Angela M. Wicks and Wynne W. Chin _____________________________
24
Pessimism and hostility scores as predictors of patient satisfaction ratings by medical out-patients
Brian A. Costello, Thomas G. McLeod, G. Richard Locke III, Ross A. Dierkhising, Kenneth P. Offord and Robert C. Colligan _________
39
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CONTENTS
continued
The role of understanding customer expectations in aged care

Leib Leventhal _________________________________________________
50
Patient claims and complaints data for improving patient safety

Pia Maria Jonsson and John vretveit _____________________________
60
Evaluating hospital service quality from a physician viewpoint

Peter Hensen, Meinhard Schiller, Dieter Metze and Thomas Luger ______
75
The influence of service quality and patients emotions on satisfaction

Maria Helena Vinagre and Jose Neves _____________________________
87
The relative importance of service dimensions in a healthcare setting

Rooma Roshnee Ramsaran-Fowdar ________________________________
104
CENTRE SECTION News and views __________________________________________ Recent publications ______________________________________
i xiv
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IJHCQA 21,1
EDITORIAL ADVISORY BOARD
Dr Waleed Albedaiwi Quality Management Advisor and Director, School of Public Health, King Saud Health Sciences University, Saudi Arabia
Dr Karen Norman Director of Nursing and Patient Servcies, St Bernards Hospital, Gibraltar Professor Dr Johannes Moeller University of Applied Sciences, Faculty of Health Sciences, Hamburg, Germany Max Moullin Director, Quality Management and Performance Measurement Research Unit, Sheffield Hallam University, UK Dr Udo Nabitz JellinekMentrum, AIAR, The Netherlands Professor John vretveit The Nordic School of Public Health, Sweden Helen Quinn Senior Lecturer/Academic Lead for Internationalism, School of Healthcare, University of Leeds, UK Professor Abdul Raouf Institute of Leadership and Management, Pakistan Ulises Ruiz Faculdad de Medicina, Universidad Complutense de Madrid, Spain Dr Keng Boon Harold Tan Ministry of Health, Singapore Peter Wilcock Visiting Professor in Healthcare Improvement, Bournemouth University and Director of Service Improvement, Salisbury NHS Foundation Trust, UK
Dr Syed Saad Andaleeb Professor and Program Chair, Marketing Black School of Business, Penn State Erie, USA Professor Jiju Antony Strathclyde Institute for Operations Management, Department of DMEM, University of Strathclyde, UK Ales Bourek National Board of Medical Standards, Czech Republic Professor Jeffrey Braithwaite Director, Centre for Clinical Governance Research, Faculty of Medicine, University of New South Wales, Australia Ian Callanan Clinical Audit Co-ordinator, St Vincents Hospital, Ireland Ellen J. Gaucher Group Vice President Operations, Quality and Customer Satisfaction, Wellmark Blue Cross Blue Shield of Iowa and South Dakota, USA Paul Gemmel Professor, Healthcare and Services Management, Faculty of Economics and Business Administration, Ghent University, Belgium Dr Kristina L. Guo Associate Professor, Allied Health Administration, University of Hawaiii-West Oahu, Hawaii
International Journal of Health Care Quality Assurance Vol. 21 No. 1, 2008 p. 4 # Emerald Group Publishing Limited 0952-6862
Editorial
Patient satisfaction structures, processes and outcomes Two things prompted us to produce our second special issue this year. First, patient satisfaction remains a popular author and reader topic; manuscript submissions and author downloads steadily increased in 2006-2007. Second, although it might not be thought possible that new patient satisfaction insights can emerge, this issues authors not only revisit stalwart patient satisfaction debates but also explore new topics not often encountered in the literature. In short, the eight manuscripts and 50 K words amount to a themed book containing novel elements on clearly what is an important and enduring quality assurance subject. We wanted to address private and public patient satisfaction, and we are fortunate to publish two private patient satisfaction-oriented studies. First, Arasli and his colleagues offer fascinating insights into Cypriot patient expectation and satisfaction. They used SERVQUAL notably the instruments ve dimension to compare and contrast private and state hospital patient satisfaction. The authors remind us that service quality is one of the most important drivers behind customer attraction, retention and loyalty. They not only explore unusual elements such as patients perceptions after using both public and private hospitals but also they reveal SERVQUAL dimension differences between the two services. The resulting Cypriot health service strengths and weakness ndings are likely to make managers and practitioners worried or proud. Readers also will benet from the lessons Arasli et al. learned from their explorations into SERVQUALs psychometric properties. The second private patient oriented manuscript emerges from Ramsaran-Fowdars Mauritian study, which usefully extends and develops Arasli et al.s commentary. A unique feature in Ramsaran-Fowdars article is her needs and wants section. Long-in-the-tooth patient satisfaction researchers know this mineeld well. That is, a patient needs a lower limb amputation owing to smoking-related peripheral vascular disease. He or she needs to stop smoking to preserve the remaining limb. It is harder, therefore, to satisfy the patient because he or she does not want this course of action. Ramsaran-Fowdar goes on to underline customer loyalty and retentions importance and relevance to private healthcare discussion that adds considerably to commentaries in the related articles we publish here. One particular sobering analysis for insurance-based healthcare managers and practitioners is the cost difference between: losing loyal patients; and recruiting new ones. Ramsaran-Fowdar too unpicks, dissects and develops SERVQUAL. Her detailed psychometric explorations relate to both general and private healthcare, and her ndings reveal that seven not ve SERVQUAL quality dimensions are needed for Mauritian private health services. Wicks and Chin also concentrate on SERVQUAL but in USA outpatient surgery contexts. They also spend time carefully explaining methods for modifying existing, valid and reliable patient satisfaction measures for use in different settings. They concentrate on two existing SERVQUAL segments: expectations (or pre-process) and perceptions (or post process), and introduce a middle process segment. Consequently, fascinating patient satisfaction issues emerge that are important for health service managers and practitioners. Unexpected ndings also materialise such as staff social skills importance in patient satisfaction. Similarly, readers will be surprised how
Editorial
International Journal of Health Care Quality Assurance Vol. 21 No. 1, 2008 pp. 5-7 q Emerald Group Publishing Limited 0952-6862
IJHCQA 21,1
relatively unimportant empathy seems to be in the patients rankings. Unusually, the authors nish with arguments for modifying their patient satisfaction measure for non-health use. Readers familiar with customer satisfaction literature know that health service researchers usually borrow from industry and commerce. It is good that healthcare research and development leads the way! We are also fortunate to publish the Mayo teams and the Vinagre-Neves ground-breaking patient satisfaction studies. Their premise is that we should not assume patient satisfaction or dissatisfaction (as healthcare outcomes) naturally follow healthcare structures and processes. Might it be possible that patient behavioural and emotional characteristics are equally if not more important satisfaction drivers? The Mayo study, a secondary analysis of archived information, combines Minnesota Multiphasic Personality Inventory (MMPI) and patient satisfaction data. The authors extracted almost 1,300 patients that answered both questionnaires. Because some patients completed the patient satisfaction questionnaire ten years after answering the MMPI, the authors concentrate on two enduring and stable personality characteristics pessimism and hostility. Moreover, they argue that these two behaviours are more tangible during patient-physician contact another reason for concentrating on these two personalities. Readers may not be surprised to learn that pessimistic and hostile patients are less likely to rate care higher. However, despite lower satisfaction scores, they are just as likely to recommend a provider to family and friends. Clearly, patient satisfaction is a complex and multi-factorial healthcare outcome. Intriguingly, the Mayo team are following-up this study with a separate analysis about which patient types are likely to respond to patient satisfaction questionnaires; a study we hope to publish later. Vinagre and Neves related project connects, among other things, Portuguese patient service expectation, satisfaction and emotions. In common with other authors in our special issue, their starting point is SERVQUAL, which they modify to t local culture. Discussion around SERVQUALs history and development reinforces discussion elsewhere. However, their warnings about adopting of-the-shelf patient satisfaction studies without adjusting them to suit local culture are salutary. Their customer-provider framework and the way they dissect patient expectation and satisfaction are also useful. Specically, the authors tie SERVQUAL data with a range of patient emotion scores from the Differential Emotional Scale II, which is often used in consumer research but infrequently if hardly ever used in patient satisfaction studies. Readers should nd their method explanation and discussion educational. Leventhals bitter-sweet article is a lesson to service providers. He concentrates on elderly patient and elderly care service stakeholder expectation and satisfaction. Readers will not nd many ner examples of analysts borrowing broader (expectation and disconrmation) theories and models and using them to explore and explain healthcare structures, process and outcomes. The author argues that elderly care services and user expectation and satisfaction are complex owing to the aged patients vulnerability particularly their retribution and reprisal fears. Moreover, other stakeholder pressures cannot be ignored. In short, the top-down (e.g., government accreditation agencies) and bottom-up (e.g., elderly patients children) inuences on face-to-face care become clear. Leventhal uses a case study to illustrate his arguments. It showcases poor service structures, processes and outcomes when statutory healthcare services are not up to the mark, and readers will emphasise with the case study family.
Jonnson and vretveits article could just as easily sit in our Patient Safety special issue (Vol. 20 No. 7) and it would pay to read their work in a patient safety context. The authors revisit information stored in three complaints and claims databases. Like other articles here, Jonnson and vretveits work is groundbreaking in several ways. Not only are complaints and claims results explored and explained but also important methodological issues are painstakingly aired as a warning to researchers analysing similar elds. Plainly, comparing complaints and claims information shows that the true adverse event frequency may be underestimated. What is known, however, is worrying. For example, one dataset shows incidents tripling in 25 years. However, the picture is complex since patient complaints in another database levelled in comparison. Nevertheless, the implications for practitioners and managers are clear. Merely benchmarking within and between countries and feeding back results, for example, is educational if not instrumental for improving service quality. Another feature readers will notice in this issue is the range of countries included. Hensen and his German co-authors, for example, completed an intriguing study and report. They concentrate on internal customers (fellow health service professionals) rather than external customers (patients). Comparing referring physician (i.e. the stakeholders and gatekeepers) with provider clinician (hospital core staff) service quality perceptions proved fascinating. Referrer behaviour is tangibly observable but variations remain unexplained. In common with other articles in this special issue, readers will benet from the authors thorough and clear method section. Specically, questionnaire surveys in this context are always on thin ice. For example, clinician response rates are notoriously poor and unfortunately the authors were victims. Unperturbed, they offer explanations and solutions to poor response rates, and despite the low turn-out, important ndings emerge. For example, provider clinicians have a strong positive image about their services, while referrers perceptions are less upbeat. Stakeholder analyses are paramount therefore. Patient commendations are a strong theme in the article and interestingly, geographically remote patients are less likely to recommend a service to family and friends. Finally, the eight articles include helpful reference lists that should arm patient satisfaction researchers and writers with a valuable resource. In short, Vol. 21 No. 1 materials range and depth makes it an essential text for the library shelf. Keith Hurst
Editorial
Erratum
We would like to point out that the paper Are health systems changing in support of patient safety? A multi-methods evaluation of education, attitudes and practice published in Vol. 20 No. 7 was authored by Jeffrey Braithwaite, Mary T. Westbrook, Joanne F. Travaglia, Rick Iedema, Nadine A. Mallock, Debbi Long, Peter Nugus, Rowena Forsyth, Christine Jorm and Marjorie Pawsey. Also, the paper Promoting safety: longer-term responses of three health professional groups to a safety improvement programme, published in the same issue, was authored by Mary T. Westbrook, Jeffrey Braithwaite, Joanne F. Travaglia, Debbi Long, Christine Jorm and Rick A. Iedema.
The current issue and full text archive of this journal is available at www.emeraldinsight.com/0952-6862.htm
IJHCQA 21,1
Gearing service quality into public and private hospitals in small islands
Empirical evidence from Cyprus
Huseyin Arasli
School of Tourism and Hospitality Management, Eastern Mediterranean University, Famagusta (North) Cyprus, Turkey
8
Received 21 December 2005 Revised 13 April 2006 Accepted 1 June 2006
Erdogan Haktan Ekiz

School of Hotel and Tourism Management, The Hong Kong Polytechnic University, New East Ocean Center, Kowloon, Hong Kong, and
Salih Turan Katircioglu

Department of Banking and Finance, Faculty of Business and Economics, Eastern Mediterranean University, Gazimagusa (North) Cyprus, Turkey
Abstract
Purpose The purpose of this research is to develop and compare some determinants of service quality in both the public and private hospitals of Northern Cyprus. There is considerable lack of literature with respect to service quality in public and private hospitals. Design/method/approach Randomly, 454 respondents, who have recently beneted from hospital services in Famagusta, were selected to answer a modied version of the SERVQUAL Instrument. The instrument contained both service expectations and perceptions questions. Findings This study identies six factors regarding the service quality as perceived in both public and private Northern Cyprus hospitals. These are: empathy, giving priority to the inpatients needs, relationships between staff and patients, professionalism of staff, food and the physical environment. Research results revealed that the various expectations of inpatients have not been met in either the public or the private hospitals Research implications/limitations At the micro level, the lack of management commitment to service quality in both hospital settings leads doctors and nurses to expend less effort increasing or improving inpatient satisfaction. Hospital managers should also satisfy their employees, since job satisfaction leads to customer satisfaction and loyalty. Additionally, hospital administrations need to gather systematic feedback from their inpatients, establish visible and transparent complaint procedures so that inpatients complaints can be addressed effectively and efciently. Originality/value The hospitals need to organize training sessions based on the critical importance of service quality and the crucial role of inpatient satisfaction in the health care industry. Future studies should include the remaining regions in Cyprus in order to increase research ndings generalizability. Additionally, including other dimensions such as hospital processes and discharge management and co-ordination may provide further insights into understanding inpatients perceptions and intentions. Keywords Customer services quality, Patients, Hospitals, Cyprus, Private hospitals, Public sector organizations Paper type Research paper
International Journal of Health Care Quality Assurance Vol. 21 No. 1, 2008 pp. 8-23 q Emerald Group Publishing Limited 0952-6862 DOI 10.1108/09526860810841129
Introduction The share of services such as tourism, education, health and so forth contributed 66.3 percent of the world Gross Domestic Product (GDP) in the year 2000. The health care expenditures equated to 9.3 percent (Public 5.4 and Private 3.9 percent) in the world GNP (World Development Indicators, 2003). Within the fast developing health care industry, hospitals, like their counterparts, have to deal with several service product characteristics such as intangibility, heterogeneity, inseparability and perishability. Moreover, high risks exist for the private hospitals whilst offering their services in a highly competitive environment dealing with human health, which involves sensitive decision making and extensive service provision in comparison to other services. State hospitals, on the other hand, are under public and government pressure in which these two stakeholders push them to understand inpatient needs and expectations and to provide a value added service quality, far superior to other organizations. Service quality, therefore, has become the focus of considerable attention in respect of satisfying and retaining customers in the service industry (Spreng and MacKoy, 1996; Reichheld and Sasser, 1990). It is currently acknowledged that service quality measurement can be used to understand how well a service organization, i.e. a hospital, has functioned in terms of outcomes like service quality over several years (Labarere et al., 2004). A strong link has been found in the literature between service quality, inpatient satisfaction and practitioner loyalty (Pakdil and Harwood, 2005; Kara et al., 2005; Labarere et al., 2004; Uzun, 2001; Hasin et al., 2001; Lim et al., 1999). It has also been claimed that, as hospital service quality improves, the number of satised inpatients and, consequently, loyalty increases in such a way that these inpatients may play an active role in the positive word of mouth business and may exert re-purchase intention and thus reduce organizational costs. Therefore, understanding inpatients evaluations of their hospital service quality performance can help to improve existing health care system output in general and, at the same time, may enhance service quality of specic healthcare processes (Meehan et al., 2002). There has been a great deal of service quality assessment research conducted on different industries. However, the authors could not come to any common conclusion on a conceptualization of service quality and customer satisfaction issues, such as a clear denition of quality service or dimensionality (Gronroos, 1990; Yi, 1990), and the situational factors in different industries. Dening service quality is complex and necessary for any measurement effort, however. Although several scales have been developed and tested to measure service quality (Parasuraman et al., 1985; Cronin and Taylor, 1992; Vandamme and Leunis, 1993; Tomes and Ng, 1995; Valdivia and Crowe, 1997) in the USA and European healthcare sectors, less attention has been paid to the comparative assessment of service quality in public and private hospitals, simultaneously, since their structure and functioning are different. It is also assumed that those inpatients, which have experienced services from both hospitals over a specic period, could provide valuable feedback that serves to identify the variations in both types of organizations in terms of their service provision. This feedback could also be used in their overall service quality improvement effort in the industry. There is a generalization that service organizations, including those in health care, require a sustainable, competitive advantage and, therefore, more attention should be given to the service quality improvement issues. This might be true for the private institutions, since the competition is unavoidable for them within the free market economic system. However, there is no scientic empirical evidence to indicate that public hospital staff attitude is the same as their private counterparts. Contrary to the above stereotyping in the literature, many government hospitals are blamed and
Service quality in public and private hospitals 9
IJHCQA 21,1
10
criticized today for their lack of speed owing to the inexibility of their traditional hierarchal structures in respect of their quality improvement (Tountas et al., 2005; Franck et al., 2004; Arasli and Ahmadeva, 2004; Withanachchi et al., 2004; Camilleri and OCallaghan, 1998; Anderson, 1995; Jack and Phillips, 1993). The contribution of this study to the relevant literature, therefore, is two fold. First, less is known about service quality differences between public and private hospitals (Jabnoun and Chaker, 2003; Arasli and Ahmadeva, 2004). Second, no empirical research exists to our knowledge on service quality, which has examined the service quality differences by collecting data from users of both types of hospital within a specied time period. Study context Healthcare services are carried out by both public and private institutions in Northern Cyprus. Specically, there are nine public and 52 private hospitals. The majority (626 beds, 67.9 percent) belong to public hospitals (Arikan, 2005). The remaining institutions are also controlled by the government. Poor service quality has been identied as a problem for many years. For example, the former Minister of Health and Social Affairs, Arabacioglu, claimed that the sectors quality and standard are suffering from a lack of structure as well as from employing poorly qualied, unprofessional personnel. He also stated that changing circumstances require an urgent major change, predominantly in legislation. Furthermore, Gulle, the Doctors Coalition Minister, highlighted additional problems such as institutions nancial incapability, long waiting lists, lack of medical equipment and instruments, disinterested staff and limited opportunities for patients to choose the doctors they want (Kibris Newspaper, 2002). In a recent study, Arasli and Ahmadeva (2004) empirically measured, for the rst time, Cyprus hospitals service quality using a public opinion survey. The authors primarily stated that both the public and private hospital administrations have little or no concept of systematic data collection about inpatient needs, service quality, and inpatient complaints. They found that, although private hospitals conditions are better than those of their public counterparts, both are still suffering from a degree of low quality equipment, medicine and facilities, poor service quality and of low priority given to the inpatients needs. Whilst pinpointing service-quality problems, their proposed model also provided indicators for overcoming these problems by employing a total quality management (TQM) approach. Just one year later, the Public Personnel Association Head, Caluda, complained about the inadequate number of personnel in the hospitals cleaning, kitchen and service sections (Kibris Newspaper, 2005). The current Minister of Health and Social Affairs, Celal, also stated that:
The Ministry does not deny these ongoing problems especially in respect of the inadequate stafng levels and the lack of well established security systems in hospitals (Kibris Newspaper, 2005).
In other words, we can conclude from our personal observations, corroborated by the above statement, that several ongoing quality problems exist in Northern Cyprus healthcare. The foremost aim of this study, then, is to assess and compare service quality in the Northern Cyprus public and private hospital sector. The present studys ndings may also provide hospital managers and government authorities with useful guidelines, with which to develop some future strategies for the promotion of a quality health care service. This introductory section provides a brief description of the service, the health care challenges, as well as the conceptual relationship between
service quality, inpatient satisfaction and recommendations and some background information about Northern Cyprus public and private hospitals. Literature review Parasuraman et al. (1985) initially developed the SERVQUAL scale. They originally identied ten service quality factors generic to the service industry, such as tangibles, reliability, responsiveness, competence, courtesy, credibility, security, access, communication and a willingness to understand the customer. The main aim at that time was to develop general criteria for measuring service quality in various service organizations in different sectors. At a later stage, Parasuraman et al. (1988), developed an instrument and validated it across various service environments, such as higher education, banks, insurance, tourism, dentistry, health care, communications, credit card services and car maintenance (Arasli et al., 2005; Lam and Zhang, 1999; Nelson and Nelson, 1995; Gabbie and Neill, 1996; Parasuraman et al., 1994; Boulding et al., 1993; Babakus and Boller, 1992). The scales founders contended that whilst each service-producing industry is unique, there are ve common characteristics, which could be applicable to service organizations: (1) tangibility facilities, equipment and the presence of personnel; (2) reliability ability to perform the promised service responsibly and accurately; (3) responsiveness willingness to provide help and a prompt service to customers; (4) assurance the knowledge and courtesy of employees and their ability to inspire trust and condence; and (5) empathy caring and understanding, which a company provides and/or offers its customers in terms of its individualized and personalized attention (Parasuraman et al., 1988). Originally, the SERVQUAL scale contained 22 pairs of items. Half were aimed at measuring service user expectations and the remaining half measured perceptions. The seven-point Likert scale is used by some researchers while others use the ve-point format. After Parasuraman et al. (1988) replaced the former version of the service quality measurement, many researchers and practitioners replicated, developed and integrated these reformed scales into the various service industry sectors (Pakdil and Harwood, 2005; Kilbourne et al., 2004; Sohail, 2003; Uzun, 2001; Sultan and Simpson, 2000; Mehta et al., 1999; Lam et al., 1997; Asubonteng et al., 1996; Coyle and Dale, 1993; Babakus and Mangold, 1992; Fick and Ritchie, 1991; Carman, 1990). Thus there are a limited number of studies, which used the SERVQUAL scale specically in the public and private health care industry. Jabnoun and Chaker (2003), for example, compared service quality practices between the private and public hospitals in the United Arab Emirates. Through the use of a modied SERVQUAL scale, which included twenty-three items representing six dimensions (empathy, tangibles, reliability, level of administrative response and support skills). They found that the public hospital inpatients were more satised with service quality than their private hospital counterparts. Moreover, they recommended that private hospitals need to carefully design inpatient-oriented strategies focusing on reliability improvement in order to compete effectively with the public hospitals, which enjoy greater government patronage and funding. Lim and Tang (2000) attempted to determine the expectations
IJHCQA 21,1
12
and perceptions of inpatients in Singaporean hospitals through the use of a modied SERVQUAL scale that included twenty-ve components representing the tangibles, reliability, assurance, responsiveness, empathy, accessibility and affordability dimensions. Analysis covering 252 inpatients revealed that there was an overall service quality gap between in-patients expectations and their perceptions. Improvements were required across all six dimensions. Finally, Andaleeb (2000) compared the quality of services provided by private and public hospitals in urban Bangladesh. A modied SERVQUAL scale, with 25 items representing ve aspects of service quality (responsiveness, assurance, communication, discipline and baksheesh (devotion or dedication)). An analysis covering 216 inpatients revealed that private hospitals provide better services than public hospitals in respect of service quality. Results also indicated that both groups have room for improvement. Based on the above discussion and arguments, we hypothesize that: H1a. Both public and private hospitals meet inpatients expectations. H1b. Both public and private hospitals do not meet inpatients expectations. H2a. There is no difference between public and private hospitals concerning their service quality. H2b. There is a difference between public and private hospitals concerning their service quality. H3a. Private hospitals are more successful than public hospitals in providing health care services for inpatients. H3b. Private Hospitals are no more successful than public hospitals in providing health care services for inpatients. Method We primarily develop and test a modied SERVQUAL scale for public and private hospitals in Northern Cyprus. We also aim to compare both types of hospitals service quality, as well as their effectiveness in meeting the expectation of their inpatients. Sample There is one public and 12 private hospitals that include large-scale clinics in which surgery is carried out. The total bed capacity in these hospitals is 294 of which 180 are public and 114 are private (Kobat, 2005). Our study sample consisted of Turkish Cypriot families (inpatients) in the Famagusta district of Northern Cyprus between December 2003 and January 2004 using judgmental sampling. Family members who had beneted from the services of both public and private hospitals within a two-year period were asked to complete a self-administered questionnaire. Judd et al. (1991, p. 136) dened judgmental sampling or purposive sampling as picking cases that are judged to be typical of the population in which we are interested, assuming that errors of judgment in the selection will tend to counterbalance one another. In order to collect quantitative data for the study, a total of 650 questionnaires were printed and distributed to respondents. In total, 454 four usable responses were obtained for a response rate of 69.8 percent a percentage we deemed acceptable.
Measures A questionnaire was developed based on the studies of Parasuraman et al. (1998), Arasli and Ahmadeva, 2004; Jabnoun and Chaker (2003); Lim and Tang (2000) and Andaleeb (2000). This was individually distributed to 15 families in the Famagusta district. A pilot study revealed that respondents had no difculty understanding the questionnaire items indicating that the face validity of the instrument scale measurement was conrmed. Moreover, the results of explanatory factor analysis showed that all factor loadings were above the recommended cut-off value of 0.5 (Nunnally, 1978). A survey instrument of 48 components was used in order to measure Famagusta hospital service quality. The quantitative survey was produced based on a synthesis of the literature we studied, which showed that dimensions like food and the physical environment were often studied. It is important to note, however, that these dimensions may not represent all service quality aspects. However, other dimensions may be added and adopted, if required, in the future studies. There were six dimensions in the present study: (1) empathy (ten items); (2) relationships (nine items); (3) giving priority to inpatients needs (eight items); (4) professionalism of staff (ve items); (5) food (six items); and nally; (6) physical environment (nine items). Responses to all items were elicited on a seven-point Likert scale ranging from 1 strongly disagree to 7 strongly agree. Results Table I demonstrates respondents demographic breakdown. More than 64 percent of the respondents were between the ages of 38-57 who were almost equally distributed in terms of their gender. Approximately 71 percent had either high school or vocational school education. The majority (57.2 percent) were married and although occupations were widely dispersed, the popular ones were: agriculture/animal related (27.1 percent); housewives (15.6 percent) and professionals (14.1 percent). Analysis The SPSS 12.0 for Windows was used to analyze our data. The reliability of the scale was tested using Cronbachs alpha. A high alpha value of 0.914 was achieved indicating a good internal consistency for the forty-eight item scale. The mean scores for the forty-eight expectation and perception statements are presented in Table II for both public and private hospitals together with the mean service quality gaps calculated using Service quality Q Expectation (E) Perception (P). Expectation scores The mean expectation scores were high when compared to the perception scores ranging from 3.2 to 5.32 for the public hospitals and from 4.19 to 6.46 for the private hospitals. The lowest public hospital expectation score was obtained from question 44: the food, which I had asked for was given to me (mean 3.2). This low expectation level may be the result of previous experience or negative word of mouth
IJHCQA 21,1
Factor Age 18-27 28-37 38-47 48-57 58-67 68 and above Total Gender Female Male Total Education Primary school Secondary High school Vocational school Undergraduate Graduate Total Marital status Married Single Other Total Occupation Professional Administration Clerical works Sales works Services Agriculture/animal Manufacturer Student Housewife Others Total
F 47 62 129 156 43 17 454 229 225 454 9 63 171 152 49 102.2 454 260 179 15 454 64 27 45 23 25 5 123 61 71 10 454
% 10.4 13.7 28.3 34.4 9.5 3.7 100.0 50.4 49.6 100.0 2.0 13.9 37.7 33.4 10.8 100.0 57.2 39.4 3.4 100.0 14.1 6.0 9.9 5.1 5.5 1.1 27.1 13.4 15.6 2.2 100.0
14
Table I. Sample demographics
communication from family members or friends who, perhaps, had disappointing experiences with the quality of food or the limited choice of food. Inpatients families sometimes cook or they purchase food from restaurants for their relatives. The lowest expectation score in private hospitals was question 5: the use of each procedure and test was explained to me before they were done (4.19). However, this is not signicantly lower than other items in the questionnaire. Although question 5 has the lowest expectation score, it is slightly above 3.5, thus it can be evaluated as a high expectation score. The highest public hospital expectation score was statement 12: doctors were capable of performing tests and procedures on me (5.32). This high
Statements Variance exp: 22:0%/a 0:92 0.824 3.82 3.74 0.08 0.802 3.91 3.74 0.17 0.783 4.00 3.64 0.36 0.780 0.779 0.776 0.769 0.747 0.741 0.737 Variance exp: 12:0%/a 0:89 0.841 4.21 4.04 0.17 0.795 4.32 4.17 0.15 0.790 4.69 4.28 0.41 0.780 3.95 3.80 0.15 0.773 4.67 4.34 0.33 0.727 0.708 0.704 0.700 4.97 5.32 4.05 3.93 4.70 5.12 3.95 3.82 0.27 0.20 0.10 0.11 4.21 4.21 3.89 3.75 3.73 3.77 3.76 3.56 0.48 0.44 0.13 0.19 0.763 0.774 0.790 0.787 3.89 3.80 0.09 0.748 4.16 3.57 0.59 0.819 4.86 4.89 5.21 5.68 6.12 5.70 3.77 3.55 0.22 0.727 5.34 5.23 4.74 5.15 5.04 5.56 5.89 5.77 Variance exp: 40:7%/a 0:89 0.821 4.91 4.74 0.17 0.782 5.16 4.92 0.24 0.752 5.23 5.19 0.04 0.11 0.12 -0.26 0.17 0.12 0.23 -0.07 Variance exp: 21:9%/a 0:87 0.792 5.32 5.24 0.08 0.809 5.81 5.79 0.02 0.762 5.27 5.21 0.06 0.771 5.41 5.27 0.14 0.723 5.15 5.08 0.07 0.748 0.786 0.779 0.768 5.70 5.48 5.92 5.34 5.81 5.40 5.87 5.43 -0.11 0.08 0.05
FL
Public hospital Exp. Per. Gap FL Gap
Private hospital Exp. Per.
Empathy 15. Doctors did their best to make me emotionally comfortable 14. Doctors worked hard to prevent me from worrying 29. Whenever I asked for help, the nurses did not pay attention (R) 16. Doctors made me feel comfortable even when they were not really successful in treating me 3. Doctors spent extra time with me to discuss my fears and concerns 18. Nurses talked to me in order to get to know me better in their spare time 32. I was presented with choices when doctors were deciding about my medical treatment 33. I was involved in the planning of medical treatment 25. Doctors took care of me as soon as I arrived on the ward 4. Doctors discussed after discharge medical issues with me
Giving priority to inpatients needs 21. Doctors were courteous while speaking with me and my family 26. In hospital, I was treated with respect 19. My personal concerns were of utmost importance for the hospital 23. Nurses were polite while speaking with me and my family 27. I had complete trust in my doctor 30. In hospital, I was taken care of as an individual not like a customer 12. Doctors were capable of performing tests and procedures on me 24. Doctors spent enough time examining me 28. I had enough condence in my doctor to discuss my very personal matters
0.09 (continued)
15
Service quality in public and private hospitals
Table II. Factor loadings, expectations, perception and gap scores in public and private hospitals
16
Statements Variance exp: 9:3%; a 0:91 0.818 0.815 0.783 0.776 0.775 0.769 0.750 0.745 0.721 3.90 4.22 3.60 3.86 3.73 3.83 3.79 4.01 3.87 4.09 3.99 3.58 3.71 3.65 0.29 0.38 0.34 -0.13 0.03 0.11 0.21 4.06 3.48 0.58 5.02 4.82 0.20 0.745 0.831 0.774 0.731 0.763 0.776 0.785 0.714 0.810
Relationships 13. My doctor was interested in not only my illness but also me as a person 7. The nurses spent time with me to discuss my concerns about my condition 5. The use of each procedure and test was explained to me before they were done 17. The nurses were kind, gentle and sympathetic at all times 6. The ward rules and regulations were explained to me 22. The nurses asked my permission before performing any test on me 20. Doctors asked my permission before performing any test on me 31. I was treated with dignity and had adequate privacy during my treatment 1. Doctors explained frankly to me the reasons for tests and procedures Variance exp: 20:7%/a 0:87 0.824 4.01 3.90 0.11 0.821 4.45 4.20 0.25 0.820 0.819 0.819 4.98 5.17 4.94 4.69 4.94 4.66 0.29 0.23 0.28
Professionalism of staff 9. Doctors talked to me frankly and politely 8. Doctors carried out my tests completely and carefully 10. Doctors gave me medical advise in a simple way that I can understand 11. I had a clear understanding of my condition during my stay in hospital 2. Doctors spent extra effort to make sure that I understaood my condition and its treatment
Table II. FL Public hospital Exp. Per. Gap FL Private hospital Exp. Per. Gap Variance exp: 15:3%/a 0:84 5.14 5.24 4.19 5.90 5.03 4.89 5.10 6.02 5.46 5.02 5.12 4.12 5.71 4.87 5.04 4.97 5.90 5.39 0.12 0.12 0.07 0.19 0.16 -0.15 0.13 0.12 0.07 Variance exp: 8:2%/a 0:93 0.841 6.09 6.03 0.06 0.803 5.25 5.09 0.16 0.745 0.784 0.767 5.34 5.98 5.14 5.21 5.79 4.97 0.13 0.19 0.17 (continued)
IJHCQA 21,1
Statements Variance exp: 15:9%/a 0:90 0.865 4.19 3.84 0.35 0.850 3.64 3.18 0.46 0.843 3.58 3.25 0.33 0.805 3.20 3.03 0.17 0.788 4.16 3.84 0.32 0.782 4.25 3.76 0.49 Variance exp: 18:8%/a 0:94 0.869 4.82 4.37 0.45 0.861 4.01 3.37 0.64 0.861 4.09 3.41 0.68 0.856 3.52 3.23 0.29 0.849 4.21 3.77 0.44 0.831 4.16 3.50 0.66 0.818 0.817 0.712 4.12 3.91 4.09 3.47 3.64 3.98 0.44 0.45 0.14
FL
Public hospital Exp. Per. Gap FL
Private hospital Exp. Per.
Gap
Food 45. 46. 44. 43. 48. 47.
The meals were well presented I was asked about the size of portion that I would like The food which I had asked for was given to me There was a choice of food on the menu After each meal the plates were cleared straight away The meals were still hot when they were served
Variance exp: 33:1%/a 0:92 0.738 5.17 5.03 0.14 0.807 4.76 4.52 0.24 0.754 4.87 4.69 0.18 0.824 4.39 4.05 0.34 0.719 5.22 4.94 0.28 0.761 5.34 5.21 0.13 Variance exp: 29:4%/a 0:93 0.749 6.46 6.37 0.09 0.815 5.88 5.67 0.21 0.784 6.43 6.20 0.23 0.717 5.12 4.98 0.14 0.768 5.61 5.51 0.10 0.796 6.04 5.89 0.15 0.724 0.732 0.772 6.02 5.91 6.22 5.87 5.72 6.14 0.15 0.19 0.08
Physical environment 40. There was adequate number of bathrooms and toilets in the ward 41. The bathrooms and toilets were always clean and pleasant to use 38. The beds, pillows and mattresses were comfortable enough 35. The ward was well furnished and decorated 39. The ward was well ventilated 34. The ward was clean at all times 37. Inside the ward, noises were kept at minimum level during night times 36. Outside noises were kept to a minimum 42. The screens were drawn around my bed, while medical procedures and examinations were carried out
Notes: Each item is measured on a seven point Likert scale; all factor loadings (FL) and co-efcient alpha scores (a) are above the cut-off value recommended by Nunnally (1978) and Tabachnick and Fidell (1996)
17
Service quality in public and private hospitals
Table II.
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expectation level may be the result of a lack of trust in the doctors, especially those in the public hospitals. The highest private hospital expectation score was related to: the bathrooms and toilets were always clean and pleasant to users (6.46). When we compared public and private hospital inpatients (Table II), interestingly, there are differences between the two types of hospital services. The empathy dimension had the highest priority in both types of hospitals with 22 percent variance in public hospitals and 40.7 percent variance in the private. Signicantly, the inpatients consider professionalism (20.7 percent), physical environment (18.8 percent), food (15.9 percent), giving priority to patient needs (12 percent), and relationships (9 percent) important in the public hospitals. However, inpatients put their priorities differently in public hospitals as: food (33.1 percent), physical environment (29.4 percent), Giving priority to patience needs (21.9 percent), and relationship (15.3 percent). Perception scores The mean perception scores were lower compared to the expectation scores; ranging from 3.03 to 5.12 for the public hospitals and from 4.12 to 6.37 for the private hospitals. Interestingly, both the lowest and the highest perceptions occurred in the same question, in which the lowest and the highest expectations are reported. The lowest perception score in public hospitals was obtained from statement 44: the food which I had asked for was given to me (3.03) and the lowest expectation score in private hospitals was obtained from the statement 5: the use of each procedure and test was explained to me before they were done (4.12). It seems that respondents are not satised with the public hospital food menu since both their expectation and perception mean scores were low. The highest perception score in public hospitals was obtained from the statement 12 doctors were capable of performing tests and procedures on me (5.12). This items expectation score was again highest in public hospitals. Therefore, it seems that people are dissatised with public hospital doctors competency level. The highest expectation score in private hospitals was obtained from statement 41 the bathrooms and toilets were always clean and pleasant to use (6.37). Of course, private investment encourages high expectations even on a simple, but vital issue like the number of ward bathrooms and toilets. Gap scores Table II shows that although overall expectation levels were low, none was met in public hospitals. The largest gap (0.68) was observed in statement 38: the beds, pillows and mattresses were comfortable enough. It was followed by gaps in ward cleanliness (0.66) and bathrooms/toilets (0.64). All these gaps came under the physical environment construct, which is a tangible quality factor, showing that public hospitals are suffering from a lack of cleanliness and comfort. Table II also shows that although the overall expectation levels were comparatively higher than public hospitals, still most expectations were not met in private hospitals. The largest gap (0.34) was observed in statement 44: the food, which I had asked for was given to me. It was followed by the gaps related to food service (0.28) and portion size (0.24). The largest quality gaps, therefore, occurred in the food construct statements. Tomes and Ng (1995, p. 27) explain: Apart from the visits, about the only thing the inpatient can look forward to are meals to break the monotony. Hence food becomes an important factor. Like public hospitals all these gaps come under the physical environment construct, which are the tangible quality factors. This conrms that private hospitals do not meet expectations about food. The hypotheses H1a and H2a, therefore, are rejected, while H3a is accepted.
Discussion and conclusions Our empirical ndings reveal that the study instrument provided sound psychometric properties. Broadly, the instrument has been found to have face and convergent validity as well as acceptable reliability coefcients. Our study has identied six service quality factors as perceived in both Northern Cyprus public and private hospitals: empathy; giving priority to the inpatients needs; relationships between staff and patients; professionalism; food and the physical environment. Results show that expectations in both hospital types were not met. Possible reasons for this gap, mentioned by the previous researchers such as Hariharan et al. (2004), Hoel and Saether (2003) and Angelopoulou et al. (1998), who examined SERVQUAL in both public and private hospitals, suggest that health care is a complex area that is unique in all its characteristics and it has too many dimensions to be tted into a simple singular unit. Therefore, it may be difcult for inpatients to accurately evaluate quality. Healthcare services were found to be better in the private hospitals with the exception of choice of food on the menu (Q. 43); doctors took care of me as soon as I arrived in the ward (Q. 25); and doctors did their best to make me emotionally comfortable (Q. 15). Moreover, private hospitals were found to provide a better service than their public counterparts, which brings us to the important assumption that privatization would offer higher performance in Northern Cyprus health services sector. However, patients expectations were not met in the private hospitals regarding the physical environment and the food quality served to them. Results derived from this study should be carefully considered by healthcare managers in both the Northern Cyprus public and private hospitals. Our ndings also revealed that there are signicant quality differences in employee related hospital activities, such as the quality of the service provided by doctors and nurses, etc., and facility-related activities, such as building infrastructure and new equipment, etc. This result is consistent with the previous empirical investigations (Withanachchi et al., 2004; Jabnoun and Chaker, 2003; Lim and Tang, 2000). Interestingly, our results contradict Jabnoun and Chaker (2003), who found that public hospital inpatients were more satised with service quality than their counterparts in United Emirate private hospitals. However, North Cypriot inpatients perceived public hospitals to be inferior in the quality of their service provision, which is aligned with the majority of recent study ndings (Pakdil and Harwood, 2005; Kara et al., 2005; Kibris Newspaper, 2005). The biggest service quality gap occurred in the physical environment dimension. Specically, the physical quality of equipment and facilities (toilets, showers, wards etc.) were perceived to be better in private hospitals. While comparing public and private hospitals, it is interesting that there were variances in inpatients priorities, except for the empathy dimension. Please note that the expectation for an empathetic response of both hospitals inpatients got the highest priority in rank. Regarding the other dimensions, inpatients seem to have preconditioned themselves to expect different health care service in both types of hospitals. Our ndings have important implications for private hospital owners, managers, government ofcials, academics and other related parties in the Northern Cyprus health services. Northern Cyprus hospitals suffer from a number of quality problems. At the micro level, hospital managers should rst be committed to delivering superior service quality and the achievement of inpatient satisfaction (Arasli and Ahmadeva, 2004). The lack of management commitment to service quality in both hospital settings leads doctors and nurses to expend less effort increasing or improving inpatient satisfaction. Hospital managers should also satisfy their employees, since job satisfaction leads to customer satisfaction and loyalty (Rust et al., 1996). Additionally, hospital administrations need to gather systematic feedback from their inpatients and to establish visible and transparent
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complaint procedures so that inpatients complaints can be addressed effectively and efciently. Most customers are reluctant (Ekiz, 2004) to make their needs and expectations explicit, including their complaints, although the opportunity to do so is clearly provided in order to promote and create a healing environment. The hospitals need to organize training sessions based on the critical importance of service quality and the crucial role of inpatient satisfaction in the health care industry. This is also supported by Arasli and Ahmadeva (2004) that hospital staff aiming to bring a total quality management philosophy to their organizations should provide evidence-based training programs. Limitations and further research implications There are several limitations to our study. First, it was conducted in a limited geographic region (Famagusta, Northern Cyprus). Thus, future studies should include the remaining regions in order to increase the research ndings generalizability. Second, for the researchers convenience, the study questionnaire included both expectation and perception questions. In future, the expectation and perception sections should be separated, although this may create difculties contacting respondents just before their treatment and just before they are discharged from hospital. Third, the present study lacks a sample power calculation to detect differences between the respondent groups. Future studies can conduct these calculations to be condent about the samples representativeness. Finally, this study used empathy, giving priority to the needs of the inpatient, positive relationships, professionalism, food and the physical environment as the determinants of service quality in hospitals. Including other dimensions such as baksheesh (extra payments in many Bangladesh services), (Andaleeb, 2000, p. 29), hospitals processes (Lim et al., 1999), discharge management and co-ordination (Labarere et al., 2004) even patient satisfaction and return intentions (Hasin et al., 2001) provided further insights into understanding inpatients perceptions and intentions. Future studies should also investigate the effects of service quality dimensions on the patients satisfaction, return intention and word-of-mouth communications about the institution. Until further studies are conducted, the present study ndings and our recommendation are inconclusive and tentative. Replication studies using large samples elsewhere would be useful in order to corroborate our study ndings.
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Received 24 March 2006 Revised 21 February 2007 Accepted 20 March 2007
Measuring the three process segments of a customers service experience for an out-patient surgery center
Angela M. Wicks
Bryant University, Smitheld, Rhode Island, USA, and
Wynne W. Chin
University of Houston, Houston, Texas, USA
Abstract
Purpose The purpose of this research is to develop an alternative method of measuring out-patient satisfaction where satisfaction is the central construct. The Gap Model operationalized by SERVQUAL is widely used to measure service quality. However, the SERVQUAL instrument only measures expectations (resulting from the pre-process segment of the service experience) and perceptions (resulting from the post-process segment). All three segments should be measured. The lack of proper segmentation and methodological criticisms in the literature motivated this study. Design/methodology/approach A partial least squares (PLS) approach, a form of structural equation modeling, is used to develop a framework to evaluate patient satisfaction in three service process segments: pre-process, process, and post-process service experiences. Findings Results indicate that each process stage mediates subsequent stages, that the process segment is the most important to the patient and that the antecedents have differing impacts on patient satisfaction depending where in the process the antecedent is evaluated. Research limitations/implications Only one out-patient surgery center was evaluated. Patient satisfaction criteria specic to hospital selection are not included in this study. Practical implications Results indicate what is important to patients in each service process segment that focus where ambulatory surgery centers should allocate resources. Originality/value This study is the rst to evaluate patient satisfaction with all three process segments. Keywords Patients, Performance levels, Customer services quality, United States of America, Outpatients Paper type Research paper
Introduction The operations management and marketing literature focus on measuring service quality as the gap between expectations and perceptions. It draws on the disconrmation paradigm from the psychology and consumer behavior literature and the Gap Model (Parasuraman et al., 1985, 1988; Bitner, 1990). The service quality Gap Model is operationalized by the SERVQUAL instrument (Parasuraman et al., 1988), an approach widely used in service operations (Spreng and Page, 1996; Oliver, 1996) and has been adopted for health care operations as well (for example, see Carman, 1990; Reidenbach and Sandifer-Smallwood, 1990; Shewchuk et al., 1991; Shelton, 2000). Although SERVQUAL is a good base for measuring service quality and
the possible trade-offs between functional areas, several problems exist owing to the nature of the creation of the gap measurement (for example, see Cronin and Taylor, 1992; Babakus and Boller, 1992; Peter et al., 1993; Teas, 1993, 1994; Rosen and Karwan, 1994). Low reliability, poor discriminant validity, spurious correlations and variance restriction problems make gap measure a poor choice as a measure of psychological constructs (Peter et al., 1993). The R 2 values for the perception scores are often higher than the overall gap scores (Cronin and Taylor, 1992; Peter et al., 1993), higher than the gap scores (Parasuraman et al., 1988), or higher than expectations scores (Brown et al., 1993). Additionally, SERVQUAL only measures the pre-process segment (expectations) and the post-process segment (perceptions). Service process measurement should include all three consumption experience segments: pre-process, process, and post-process (Babin and Grifn, 1998; Singh, 1990; Vandamme and Leunis, 1993). Therefore, our study develops an alternative method for measuring patient satisfaction in a larger retention framework where satisfaction, not quality, is the central construct in a series of partial least squares (PLS) models based on the tripartite evaluation model (Figure 1) from the psychology literature (Rosenberg and Hovland, 1960). Our framework was developed from operations management, service operations, marketing, customer satisfaction, psychology and health care operations literature and by a series of focus group discussion. An out-patient surgery center was selected for this study. Few patient satisfaction studies have been performed on out-patient surgical experiences even though many traditional in-patient procedures have been converted to out-patient procedures (Peyrot et al., 1993). The difference between in-patient and out-patient treatments is important because the transient nature of this type of service experience could produce different patient satisfaction antecedents than an in-patient experience (Reidenbach and Sandifer-Smallwood, 1990).
Measuring the three process segments 25
Figure 1. Overall satisfaction model
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Method Our pilot survey consists of 100 questions related to the survey constructs, six demographic questions, two insurance questions and one open-ended question. Pilot survey data were drawn from 112 usable responses. The revised survey was administered to all the hospitals out-patient surgery patients over 18 years and was conducted for a period of eight weeks. A total of 631 usable surveys were completed and returned (17 percent response rate). The questionnaire was included with the patients discharge papers, which patients were expected to return to the doctor at a post-operative appointment. Some doctors did not forward the surveys to the hospital resulting in a lower than expected response rate. However, the sample size is sufcient for our regression-based PLS analyses. The sample size requirement in PLS is typically determined by locating the dependent construct in the model with the largest number of predictors (i.e. independent variables) and applying procedures used in multiple regression (Chin and Newsted, 1999). In our study the constraining construct involved twelve predictors. Therefore, a sample size of 631 far exceeds the minimum required to provide sufcient analytical power (Cohen, 1988). There were few missing data in the survey results. The expectations minimization algorithm was used to substitute missing data in both the pilot and nal surveys. See Witten and Frank (2001) for a detailed discussion of the algorithms use. The relevant constructs were determined for each service process segment from the literature and focus groups. The Overall Satisfaction Model is presented in Figure 1. The dotted lines leading into and out of overall satisfaction indicate how satisfaction ts within the larger retention framework (Figure 2). The same patient satisfaction antecedents were used for each segment except for tangibles. That is, the post-process transactions primarily relate to errors in insurance submission. These types of processes are primarily phone transactions; therefore, tangibles are not applicable for the post-process segment. The dotted lines indicate where the exogenous variable for cognitive and behavioral antecedents relates to overall satisfaction. The degree of loyalty depends on the patients overall satisfaction. Therefore, Overall Satisfaction in the model leads directly to loyalty and loyalty leads directly to retention. The patient satisfaction denitions for each segment and for overall satisfaction are listed in Table I; the patient satisfaction denition antecedents are listed in Table II (see Wicks et al. (2004a, 2004b) for a complete discussion of the
Figure 2. Retention model
Latent variable Overall satisfaction Pre-process satisfaction Process satisfaction Post-process satisfaction
Denition The degree of positive affective orientation toward the patients outpatient surgery experience The degree of positive affective orientation toward the patients pre-admission experiences The degree of positive affective orientation toward the patients outpatient stay experiences The degree of positive affective orientation toward the patients post-discharge experiences

Table I. Patient satisfaction denitions
Antecedent Assurance Empathy Communication Competence Condentiality Convenience Courtesy Reliability Responsiveness Security Tangibles
Denition The degree to which the health care provider has the ability to convey trust and condence to the patient The degree to which the health care provider attempts to understand the patients feelings and concerns The degree to which patients are informed about the outpatient surgery in language they can understand The degree to which the health care provider displays the ability required to perform the health care service The degree to which the patients records, diagnosis and treatment are kept condential The degree to which the health care service is convenient and easy to use The degree to which patients are treated with courtesy by the health care providers The degree to which the health care provider performs the service in a manner that can be relied on to be proper (i.e. rigorously correct) The degree to which the health care provider promptly responds to the needs of the patient The degree to which the risk in the health care environment is reduced for the patient The degree to which the health care facilities, equipment, and personnel appear neat and clean Table II. Patient satisfaction antecedents denitions
frameworks development, the satisfaction denitions and the patient satisfaction denition antecedents used in this study). The validity of several other constructs outside the satisfaction portion of the PLS model is logically connected to this study in Figure 2. Cognition, for example, is dened as the mental process by which knowledge is acquired about the out-patient surgery center. Behavior is dened as the mental process linked to specic directed action toward the out-patient surgery center. Loyalty is dened as the attitude toward reuse of the center. Retention is dened as the actual reuse of the center by the patient.
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Evaluation criteria Five models are evaluated using a PLS software package developed by Chin (2001). Partial Least Squares focuses on prediction using an econometric perspective and inference related to latent variables using a psychometric perspective (Chin, 1998). These two perspectives create a method that allows analytical modeling with latent variables and provides:
. . . the researcher with the exibility to: (a) model relationship among multiple predictor and criterion variables; (b) construct unobservable Latent Variables; (c) model errors in measurement for observed variables; and (d) statistically test a priori substantive/theoretical and measurement assumptions against empirical data (i.e. conrmatory analysis) (Chin and Newsted, 1999, p. 308).
The PLS method is less stringent on the sample size and residual distribution restrictions found in other analysis models (Chin et al., 2003) and is better suited for explaining complex relationships with small data sets as it tends to avoid inadmissible solutions and factor indeterminacy (Chin et al., 2003). The PLS approach has also proved to be a robust method, providing results that are unattainable relative to other types of covariance methods. See Chin et al. (2003) for a more thorough discussion of PLS benets and a comparison of PLS and other covariance methods. As in other Structural Equation Modeling (SEM) approaches, PLS modeling provides both measurement and theoretical/structural information in terms of the network of constructs, indicator loadings and path coefcient measures. Indicator loadings represent the measures strength and their underlying constructs. Estimated path coefcients indicate the strength and the sign of the theoretical relationships among model constructs (Thompson et al., 1985; Igbaria and Greenhaus, 1992; Hulland, 1999). The PLS analysis rst stage typically assesses the measurement model that includes item reliability, construct validity and discriminant validity. The second stage involves assessing the structural model using the PLS bootstrap procedure Q2 and R2 calculations. Wold (1982) found that PLS was appropriate for complex predictive models. Ryan et al.(1999) showed that PLS was a better loyalty predictor because of its ability to test all the relationships among the model indicators. Recommendations for model evaluation criteria from Chin (1998) were used. Table III indicates the measurement model tests while Table IV shows the structural model tests.
Item reliability Loading scores of the indicators Average Variance Extracted (AVE) Composite reliability (rho) Overall AVE Cross loadings Greater than 0.70 Greater than 0.50 Greater than 0.70 AVE values of the latent variable (LV) are greater than the square of the correlation among the LVs The correlations of the indicators should load higher within their own blocks than to the correlations with other blocks
Convergent validity Discriminant validity Table III. Measurement model test criteria
Results Overall patient satisfaction model The overall patient satisfaction model is composed of four latent variables. Three measure the patients overall satisfaction with each of the three process stages and one latent variable measures the patients overall satisfaction with the entire service process. Stages correspond to the service process segments and are labeled OA Stage 1, OA Stage 2, and OA Stage 3 in Figure 3. Assessing the measurement model The block of items weights and loadings (i.e. indicators) measuring overall satisfaction are given in Table V. Indicators OAA_1 and OAA_2 represent the overall affective evaluation towards the out-patient experience. The remaining indicators as presented in the table, tap into each more detailed aspects of satisfaction and are labeled as follows: . assurance (ASR); . communication (CMM); . competence (CMP); . condentiality (CFD); . convenience (CNV); . courtesy (CRT);
Nomological validity R 2 Path coefcients Effect size Similar to regression analysis Similar to standardized beta weights in regression analysis Small effect: 0.02 Medium effect: 0.15 Large effect: 0.35 Greater than zero
Signicance testing Predictive relevance
Bootstrapping: 500 samples Bootstrap t-tests Stone-Geisser Q2
Table IV. Structural model test criteria
Figure 3. Overall satisfaction model
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Indicator OAA_1 OAA_2
Weights 0.078 0.079
Loadings 0.961 0.963 How satised/dissatised are you with your entire out-patient surgery experience? Overall, how satised or dissatised were you with all aspects of your out-patient surgery experience? Overall, during your entire out-patient surgery experience, how satised or dissatised were you with: The trust and condence you had in the hospital personnel you dealt with How well everyone you dealt with clearly explained the procedures to you How competent the personnel were that you dealt with How well all aspects of your patient information were kept condential How easy and convenient it was to reach and use the out-patient surgery facilities How courteous all the personnel were How understanding and concerned all the personnel were How reliable all aspects of the service were How responsive all personnel were How well all personnel provided an environment safe from criminal activity and accident How neat and clean all the facilities and personnel appeared Overall, I believe the Out-patient Surgery Center performed my surgery properly Overall, I believe the decision to use the Out-patient Surgery Center was a wise choice
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ASR_OA1 CMM_OA1 CMP_OA1 CFD_OA1 CNV_OA1 CRT_OA1 EMP_OA1 RLB_OA1 RSP_OA1 SCR_OA1 TNG_OA1 Table V. Overall satisfaction construct outer model weights and loadings COG_1 COG_1 0.069 0.073 0.069 0.066 0.067 0.073 0.073 0.076 0.073 0.070 0.071 0.073 0.072 0.919 0.925 0.923 0.867 0.884 0.937 0.932 0.943 0.934 0.902 0.920 0.930 0.917
. . . . .
empathy (EMP); reliability (RLB); responsiveness (RSP); security (SCR); and tangibles (TNG).
Additionally, indicators COG_1 and COG_2 were included to measure the cognitive evaluation towards the experience. Each indicators wording is also provided in Table V and in total is meant to converge towards a global measure of satisfaction with the entire out-patient experience. Examining the Table reveals that of 15 indicators, the loadings for all indicators except two, are equal to or greater than 0.90 representing a strong link between the indicator and overall satisfaction construct. The two remaining indicators, condentiality with a loading of 0.867 and convenience with a loading of
0.884, represent a strong relationship. All the loadings are signicant at an alpha of 0.01. The composite reliability, 0.980, indicates strong item convergence towards a highly reliable scale. For each of the three process stages (OA Stage 1, OA Stage 2, and OA Stage 3), two indicators were used. Using the same wording for items OAA_1 and OAA_2, we replaced out-patient surgery with pre-admission experiences for OAPR_1 and OAPR_2, surgery stay experiences for OAS_1 and OAP_S, and post-discharge experiences for OAP_1 and OAP_2. The item loadings are provided in Table VI also resulting in high composite reliabilities for the three stage constructs of 0.997, 0.998 and 0.988 respectively. Table VII presents the correlations among construct scores with the AVE results on the diagonal. The AVE value square roots, as required, are all larger than the correlations. The cross-loadings provide similar results; all item cross loadings are higher for the construct on which the item should load than on any other construct. The results of both analyses indicate that the models psychometric properties are sufciently strong to enable structural model estimate interpretation.
Overall OAA_1 OAA_2 ASR_OA1 CMM_OA1 CMP_OA1 CFD_OA1 CNV_OA1 CRT_OA1 EMP_OA1 RLB_OA1 RSP_OA1 SCR_OA1 TNG_OA1 COG_1 COG_2 OAPR_1 OAPR_2 OAS_1 OAS_2 OAP_1 OAP_2 0.961 0.965 0.920 0.926 0.923 0.869 0.884 0.941 0.932 0.944 0.934 0.902 0.921 0.932 0.919 0.895 0.895 0.950 0.954 0.872 0.859
OA Stage 1 0.900 0.902 0.809 0.843 0.793 0.773 0.757 0.835 0.861 0.869 0.846 0.835 0.809 0.826 0.796 0.997 0.997 0.889 0.889 0.832 0.837
OA Stage 2 0.955 0.969 0.836 0.900 0.837 0.802 0.815 0.902 0.885 0.935 0.892 0.846 0.866 0.900 0.882 0.887 0.887 0.998 0.998 0.865 0.842
OA Stage 3 0.852 0.869 0.778 0.808 0.760 0.746 0.787 0.834 0.824 0.831 0.837 0.810 0.789 0.794 0.812 0.840 0.841 0.856 0.867 0.988 0.989
Table VI. Overall satisfaction model loadings/cross loadings of items
Overall Overall Stage 1 Stage 2 Stage 3 0.924 0.898 0.954 0.875
Stage 1 0.996 0.891 0.843
Stage 2
Stage 3
0.998 0.863
0.988
Table VII. Overall satisfaction Survey: Correlation among construct scores (square root of the AVE extracted in diagonals)
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Structural model assessment Bootstrapping results indicate that all path coefcients are signicant at an 0.01 alpha and estimates are presented in bold in Figure 3. Typical for path analytic/structural equation techniques, it should not be surprising to nd signicance for all paths owing to the relatively large sample size independent of the effect size (i.e. whether paths minimally impact or larger). As such, what is also important is whether paths estimated are also substantive with high R-squares. Moreover, the relative strength of each stages impact on overall satisfaction as well as among each other is consistent. Specically, satisfaction towards the out-patient stay (i.e. Stage 2) has the most impact on overall satisfaction with the pre and post stage satisfactions being much less inuential and approximately equivalent. In terms of satisfaction at the start of the process in Stage 1 impact, the results are consistent with our intuition that it should have the most impact on Stage 2 and less direct effect on each subsequent stage. In particular, we see that the model explains 92.6 percent of the variance in overall patient satisfaction with out-patient surgery experience. While this is high for predictive models, as just noted, it is consistent with logic that that the degree of patient satisfaction with the actual process stage service experience should have the most dramatic impact on the patients overall satisfaction with the entire service experience with a path coefcient of 0.67. The pre-process stage has a signicantly lower path coefcient of 0.18 and the post-process stage has only a 0.148 path coefcient. Furthermore, the global set of 15 items for overall satisfaction provides an operationally discriminant difference to those used for the three stages. As found when assessing the measurement model, we noted the construct discrimination among the stages as well. The path coefcients for Overall Stage 1 indicate that the pre-process stage has the highest impact on the stage immediately following the registration process and decreases as the patient moves father away from the pre-process stage. The highest impact is the path coefcient value of 0.891 from Overall Stage 1 to Overall Stage 2, with a lower value of 0.36 from Stage 1 to Stage 3 and an even lower value of 0.18 from Stage 1 to Overall Satisfaction. In terms of substantive effects and predictive relevance, Stage 2 has a large impact on overall patient satisfaction with an f 2 of 0.973. The f 2 for Stage 1 and Stage 3 are 0.0811 and 0.0676 respectively, indicating a small effect for both segments on overall patient satisfaction. The Q2 predictive relevance values, using the cross-validated redundancy option, are 0.790 for overall satisfaction, 0.7511 for the Stage 3 and 0.788 for Stage 2. This implies that the model constructs have high predictive ability. Conclusions and recommendations Our study establishes and tests the relationships between three service process segments and overall patient satisfaction. The model is an excellent overall patient satisfaction predictor. The strength of the relationships between patient satisfaction and the three service experience process segments is also tested. Overall satisfaction model results indicate that the patients satisfaction with the actual surgical stay, indicated in the model as Stage 2 in Figure 3 has the most signicant impact on the patients overall satisfaction with the entire service process. Stage 2s impact (path coefcient) on overall satisfaction is 0.666. The pre-process segment (Stage 1) has a signicantly lower impact of 0.18 and the post-process segment (Stage 3) has only a 0.148 effect on overall satisfaction. These results indicate that models based on
expectations, equivalent to the Stage 1 service experience pre-process segment, have signicantly less impact on overall satisfaction. The greatest impact on overall satisfaction is the actual surgical experience; however, each process stage inuences the development of overall patient satisfaction and all three stages should be included in the model. Our analysis also found that, for this model, each process stage mediates subsequent stages. For example, the highest impact is represented by the path coefcient of 0.891 from Overall Stage 1 to Overall Stage 2. Overall Stage 1 has a dramatically lower effect on Stage 3 (0.180). The path coefcients for Overall Stage 1 indicate that the pre-process stage has the highest impact on the stage immediately following the registration process and decreases as the patient moves farther away from the pre-process stage. This indicates that pre-process segment impact, or expectations, diminishes as the patient moves away from the pre-process segment. These results cannot be generalized to all segments since process satisfaction impacts overall satisfaction more than the post-process segment, but this may be true since process satisfaction had such a large effect on overall satisfaction. Our research establishes and tests the relationships between patient satisfaction antecedents and overall satisfaction for each service process stage. The same 11 antecedents were evaluated for Pre-Process Satisfaction and for Process Satisfaction. The tangibles antecedent was not included for Post-Process Satisfaction. The results of the Pre-Process Satisfaction model indicate that courtesy has the most impact on customer satisfaction for this segment; in fact, the path coefcient for courtesy is almost twice that of the next highest path coefcients: reliability, empathy, assurance and tangibles. The remaining antecedents are ranked in order of impact on pre-process satisfaction as follows: reliability, empathy, competence, responsiveness, communication, condentiality, security and then convenience. For this service process segment, courtesy is most important. However, patients pay attention to the facilitys neatness and cleanliness. Tangibles may be important in this case because of the correlation between cleanliness and a good surgical outcome (i.e. no infection following surgery). The health care provider needs to convey to patients that the registration process will be done correctly and that everything the patient needs for the actual surgery will be processed and ready. Assurance at this stage can impact how comfortable the patient feels about the surgical process. If the health care provider can handle the pre-registration process well then it can probably handle the surgery to a good standard. The results of the Process Satisfaction model indicate that convenience has the most impact on the formation of overall process satisfaction. Convenience is closely followed by assurance and courtesy. The remaining antecedents were ranked as competence, responsiveness, condentiality, security, tangibles, communication, reliability, and empathy. The number one ranking for convenience in the process satisfaction segment was unexpected. One possible explanation could be that the process segment convenience aspects act to reduce stress over the actual surgical process. Assurance, however, ranked second in the process segment, closely followed by courtesy. Assurance has the greatest impact on the formation of Post-Process satisfaction. The remaining antecedents are ranked as condentiality, communication, responsiveness, reliability, empathy, competence, courtesy, and security. When the Overall Satisfaction model was evaluated, assurance had the highest rankings across all process segments,
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followed closely by courtesy, responsiveness, competence, reliability, communication, empathy, and security. Condentiality and convenience had the lowest impact. Tangibles were not evaluated in the Post-Process Satisfaction model, so tangibles were not included in the rankings. The results of some rankings were unexpected. The health care literature stresses the importance of communication in evaluating patient satisfaction (Shelton, 2000). However, communication was eighth in the overall rankings, which may have occurred since a communication aspect was included in the assurance denition. The patient may view the health care providers ability to convey trust and condence is more crucial than the ability to explain the procedure or merely convey information. Empathy ranked ninth out of ten antecedents consistently evaluated in all three process-segment models and ranked last in the process segment. The empathy denition developed for this study limits the measurement to the degree to which the health care provider attempts to understand patients feelings and concerns. The low ranking for empathy may have occurred because approachability and sense of security were omitted from the newly-developed denition. Patients may consider assurance more important in the out-patient surgical setting than how empathetic the health care providers appear to be. How well the patient feels that the surgery will be performed may be much more important. Condentiality ranked low in all aspects of the out-patient surgery experience. This result was also surprising since governmental regulatory agencies have emphasized patient condentiality and motivated the development of the patients bill of rights (Shelton, 2000). Perhaps these policies have been in place so long and so much emphasis has been placed on them that patients do not question this aspect of the service unless a problem arises. The results of the different satisfaction models indicate the antecedents have differing impacts on satisfaction depending on where the antecedent is measured. The most important pre-process segment antecedent for the patient was courtesy, convenience for the process segment, assurance for the post-process segment and for overall satisfaction. Results indicate that health care service staff should allocate resources to training service providers to be able to courteously convey trust and condence to the patient in all three of the service process segments, but the organization should focus on these aspects during the registration process to alleviate anxiety about the impending surgery. The organization should also allocate resources to make the out-patient surgery experience as easy to get through as possible by minimizing any additional stress on the day of surgery. The organization should focus on making the center easy to nd by providing good directions and appropriate signage for example, staff should design parking facilities and procedures to be as convenient as possible by providing adequate signage, specic entry and departure areas for the patients and perhaps valet parking. Directional assistance should be available so patients can easily arrive at the proper location within the facility; assistance could be in the form of clear and adequate directions possibly from an information desk at the out-patient entry. Patients are pre-registered for out-patient surgery, so paperwork should be in place when he or she arrives at the surgery center. The remaining surgical procedures should be designed to be as stress-free as possible. When the patient is discharged, transportation to the facility exit should be ready and waiting so the patient can easily leave the facility. Designing the out-patient surgery process to be convenient for the patient on the day of surgery can have the greatest
impact on evaluating overall satisfaction. Assurance needs to be the focus in any post-process interactions with the patient. He or she needs to feel that any billing or insurance problems are going to be taken care of appropriately. Patients also need to feel that any nancial information will be kept strictly condential. Training programs for administrative personnel in billing and insurance to properly address these issues can also have a great impact on post-process satisfaction. The literature reviews and focus groups determined general patient satisfaction antecedents. Our study only evaluated patient satisfaction antecedents for an out-patient surgery center located in a large USA city, and focuses on an insurance-based healthcare system. Many other types of health care services exist and should be studied to see if the antecedents weights from this study differ when evaluating other health care service operations. The assumption was made that the health care provider and the extent of health care coverage had already been determined. Therefore, this study does not include access, image and value as satisfaction antecedents. Access has been included in numerous health care studies as a construct for determining health care quality and/or patient satisfaction (Ware et al., 1978; Waldbridge and Delene, 1993; Sale, 2000; Shelton, 2000; Shi and Singh, 2001). Waldbridge and Delene (1993) determined that image was an important health care quality determinant. Value has been determined to be important in health care (Donabedian, 1988; Shi and Singh, 2001). Further studies should be conducted to clarify the importance of these factors in the determination of patient satisfaction when the patient has some input into selecting the health care provider and the type of health care coverage. A more generalized model should be developed to evaluate satisfaction in other types of services. Access, image and value should be included in the generalized model. These factors have been included in quality studies in non-health-care services (see Anton, 2000) for a review of access). Kristensen et al. (2001); Naumann and Giel (1995) and John (1992) found image an important quality determinant. Archer and Wesolowsky (1994); Barsky (1995); Bolton and Lemon (1999); Naumann and Giel (1995) and Rust et al. (1994, 1995) included value in their studies; however, more work is needed to determine if satisfaction antecedents vary in impact among service industries. The generalized model could also be applied to public service and not-for-prot service areas. The model should be modied for public services by determining satisfaction antecedents and the importance of each antecedent in not-for-prot organizations. Service models have been applied to service segments within manufacturing organizations (OHara and Frodey, 1993) and the satisfaction model might prove valuable in this area as well. Supply chain management is a particularly rich area where retailer satisfaction, the distributor and other entities along the supply chain is extremely important (Preis, 2003). The generalized model could be easily modied for supply chain applications. Technology has had an enormous impact on how organizations do business (Harvey et al. 1993; Barsky, 1995; Shi and Singh, 2001). Satisfaction antecedents developed for this study should be modied and applied to on-line services; while access, value and image should be included as well. Good results were obtained from these models in an out-patient surgical setting. The model also appears generalizable; the major determination would need to be about selecting satisfaction antecedents for industry-specic applications in the service sector. The
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model should also be applicable to manufacturing organizations that include signicant service segments. Again, determining applicable satisfaction antecedents is vitally important; however, the model provides a foundation upon which to build industry-specic models.
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Hulland, J. (1999), Use of partial least squares (PLS) in strategic management research: a review of four recent studies, Strategic Management Journal, Vol. 20, pp. 195-204. Igbaria, M. and Greenhaus, J. (1992), The career advancement prospects of managers and professionals: are MIS employees unique?, Decision Sciences, Vol. 23 No. 2, pp. 478-500. John, J. (1992), Improving quality through patient-provider communication, Journal of Health Care Marketing, Vol. 11 No. 4, pp. 51-61. Kristensen, K., Juhl, H. and Ostergaard, P. (2001), Customer satisfaction: some results for European retailing, Total Quality Management, Vol. 12 Nos 7-8, pp. 890-7. Naumann, E. and Giel, K. (1995), Customer Satisfaction Measurement and Management, Quality Press, Milwaukee, WI. OHara, J. and Frodey, C. (1993), A service quality model for manufacturing, Management Decision, Vol. 31 No. 8, pp. 46-51. Oliver, R. (1996), Satisfaction: A Behavioral Perspective on the Consumer, Irwin/McGraw-Hill, Boston, MA. Parasuraman, A., Berry, L. and Zeithaml, V. (1985), A conceptual model of service quality and its implications for future research, Journal of Marketing, Vol. 49 No. 4, pp. 41-50. Parasuraman, A., Zeithaml, V. and Berry, L. (1988), SERVQUAL: A multiple-item scale for measuring consumer perceptions of service quality, Journal of Retailing, Vol. 64 No. 2, pp. 12-40. Peter, J., Churchill, G. and Brown, T. (1993), Caution in the use of differenced scores in consumer research, Journal of Consumer Research, Vol. 19 No. 3, pp. 655-62. Peyrot, M., Cooper, P. and Schnapf, D. (1993), Consumer satisfaction and perceived quality of out-patient health services, Journal of Health Care Marketing, Vol. 13 No. 1, pp. 24-34. Preis, M. (2003), The impact of interpersonal satisfaction in repurchase decisions, Journal of Supply Chain Management, Vol. 39 No. 3, pp. 30-8. Reidenbach, R. and Sandifer-Smallwood, B. (1990), Exploring perceptions of hospital operations by a modied SERVQUAL approach, Journal of Health Care Marketing, Vol. 10 No. 12, pp. 47-55. Rosenberg, M. and Hovland, C. (1960), Cognitive, affective, and behavioral components of attitudes, in Hovland, C.I. and Rosenberg, M.J. (Eds), Attitude Organization and Change: An Analysis of Consistency Among Attitude Components, Yale University Press, New Haven, CT. Rosen, L. and Karwan, K. (1994), Prioritizing the dimensions of service quality: an empirical investigation and strategic assessment, International Journal of Service Industry Management, Vol. 5 No. 4, pp. 39-52. Rust, R., Zahorik, A. and Keiningham, T. (1994), Return on Quality: Measuring the Financial Impact of Your Companys Quest for Quality, Probus Publishing Company, Chicago, IL. Rust, R., Zahorik, A. and Keiningham, T. (1995), Return on quality (ROQ): making service quality nancially accountable, Journal of Marketing, Vol. 59 No. 2, pp. 58-70. Ryan, M., Rayner, R. and Morrison, A. (1999), Diagnosing customer loyalty drivers, Marketing Research, Vol. 11 No. 2, pp. 18-27. Sale, D.T. (2000), Quality Assurance: A Pathway to Excellence, Macmillan Press, Basingstoke. Shelton, P. (2000), Measuring and Improving Patient Satisfaction, Aspen Publishers, Gaithersberg, MD.
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Shewchuk, R., OConnor, S. and White, J. (1991), In search of service quality measures: some questions regarding psychometric properties, Health Services Management Research, Vol. 4 No. 1, pp. 65-75. Shi, L. and Singh, D. (2001), Delivering Health Care in America: A Systems Approach, Aspen Publishers Inc., Gaithersburg, MD. Singh, J. (1990), A multifacet typology of patient satisfaction with hospital stay, Journal of Health Care Marketing, Vol. 19 No. 12, pp. 8-21. Spreng, R. and Page, T. (1996), A reexamination of the determinants of consumer satisfaction, Psychology and Marketing, Vol. 18 No. 11, pp. 1187-205. Teas, R. (1993), Expectations, performance, evaluation, and consumers perceptions of quality, Journal of Marketing, Vol. 18 No. 10, pp. 18-34. Teas, R. (1994), Expectations as a comparison standard in measuring service quality: an assessment of a reassessment, Journal of Marketing, Vol. 58 No. 1, pp. 132-9. Thompson, P., DeSouza, G. and Gale, B. (1985), The strategic management of service quality, Quality Progress, Vol. 18 No. 6, pp. 20-6. Vandamme, R. and Leunis, J. (1993), Development of a multiple-item scale for measuring hospital service quality, International Journal of Service Industry Management, Vol. 4 No. 3, pp. 30-49. Walbridge, S. and Delene, L. (1993), Measuring physician attitudes of service quality, Journal of Health Care Marketing, Vol. 13 No. 1, pp. 6-16. Ware, J., Davies-Avery, A. and Stewart, S. (1978), The measurement of meaning of patient satisfaction, Health and Medical Care Services Review, Vol. 1 No. 1, pp. 2-15. Wicks, A., Fletcher, A. and Chin, W. (2004a), The development and evaluation of a patient satisfaction model for health service organizations, working paper, Bryant University, Smitheld, RI. Wicks, A., Fletcher, A. and Chin, W. (2004b), Denitions of the antecedents of patient satisfaction for an ambulatory surgery center, working paper, Bryant University, Smitheld, RI. Witten, I. and Frank, E. (2001), Data Mining Practical Machine Learning Tools and Techniques with Java Implementations, Academic Press, San Diego, CA. Wold, H. (1982), Soft modeling: the basic design and some extensions, in Joreskog, K.G. and Wold, H. (Eds), Systems under Indirect Observations: Causality, Structure, Prediction, Part 2, pp. 1-54. Further reading Parasuraman, A., Zeithaml, V. and Berry, L. (1991), Renement and reassessment of the SERVQUAL scale, Journal of Retailing, Vol. 67 No. 4, pp. 420-51. Corresponding author Angela M. Wicks can be contacted at: awicks@bryant.edu
Pessimism and hostility scores as predictors of patient satisfaction ratings by medical out-patients
Brian A. Costello, Thomas G. McLeod and G. Richard Locke III
Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
Pessimism and hostility scores
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Received 6 May 2006 Revised 13 September 2006 Accepted 23 September 2006
Ross A. Dierkhising and Kenneth P. Offord

Division of Biostatistics, Mayo Clinic, Rochester, Minnesota, USA, and
Robert C. Colligan
Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA
Abstract
Purpose The purpose of this research is to determine whether a pessimistic or hostile personality style adversely affects satisfaction with out-patient medical visits. Many patient and health care provider demographic characteristics have been related to patient satisfaction with a health care encounter, but little has been written about the association between patients personality characteristics and their satisfaction ratings. Design/methodology/approach An eight-item patient satisfaction survey was completed by 11,636 randomly selected medical out-patients two to three months after their episode of care. Of these, 1,259 had previously completed a Minnesota Multiphasic Personality Inventory (MMPI). The association of pessimism and hostility scores with patient satisfaction ratings was assessed. Findings Among patients who scored high on the pessimism scale, 59 percent rated overall care by their physicians as excellent, while 72 percent with scores in the optimistic range rated it as excellent (p 0:003). Among the hostile patients, 57 percent rated their overall care by physicians as excellent, while 66 percent of the least hostile patients rated it as excellent (p 0:002). Originality/value Pessimistic or hostile patients were signicantly less likely to rate their overall care as excellent than optimistic or non-hostile patients. Keywords Patients, Personality, United States of America, Health services Paper type Research paper
Introduction Practicing clinicians know that certain patients are difcult to satisfy, inconsolable and personally challenging, no matter how comprehensive, efcient and expert their care, nor how polished the physicians interpersonal skills. Patient satisfaction has been widely studied. Satisfaction determinants range from structurally-based ones such as the type of health care delivery system, to physician characteristics, including interactional style and the physicians age (Kirsner and Federman, 1997). The Medical Outcomes Study (MOS) evaluated patient satisfaction based on practice type and payment method (Rubin et al., 1993). The MOS included more than 17,000 patients who had lled out a nine-item questionnaire after an out-patient visit. Patients seen in a solo or single-specialty practice, rather than in multi-specialty groups or health maintenance organizations, were most likely to rate the overall visit as excellent.
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Physician age and gender have also been correlated with patient satisfaction; specically, lower satisfaction is reported by patients after seeing younger, female physicians (Hall et al., 1994). Effective communication skills and particular physician behaviors, such as performing a physical examination, have been associated with higher patient satisfaction ratings (DiMatteo et al., 1980; Bartlett et al., 1984; Robbins et al., 1993). Organizational factors, particularly patient waiting time, have been studied and, as expected, longer waiting times result in lower patient satisfaction (Probst et al., 1997). Although much has been written about organizational, structural, and physician-specic factors related to patient satisfaction, surprisingly little has been written about patient characteristics and their relationship to medical care satisfaction ratings. For example, patients who believe their health status is good are more satised with their care (Probst et al., 1997). Patient satisfaction is associated with compliance and willingness to continue receiving care from a particular physician (Rubin et al., 1993). Conversely, patients with depression or anxiety disorders are more likely to express dissatisfaction from unmet expectations (Kroenke et al., 1997). Furthermore, in a study of patient characteristics among out-patients at our center, lower satisfaction ratings were reported by patients who were young, who were employees of the center, and who lived locally (Locke, G.R. personal communication, September 2002). Therefore, understanding factors associated with patient satisfaction, including the patients personality characteristics, is important. This study investigated the personality characteristics of pessimism and hostility as they relate to patient satisfaction ratings. We hypothesized that pessimistic or hostile patients would report less satisfaction with their care. Methods Two archival data sets were abstracted. The rst data set consisted of information from 11,636 medical out-patients who completed a patient satisfaction survey for the Department of Internal Medicine from March 1998 through March 1999. An eight-item questionnaire was mailed to randomly selected medical out-patients two to three months after their care episode. A ve-point scale was used to rate seven items pertaining to satisfaction with access, interactions with physicians and allied health staff, general satisfaction with the visit and willingness to recommend our center to others. The topic of the eighth item was the completion of all scheduled tests and consultations (yes/no), not satisfaction. The survey response rate was 60 percent. The second data set comprised scores from approximately 335,000 Minnesota Multiphasic Personality Inventories (MMPIs) archived at our institution since 1959. When the two data sets were merged we found that 1,259 medical out-patients had completed both the patient satisfaction survey and, before that survey was completed, an MMPI. All MMPIs had been obtained before the satisfaction survey. Of the MMPI and the patient satisfaction responses, 1,259 out-patients formed the basis for our study. We then assessed the degree of association between: . personality traits of pessimism and hostility, as assessed by the MMPI; and . patients reports of satisfaction with care. The study was approved by our institutional review board, and all study subjects gave research authorization. Pessimism and hostility were chosen for study because these
personality traits, as assessed by the MMPI, are considered relatively stable (Maruta et al., 1993; Maruta et al., 2000). Furthermore, in our experience, these qualities come closest to dening the intangible characteristics that physicians sense in patients who are difcult to satisfy. The MMPI consists of 550 unique true/false items about thoughts, feelings, attitudes, physical symptoms, emotional symptoms, and previous life experiences (Swenson et al., 1990). It was initially developed when McKinley and Hathaway (1943) noted that:
Competent internists have estimated variously that from 30 to 70 percent of the ambulatory patients who appear for medical attention come primarily because of one or more complaints that turn out to be psychoneurotic in nature.
41
The MMPI scales are reported as T-scores, which are standardized to a mean of 50 and an SD of 10. High scores on the pessimism (PSM) scale reect a pessimistic explanatory style; low scores, optimistic. The PSM scale for the MMPI is based on Seligmans explanatory style theory (Colligan et al., 1994), which suggests that people who believe that the cause of an adverse event is internal and personal (rather than external), stable (rather than transient) and global (rather than specic) possess a pessimistic personality trait. Research shows that a pessimistic explanatory style is predictive of an increased likelihood of depression, poorer physical health, lower levels of achievement and increased use of medical and mental health services (Seligman, 1989, pp. 5-32). Hostility was measured by the MMPI hostility (Ho) scale (Cook and Medley, 1954). The scales developers describe a hostile person (i.e. scoring high on the Ho scale) as:
. . . lone who has little condence in his fellowman. . . [and] sees people as dishonest, unsocial, immoral, ugly and mean. . .Hostility amounts to chronic hate and anger.
Statistical methods Logistic regression models were used to assess the association between patient satisfaction ratings and the PSM and Ho scores. Our large sample size allowed us to detect small, but signicant, relationships that might not otherwise be uncovered in smaller or more highly selected samples. The dependent variables were seven patient satisfaction responses from the eight-item survey. For six questions, responses were coded 1 for excellent or 0 for all other response categories to that item. For the question about recommending the medical center to others, responses were coded 1 for denitely would recommend or 0 for any other response. This procedure for collapsing and dichotomizing the ve-point scale is in keeping with the convention from marketing literature (Jones and Sasser, 1995). Additionally, from experience with previous internal analyses, we also adjusted for previously identied predictive covariates. These included patients residence distance from our medical center, age, being a medical center employee or a dependent of an employee (employee/dependent; 1 yes; 0 no) and receiving primary care. Two interaction variables were included in the models as well: 1 distance of residence from our center by employee/dependent status and 2 age by employee/dependent status. These are known and important explanatory variables when modeling patient satisfaction at our center. Finally, we adjusted for the patients rating of whether all the tests and consultations ordered had been completed during the patients episode of care (yes/no). We considered this variable because many of our patients travel long distances to our center for intensive out-patient
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evaluations during a single episode of care. Therefore, we believed that scheduling a timely, efcient, and complete appointment itinerary could affect ratings of patient satisfaction. Three sets of explanatory variables were used in the modeling. The rst model was done univariately, including only the MMPI scale of interest (i.e. either PSM or Ho). The second model included only one of the MMPI scales of interest and the adjusting variables described above. The third included both MMPI scales of interest and the adjusting variables already mentioned. Wald x2 statistic p values were calculated from these logistic regression models. Since the MMPI and the patient satisfaction survey were not completed concurrently, we assessed whether the time between completing the MMPI and the patient satisfaction survey affected the associations we intended to study. Therefore, we modeled the interaction of time and the MMPI scale score within the context of two models. One included the MMPI scale of interest (i.e. either PSM or Ho) and the interaction between time and the MMPI scale of interest as explanatory variables. The other model consisted of the MMPI scale of interest, the adjusting variables described above and the interaction between time and the MMPI scale as explanatory variables. Results Patient characteristics At the time the satisfaction survey was completed by the 1,259 out-patient participants: . 27 (10 percent) were 18 to 40 years old; . 617 (49 percent) were 41 to 65 years old; and . 515 (41 percent) were 66 years or older. Travel distance varied considerably: . 388 patients (31 percent) lived within 20 miles; . 386 (31 percent) lived 21 to 120 miles away; . 199 (16 percent) lived 121 to 250 miles away; and . 286 (23 percent) lived more than 250 miles away. The survey was completed as follows: . 185 (15 percent) within 1 year after taking the MMPI; . 222 (18 percent) 1.1 to 5 years after the MMPI; . 219 (17 percent), 5.1 to 10 years after the MMPI; . 632 (50 percent), more than 10 years after the MMPI; and . 1 had missing time data. Among these patients: . 719 (57 percent) were female; . 201 (16 percent) were medical center employees or dependents; and . 277 (22 percent) were seeking primary care. During the visit studied, 1,039 patients (83 percent) had their tests and consultations completed (85 [7 percent] had missing data).
Findings Table I shows the percentage of excellent ratings by PSM T-score categories and the p values from the logistic regression models with three sets of explanatory variables. In general, with higher PSM T-scores, reecting an increasing pessimistic explanatory style, the percentage of patients giving excellent ratings was signicantly lower. This pattern was fairly consistent for all survey questions. With higher PSM T-scores, the odds of a patient giving the center an excellent rating were signicantly lower, even after adjusting for completion of tests/consultations and for all the previously identied predictors of satisfaction. However, the association weakened when adjusting for the Ho T-score. This can be explained by the relatively large positive correlation between the PSM and Ho T-scores (r 0:61; p , 0.001). The exception is the question pertaining to the patients willingness to recommend the center, for which the ratings were not associated with these MMPI scale scores. Pessimistic patients (PSM T-score $ 60) were signicantly less likely to give excellent ratings for various aspects of their care than those classied as optimistic (T-score # 39). Specically, 72 percent of the optimistic patients rated it excellent (p 0:003), while 59 percent of the pessimistic patients rated the overall care provided by their physicians as excellent. Furthermore, a signicantly smaller proportion of pessimists than optimists rated other aspects of their care as excellent: . respect shown by physicians (64 percent v. 75 percent; p 0:008); . willingness of physicians to listen to the patient and family (60 percent v. 67 percent; p 0:047); . physicians responding to questions about the patients medical condition and treatment (57 percent v. 71 percent; p 0:002); . helpfulness of allied health staff (53 percent v. 65 percent; p 0:002); and . overall care received (55 percent v. 63 percent; p 0:003). However, the PSM scale scores were not associated with willingness to recommend the center (86 percent of pessimists v. 89 percent of optimists; p 0:282). Table II displays the percentage of excellent ratings by Ho T-score groupings and the p values from the logistic regression models. The same patterns were present among the excellent ratings in relation to patient hostility (i.e. higher Ho T-scores) as for the PSM scale. The results from the models were also similar. A smaller proportion of patients who scored high on hostility (Ho scale T-score $ 60) gave excellent ratings on various aspects of their care than did patients who scored low on the Ho scale (T-score # 39). This is evident in their responses on individual items: . overall care provided by their physicians (57 percent v. 66 percent; p 0:002); . respect shown by physicians (57 percent v. 70 percent; p 0:008); . willingness of physicians to listen to patient and family (54 percent v. 66 percent; p 0:001); . physicians responding to questions about the patients medical condition and treatment (53 percent v. 67 percent; p , 0.001); . helpfulness of allied health staff (47 percent v. 64 percent; p , 0.001); and . overall care received (52 percent v. 63 percent; p 0:001).
43
44
IJHCQA 21,1
Questionnaire item 83 83 83 83 100 83 100 88 89 86 86 62 62 62 64 61 59 57 56 43 51 88 70 64 61 59 52 71 65 63 89 71 75 66 65 68 64 64 67 62 61 65 60 55 61 59 72 75 67
Overall care by physician Respect by physician Listening by physician Physician addressing questions Helpfulness of allied health staff Overall care Willingness to recommend centerd
Notes: PSM pessimism scale of the Minnesota Multiphasic Personality Inventory; * Entries are the percentages of patients rating that aspect of care as excellent. Within PSM groupings, sample sizes are ranges because the number of respondents varied among questions. Patients with low scores (#39) were classied as optimistic; patients with high scores ($60), pessimistic; a p1 is the p value from the test of the coefcient of the PSM T-score variable from the logistic regression model with the dependent variable being the rating (1 excellent; 0 not excellent) and the independent variable being the PSM T-score; b p2 is the p value from the test of the coefcient of the PSM T-score variable from the logistic regression model with the dependent variable being the rating (1 excellent; 0 not excellent) and the independent variables being completion of tests and consultations during the initial visit (1 yes; 0 no). PSM T-score; and variables previously identied from the analysis of the patient satisfaction survey (distance of residence from the center [in miles], patient age [in years], center employee/dependent [1 yes; 0 no], seen in primary care area [1 yes; 0 no], distance from the center by center employee/dependent status interaction, and patient age by center employee/dependent status interaction); c p3 is the p value from the test of the coefcient of the PSM T-score variable from the logistic regression model with the dependent variable being the rating (1 excellent; 0 not excellent) and the independent variables as for p2 but with both the PSM and hostility scale T-scores included in the model; d Entries are the percentages of patients who denitely would recommend the center
Table I. Relationship between patient satisfaction rating of Excellent and the PSM T-score PSM T-score groups * Subtotals ,30 30-39 40-49 50-59 60-69 $ 70 Optimistic Pessimistic (n 6) (n 92-95) (n 307-311) (n 393-401) (n 323-329) (n 102-106) (#39) ($60) 59 64 60 57 53 55 86 p1 a p2 b p3 c 0.003 0.002 0.056 0.008 0.011 0.133 0.047 0.075 0.774 0.002 0.002 0.221 0.002 0.002 0.229 0.003 0.005 0.219 0.282 0.843 0.841
Questionnaire item 47 65 65 53 59 53 71 89 87 89 84 82 88 65 64 57 59 58 56 50 54 35 43 64 63 68 61 58 56 39 67 53 47 52 83 67 70 66 63 66 60 61 69 63 59 60 57 48 48 39 66 70 66 57 57 54
Ho T-score groups * Subtotals , 30 30-39 40-49 50-59 60-69 $70 Nonhostile Hostile (n 6) (n 92-95) (n 307-311) (n 393-401) (n 323-329) (n 102-106) (# 39) ($60) p1 a p1 b
p1 c
0.002 0.006 0.328 0.008 0.026 0.403 0.001 0.011 0.068 ,0.001 0.001 0.046 ,0.001 0.001 0.048 0.001 0.002 0.097 0.434 0.947 0.941
Overall care by physician Respect by physician Listening by physician Physician addressing questions Helpfulness of allied health staff Overall care Willingness to recommend centerd
Notes: Ho hostility scale of the Minnesota Multiphasic Personality Inventory; * Entries are the percentages of patients rating that aspect of care as
excellent. Within Ho groupings, sample sizes are ranges because the number of respondents varied among questions. Patients with low scores (#39) were classied as nonhostile; patients with high scores ($ 60), hostile; a p1 is the p value from the test of the coefcient of the Ho T-score variable from the logistic regression model with the dependent variable being the rating (1 excellent; 0 not excellent) and the independent variable being the Ho T-score; b p2 is the p value from the test of the coefcient of the Ho T-score variable from the logistic regression model with the dependent variable being the rating (1 excellent; 0 not excellent) and the independent variables being completion of tests and consultations during the initial visit (1 yes; 0 no); Ho T-score; and variables previously identied from the analysis of the patient satisfaction survey (distance of residence from the center [in miles], patient age [in years], center employee/dependent [1 yes; 0 no], seen in primary care area [1 yes; 0 no], distance from the center by center employee/dependent status interaction, and patient age by center employee/dependent status interaction); c p3 is the p value from the test of the coefcient of the Ho T-score variable from the logistic regression model with the dependent variable being the rating (1 excellent; 0 not excellent) and the independent variables as for p2 but with both the optimism-pessimism scale and Ho T-scale scores included in the model; d Entries are the percentages of patients who denitely would recommend the center
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Table II. Relationship between patient satisfaction rating of Excellent and the Ho T-score
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Again, the exception to this trend was the question pertaining to a patients willingness to recommend the medical center to others. There was no signicant difference in the percentages of hostile patients (Ho T score $ 60; 83 percent) and non-hostile patients (Ho T score # 39; 88 percent) who reported denitely would recommend the center (p 0:434). Table III displays the odds ratios for excellent ratings corresponding to 10-unit (1 SD) increases in MMPI scale scores for PSM and Ho. The odds ratios were estimated for each of the three models. When signicant associations existed, there was an approximately 15 percent to 20 percent decrease in the odds of giving an excellent rating for every 10-point increase in the PSM or Ho T-scores. The time interval between completing the MMPI and the patient satisfaction survey did not affect the association between the MMPI T-scores and the satisfaction ratings, except for the question about willingness to recommend the center. Patients who had a long interval between completing the MMPI and the patient satisfaction survey were more likely to denitely recommend the center to others than were those with a shorter interval. Among patients who would denitely recommend the center, the estimated odds ratios that corresponded to a 10-unit (1 SD) increase in the MMPI T-scores increased with the interval. In general, these odds ratios increased by about 0.02 to 0.03 for every 5-year interval increase. Discussion Patient satisfaction has been studied from various vantage points. However, our approach to studying the contributions of patient personality has not been previously taken. Our analysis shows that pessimistic patients (i.e. having a pessimistic explanatory style as theorized by Seligman) or hostile patients (i.e. high scores on the Ho scale) are signicantly less likely to rate satisfaction with their care as excellent. Our results are a rst step towards understanding that certain aspects of the patients personality affect ratings of their satisfaction with care. Previously, these aspects of patient personality were experienced subjectively and understood solely through physicians intuition and judgment. Adverse encounters were believed to result from the physicians characteristics and behaviors or from organizational and structural factors surrounding the care episode. Now it is evident that some aspects of the patients personality affect ratings of satisfaction with care. These occur independently of other factors already known to contribute to variations in ratings of patient satisfaction. Clearly there are likely to be other patient-related characteristics that affect patient satisfaction ratings. These may include emotional states (e.g., depression) at the time of the survey or episode of care, or certain patient expectations, unknown to the physician, before the encounter. Additionally, patient satisfaction ratings for particular physicians and health care organizations are tacitly assumed to be a reection of physicians or health care system. However, our ndings indicate that important data about the factors contributing to patient satisfaction ratings are missing if patient personality characteristics are not considered. It is notable that willingness to recommend our center to family and friends was not associated with hostility or pessimism. This may result from feelings that, regardless of their opinion about some aspects of their experience during a particular care episode, these patients would still recommend the center because of other factors such as the centers reputation. We included all patients who had completed both a patient
Questionnaire item 0.85d 0.86 0.90 0.85 0.85 0.85 0.92 (0.76-0.95) (0.77-0.96) (0.81-1.00) (0.76-0.94) (0.76-0.94) (0.77-0.95) (0.79-1.07) 0.83 0.86 0.90 0.84 0.84 0.85 0.98 (0.74-0.93) (0.77-0.97) (0.81-1.01) (0.75-0.94) (0.76-0.94) (0.76-0.95) (0.84-1.16) 0.87 0.90 0.98 0.92 0.92 0.92 0.98 (0.75-1.00) (0.78-1.03) (0.85-1.13) (0.80-1.06) (0.80-1.06) (0.80-1.05) (0.80-1.21) 0.83 0.85 0.83 0.79 0.81 0.82 0.94 (0.74-0.94) (0.76-0.96) (0.74-0.93) (0.70-0.89) (0.72-0.91) (0.73-0.92) (0.79-1.11) 0.84 0.87 0.86 0.81 0.81 0.83 0.99 (0.75-0.95) (0.77-0.98) (0.76-0.97) (0.71-0.91) (0.72-0.91) (0.73-0.94) (0.83-1.19)
Model 1a
PSM scale Model 2b Model 3c Model 1a 0.93 0.94 0.87 0.86 0.86 0.88 1.01
Ho scale Model 2b
Model 3c (0.79-1.08) (0.80-1.10) (0.74-1.01) (0.73-1.00) (0.74-1.00) (0.75-1.02) (0.80-1.28)
Overall care by physician Respect by physician Listening by physician Physician addressing questions Helpfulness of allied health staff Overall care Willingness to recommend center * *
Notes: CI confidence interval; Ho MMPI hostility scale; MMPI Minnesota Multiphasic Personality Inventory; OR odds ratio; PSM MMPI pessimism scale; * See Tables I and II for the p values of the ORs that were signicantly different from 1 (associated coefcient was different from 0). In addition, if the 95 percent CI for the OR contained 1, the OR was not signicantly different from 1 at the a 0:05 level; * * ORs are for the percentage of patients who denitely would recommend the center; a Model 1 is a logistic regression model with the dependent variable being the rating (1 excellent; 0 not excellent) and the independent variable being the PSM or Ho T-score; b Model 2 is a logistic regression model with the dependent variable being the rating (1 excellent; 0 not excellent) and the independent variables being completion of tests and consultations during the initial visit (1 yes; 0 no); PSM or Ho T-score; and variables previously identied from the analysis of the patient satisfaction survey (distance of residence from the center [in miles], patient age [in years], center employee/dependent [1 yes; 0 no], seen in primary care area [1 yes; 0 no], distance from center by center employee/dependent status interaction, and patient age by center employee/dependent status interaction); c Model 3 is a logistic regression model with the dependent variable being the rating (1 excellent; 0 not excellent) and the independent variables as in model 2 but including both PSM and Ho T-scores; d For example, for the PSM scale and the overall care by the physician, there is a 15 percent decrease in the odds of giving an excellent rating for every 10-unit (1 SD) increase in the PSM T-score
47
Table III. Odds ratios (95 percent CI) for percentage of Excellent ratings for a 10-unit (1 SD) increase in the MMPI T-scores *
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satisfaction survey and an MMPI and did not exclude cases in which there was a long interval between the survey and the MMPI. Time limits were not imposed because we were studying two personality traits that are relatively stable. Furthermore, one might speculate that patients coming to a tertiary care medical center for evaluation, who had also been asked to complete an MMPI, had a combination of medical and psychological issues requiring multidisciplinary investigation. Such patients are diagnostically and personally challenging for physicians. Patient satisfaction ratings may be decreased if these patients are also characterized by traits of pessimism or hostility. Patient satisfaction at our center is associated with several variables, including status as employee/dependent, age of patient, distance traveled for care, and type of care received. We included these independent variables in the models as adjusting variables. Nonetheless, signicant differences were noted in satisfaction on the basis of levels of hostility or pessimism. Although these ndings are intriguing, the possibility exists that physician care or manner may be modied by patient personality factors, since astute physicians are attuned to the personal qualities of their patients. Finally, while contributing little to the practical management of hostile or pessimistic patients, this research is a rst step towards understanding how patient personality affects reported levels of satisfaction with medical care and why some patients are difcult to satisfy regardless of other factors related to their care. Conclusions and recommendations This research clearly demonstrates that patient personality characteristics play an important role in the results derived from patient satisfaction surveys. Physicians are much less likely to obtain excellent ratings from pessimistic or hostile patients, as dened in this article. This inuence is independent of physician or practice characteristics. Patient mix may temper an individual doctors satisfaction ratings. Therefore, institutional policy makers need to be aware of the potentially signicant contribution of patient personality factors in adversely affecting the patient satisfaction ratings of individual physicians. This research also suggests that it may be informative to identify personality characteristics of those who were sent satisfaction questionnaires and did not return them.
References Bartlett, E.E., Grayson, M., Barker, R., Levine, D.M., Golden, A. and Libber, S. (1984), The effects of physician communications skills on patient satisfaction, recall, and adherence, Journal of Chronic Diseases, Vol. 37 Nos 9-10, pp. 755-64. Colligan, R.C., Offord, K.P., Malinchoc, M., Schulman, P. and Seligman, M.E. (1994), CAVEing the MMPI for an optimism-pessimism scale: Seligmans attributional model and the assessment of explanatory style, Journal of Clinical Psychology, Vol. 50 No. 1, pp. 71-95. Cook, W.W. and Medley, D.M. (1954), Proposed hostility and pharisaic-virtue scales for the MMPPI, Journal of Applied Psychology, Vol. 38, pp. 414-8. DiMatteo, M.R., Taranta, A., Friedman, H.S. and Prince, L.M. (1980), Predicting patient satisfaction from physicians nonverbal communication skills, Medical Care, Vol. 18 No. 4, pp. 376-87. Hall, J.A., Irish, J.T., Roter, D.L., Ehrlich, C.M. and Miller, L.H. (1994), Satisfaction, gender, and communication in medical visits, Medical Care, Vol. 32 No. 12, pp. 1216-31.
Jones, T.O. and Sasser, W.E. Jr. (1995), Why satised customers defect, Harvard Business Review, Vol. 736, pp. 88-99. Kirsner, R.S. and Federman, D.G. (1997), Patient satisfaction: quality of care from the patients perspective, Archives of Dermatology, Vol. 133 No. 11, pp. 1427-31. Kroenke, K., Jackson, J.L. and Chamberlin, J. (1997), Depressive and anxiety disorders in patients presenting with physical complaints: clinical predictors and outcome, American Journal of Medicine, Vol. 103 No. 5, pp. 339-47. McKinley, J.C. and Hathaway, S.R. (1943), The identication and measurement of the psychoneuroses in medical practice, Journal of the American Medical Association, Vol. 122, pp. 161-7. Maruta, T., Colligan, R.C., Malinchoc, M. and Offord, K.P. (2000), Optimists vs pessimists: survival rate among medical patients over a 30-year period, Mayo Clinic Proceedings, Vol. 75 No. 2, pp. 140-3 (Erratum, in Mayo Clinic Proceedings, (2000), Vol. 75 No. 3, p. 318). Maruta, T., Hamburgen, M.E., Jennings, C.A., Offord, K.P., Colligan, R.C., Frye, R.L. and Malinchoc, M. (1993), Keeping hostility in perspective: coronary heart disease and the Hostility Scale on the Minnesota Multiphasic Personality Inventory, Mayo Clinic Proceedings, Vol. 68 No. 2, pp. 109-14. Probst, J.C., Greenhouse, D.L. and Selassie, A.W. (1997), Patient and physician satisfaction with an out-patient care visit, Journal of Family Practice, Vol. 45 No. 5, pp. 418-25. Robbins, J.A., Bertakis, K.D., Helms, L.J., Azari, R., Callahan, E.J. and Creten, D.A. (1993), The inuence of physician practice behaviors on patient satisfaction, Family Medicine, Vol. 25 No. 1, pp. 17-20. Rubin, H.R., Gandek, B., Rogers, W.H., Kosinski, M., McHorney, C.A. and Ware, J.E. Jr. (1993), Patients ratings of out-patient visits in different practice settings: results from the Medical Outcomes Study, Journal of the American Medical Association, Vol. 270 No. 7, pp. 835-40. Seligman, M.E.P. (1989), Explanatory style: predicting depression, achievement, and health, Brief Therapy Approaches to Treating Anxiety and Depression, Brunner/Mazel, New York, NY. Swenson, W.M., Osborne, D. and Colligan, R.C. (1990), A Users Guide to the Mayo Clinic Computerized Scoring and Interpretative System for the Minnesota Multiphasic Personality Inventory (MMPI), 3rd ed., Mayo Foundation, Rochester. Corresponding author Brian A. Costello can be contacted at: costello.brian@mayo.edu
49
IJHCQA 21,1
The role of understanding customer expectations in aged care

Leib Leventhal
Conict Management Systems Designer, Cauleld North, Australia
Abstract
Purpose The purpose of this paper is to argue that understanding and exceeding customer expectations in the aged care services is more complex than other health services and general services because of the multiple stakeholders and additional intimacies that exist. Design/method/approach The author rst explores expectation theory and how it links to customer behaviour and then discusses conrmation/disconrmation theory. Findings The author builds an argument that aged care service providers must understand consumer needs and expectations so that customer satisfaction is generated. Originality/value Exploring patient and relative expectation and satisfaction in different theoretical contexts. Keywords Elder care, Patients, Australia, Customer satisfaction Paper type Case study
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Received 21 June 2006 Revised 10 July 2006 Accepted 15 July 2006
Introduction This article discusses the role expectations play in complaints handling and argues that aged care face more complexities in understanding expectations than most other services. Understanding the role of expectations in aged care is important because it can increase customer satisfaction. Additionally, understanding customer expectations at the outset of providing services can reduce the incidence of complaints that may occur after the services have been rendered. Additionally, with the onset of the baby-boomer generation entering into aged care, developing and implementing effective complaints handling systems to assist the industry as it grows in demand, both owing to the ageing population and to the social nature of baby boomers to complain when their expectations are not met, is critical. The articles rst section discusses expectations theory outlined in customer satisfaction and service quality literature with particular reference to the Santos and Boote (2003) disconrmation model. Section two builds the argument that aged care services involve a unique and complex form of customer expectations. It begins by differentiating between customer expectations in tangible products and intangible services. Section three continues to build the argument by further differentiating between customer expectations in intangible services and then health care services. Section four outlines how the role of expectations in aged care differs from those in health care. This section nishes the argument by illustrating why aged care service
This article arose from the authors Master of Conict Resolution at Latrobe University, School of Law.
staff must adopt unique approaches to understanding customer expectations. The penultimate section examines a case study that illustrates how customer expectations in aged care involves multiple stakeholders and that understanding customer expectations is critical as the rst step in managing complaints. In the nal section, strategies for understanding customer expectations and implications for the aged care sector in the wake of its baby-boomer growth stage are discussed. A review of customer expectation theory Customer expectations are related to complaints through post-purchase affective states that cause affective behaviour such as complaining. These post-purchase affective states range from delight, satisfaction and dissatisfaction all relative to the original customer expectation. Affective behaviours stemming from satisfaction and delight are compliments. Those emerging from dissatisfaction are complaints, increasing in intensity as more dissatisfaction is felt (Santos and Boote, 2003). As Gilbert et al. (1992, p. 47) put it:
Expectations provide the yardstick people use to evaluate the attractiveness and desirability of outcomes, events, people, products, services and the like.
Understanding customer expectations 51
How expectations form What forms the basis of expectations has been discussed extensively in the literature. Expectations can be based on market communication, image, word of mouth or customer needs. Additionally, customer pre-attitudes or even the traditional marketing mix can inuence what the consumer will expect from a product or service. Prior experiences with organisations also form the basis of consumer expectations, along with organisational and structural attributes. Predictive or will expectations are those that the consumer thinks will happen in the next service encounter, while should expectations are those that the consumer thinks should happen in the next encounter. Expectations have also been described as standards: . an ideal standard or subjective norm; . an industry standard or objective norm relating to the marketplace; and . a relationship standard based on the overall experience a customer has had in the past with a particular product or service. They have also been identied as being fuzzy or focused, implicit or explicit, unrealistic or realistic (Ojasalo, 2001). Expectations have also been described as customer needs divided into three main categories: (1) must be needs those which the customer would not think about expressing, but will only be missed if not provided for; (2) expected needs those which customers are able to articulate when asked about what they want; and (3) exciting requirements those unexpected needs that produce great satisfaction. Over time, customers expected needs can become must be needs, which therefore, places responsibility on the provider of goods or services to continually improve
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products and services (Lim et al., 1999). In line with what has been termed adaptation theory, which states that customers of particular groups of products or services do not change their suppliers or providers because their expectations have adapted to an environment where there has been no additional stimuli to cause them to change. However, over time, when new information becomes available regarding other suppliers or providers, and the consumers expectations change, consumers will weigh up the cost of staying with the adapted current provider against moving to a new one (Gilbert et al., 1992). Disconrmation theory Adaptation theory was the basis of what has now become known as Disconrmation of Expectations Theory rooted in the works of Helson (1964). At a basic level, conrmation or disconrmation theory has been explained as meaning whether the product or service delivery met the consumers expectations. If expectations were met then they are said to have been conrmed. If consumer expectations were not met, they are said to have been disconrmed. Ultimately, conrmation of expectations is what determines consumer retention (Bendall and Powers, 1995). At this level, conrmation happens when expectations are met. Others argue that conrmation occurs when performance exceeds expectations and disconrmation occurs when performance falls short of expectations. When performance meets expectations, indifference is said to occur (Gilbert et al., 1992). Notwithstanding the wide acceptance of conrmation/disconrmation theory, authors maintain that it is lacking (Olshavsky and Kumar, 2001). Spreng et al. (1996) in Olshavsky and Kumar (2001) found that expectations as well as desires inuence overall satisfaction. Swan and Trawick (1979) also cited by Olshavsky and Kumar (2001) distinguish predictive expectations and desired expectations:
Predictive expectation is the pre-usage estimate of the performance level that the product was anticipated to achieve. . .Desired Expectation was the consumer pre-usage specication of the level of performance that the consumer wanted (Olshavsky and Kumar, 2001 p. 60).
Under the conrmation/disconrmation model, predictive expectations are used as the measure. In their study, Swan and Trawick (1979), cited by Olshavsky and Kumar (2001), found that when performance was equal to (met) predicted expectations, the result was (as noted earlier) consumer indifference. In contrast, however, when performance was equal to (met) desired expectations, satisfaction was exceedingly higher. This theory is known as the desires as standards model. Thus, the disconrmation of expectations model has been seen as only providing part understanding of customer satisfaction causes. To address this lack of acknowledgment of desired expectations as a source of customer satisfaction, Santos and Boote (2003) formulated a model based on disconrmation of expectations theory that included delight (as an affective state) in addition to satisfaction. They maintain that expectations range, starting at the peak (see Figure 1). The predicted expectation, located at the centre of the vertical spectrum, generates an indifferent response when it is fullled (conrmation, as stated above). Moving upward from the centre, satisfaction occurs in between the fullment of predicted and desired expectations. Positive disconrmation exists when satisfaction occurs. Of course this applies when the higher should be and ideal expectations are met. At this level delight occurs. Delight and satisfaction lead to complimentary behaviour
(Santos and Boote, 2003). Moving below the centre of the vertical spectrum, negative disconrmation exists when expectations fall between predicted and worst imaginable. In between predicted and minimum tolerable, negative disconrmation will generate acceptance by the consumer and dissatisfaction occurs when expectations fall below minimum tolerable until worst imaginable. Dissatisfaction leads to complaints behaviour (Santos and Boote, 2003). This conceptual model incorporates desires into the disconrmation of expectations theory. In doing so, we see that when predicted expectations are met (conrmation), indifference occurs. On the other hand, when desired expectations are met (positive disconrmation), satisfaction occurs. These two affective states become complimentary and inclusive. Up until this article, only the predictive expectation was used when looking at the disconrmation of expectations model, which calls the predictive expectation the core expectation; that is, at the centre of the vertical spectrum and the other expectations such as desired, peripheral expectations (Santos and Boote, 2003). In summary, expectations have been identied as the foundation of affective states such as being satised or dissatised with products or services, which leads consumers to either compliment or complain about the product, supplier, service or service provider. Expectations were dened and an extensive list of types of expectations was identied. Expectations were also identied as customer needs and three types of needs were found. Adaptation and disconrmation theory was found to be the dominant model for understanding expectations and supported how negative disconrmation of expectations can lead to complaining behaviour by the consumer. This review supports the argument that effective complaints handling begins with effective management of consumer expectations. The article goes on to illustrate how expectations become more complex in services than in products, leading to the additional complexities of the health industry and then aged care. Customer expectation in products and services Product quality is commonly ascertained by tangible cues such as style, hardness, colour, label, feel, package, t and functionality, and has been epitomised by the Japanese Zero Defects philosophy doing it right the rst time (Parasuraman et al., 1985). Product quality has been measured by counting the incidence of internal and external failures (Garvin, 1983 as cited by Parasuraman et al., 1985). Service quality, on the other hand, is largely undened and harder to understand because of its intangible nature. Additionally, there is heterogeneity amongst providers of the same services as well as between each time a service is delivered by individual providers themselves.
Figure 1. Disconrmation of expectations
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Finally, different products, production and consumption take place at the same time in service delivery (Parasuraman et al., 1985). Within services, customers, comparing their expectations to actual performance, judge quality. Customers seek consistent performance delivery and service satisfaction is determined by whether there was positive or negative disconrmation of expectations as discussed above (Parasuraman et al., 1985). Additionally, service outcomes and delivery processes are critical to providing services. Sasser et al. (1978), as cited by Parasuraman et al. (1985), argued that service quality is determined by three factors: (1) materials; (2) facilities; and (3) personnel. Gronroos (1982) as cited by Parasuraman et al. (1985) talked about two types of quality: technical (outcomes) and functional (delivery). Additionally, Lehtinen and Lehtinen (1982) as cited by Parasuraman et al. (1985) discussed three service quality dimensions: corporate quality (image), physical quality and interactive quality. Other service quality expectations have been identied in the literature; including reliability, responsiveness, competence, access and approachability, courtesy, communication, credibility, security, understanding customers and nally the tangible aspects of service delivery (Parasuraman et al., 1985). Services intangibility and delivery process inclusion make identifying quality and understanding expectations in service delivery more elusive and multi-dimensional than that of products (Lim et al., 1999). Health care customer service expectations Health services have undergone major change owing to environmental forces including increased competition from alternative providers (Gilbert et al., 1992). It is thus critical for health care service providers to understand customer expectations; enabling them to compete effectively and retain customers (Gilbert et al., 1992). Customer expectations of health care and other industry services are different. The health care industry is complex, multifaceted and undergoing rapid changes. The most noted difference that contrasts health services to other professional services is the intimate relationship that exists between the customer and the health care provider. Within health care, intimate relationships form the foundation of customer satisfaction. This intimate relationship is epitomised by caring the central unifying health service domain (Perucca, 2001). Caring has been identied as the most important factor that impacts on health care customer satisfaction, which includes staff interpersonal attributes and how they respond to patient needs (Perucca, 2001). Specic skills that customers expect in health care are: . competence, such as skillful and timely medication administration; and . knowledge, honesty, listening skills, availability and professional attitude (Perucca, 2001). Similarly, Lim et al.(1999) stated that caring is divided into technical aspects (competence of the provider, thoroughness, clinical and operating skills of doctors) and interpersonal aspects (humane, socio-psychological relationships between patient and health care provider, explanations of illness and treatment, availability of information
and courtesy and warmth received). Interpersonal elements that inuence health care customer impressions include: . eye contact; . attitude, and ability to break preoccupations; . being able to tune out the world and tune in the patient; and . non-verbal gestures, body language and facial expressions (Perucca, 2001). Finally, ve common interpersonal expectations in health care important to patients wellbeing are staff attitudes (sincerity and trust), responsiveness (recognising needs and responding), sensitivity (open ended questioning), privacy (advocating for patient privacy) and appearance (all tangible aspects of care) (Perucca, 2001). In short, quality of care:
. . . becomes that kind of care, which is expected to maximise an inclusive measure of patient welfare, after one has taken into account the balance of gains and losses that attend the process of care in all its parts (Donabedian, 1980, cited by Lim et al., 1999, p. 424). . . . [is] fully meeting the needs of those who need the service most, at the lowest cost to the organisation within limits and directives set by higher authority and purchasers (Ovretveit, 1992 as cited by Lim et al., 1999, p. 424).
Quality of care impacts on the patients intention to return to the health care provider. Like other products and services, if patients quality of care expectations have been exceeded, they will be satised and the health care service provider will retain customers (Bendall and Powers, 1995, p. 50), dened as:
A process by which health care providers inuence loyalty and maintain existing patients.
Loyalty comes from satisfaction, which turns into customers intention to return to the service provider. Of course, if expectations are negatively disconrmed, customer dissatisfaction will occur and the possibility of complaints opens (Bendall and Powers, 1995). An important health industry feature is that meeting customer expectations is not enough to guarantee customer loyalty and retention. In summary, in addition to intangible and process elements of service quality, which make it harder to understand customer expectations in general services, health care services have the additional complexity of expected interpersonal skills and caring attitudes that staff must have in addition to their technical based competencies. Customer expectations in aged care services In addition to the interpersonal skills and caring attitudes needed to meet customer expectations in health care, aged care services have additional layers of customer expectations that make providing these services far more complex than general health care. Aside from involving care recipients physical wellbeing, aged care service customers are frail and elderly who, in a majority of cases, are unable to articulate their concerns because of a lack of self condence and fear of retribution (ACAA, 2005). Consequently, a plethora of other stakeholders often become involved with service delivery, each with his or her own set of interests and concerns (ACAA, 2005). In addition, unlike health care services, aged care residential services are permanent residential arrangements and with that comes more extreme intimate issues such as
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home, security and emotional support (Thomas, 2006). Moreover, other stakeholders, including immediate family members, often feel guilty for having to place their elderly relative in a home and expect the best of care (however so undened) to be given to their loved one (Thomas, 2006). Different family fragments give an additional complexity as multiple sets of expectations are involved. Finally, with the onset of baby-boomer generation retirement and the aging population, customer expectations in aged care will broaden to include updated information technology processes. In summary, in addition to the intangible nature of services, the importance of process delivery and the necessity of having a quality caring environment, aged care services have the additional complexities of understanding and meeting the expectations of other stakeholders aside from the direct customer. It also involves deeply personal issues such as customer residency and security and family guilt. To assist in meeting the aged care residents and their families expectations, the Aged Care Act 1997, Quality of Care Principles 1997 and User Rights Principles 1997 dene what aged care service customers should expect from their service and service provider. However, owing to the intangibility of the nature of service and lack of communication that exists within aged care facilities, these rules and principles may not be made clear to residents relatives. A good example of this scenario is illustrated in the following case study. Case study This case study is the basis of a complaint lodged against a nursing home. The case solely represents the views of the complainant, the purpose of which is to analyse the model of disconrmation of expectations theory in a real case scenario. In no means is the following case meant to be treated as a judgement of the circumstances that surrounded the complaint. The information in this case study has been gathered from written documents and interviews with the daughter of a care recipient (her mother) who resided in an aged-care facility. The daughter cared for her mother from 1994, when her mother began to suffer dementia, until 2003, when, at the age of 92, was placed in the care of a nursing home. The daughter and mother had lived together all their lives. During the course of their lifelong companionship, the mother asked her daughter to swear to her that she would never put her into a hospital or nursing home. The daughter agreed to this oath and was faithfully fullling her carers role until 2003, when she could no longer bear the burden of being a full-time carer. The mothers dementia worsened to the point of not knowing her daughter by face most of the time. The daughter felt that she was at the point of breakdown and let herself be persuaded by family and friends that after nine and a half years of caring, it would be the best thing to place her mother in the hands of professional carers. During the nine and a half years of care that the daughter experienced, she became an expert at knowing every aspect of her mothers needs, wants, concerns, fears, likes and dislikes. Additionally, she was expert at administering medication, dressing and bathing, feeding, walking, hearing and anxiety, all of which the daughter expected to be done in the same manner in the aged-care facility. The daughter wrote a full list of expectations and instructions (care plan) for the home staff to follow. This way, the daughters heartbreak and guilt feeling for breaking her vow to her mother could at least be minimised by making sure her mother received the same treatment in the aged care facility. Upon admission to the home, the mother was independently able to go to
the toilet at night time, wash herself after toileting, converse, feed herself with minimal assistance and walk with a walking frame. Unfortunately, over the next few weeks, it became evident that the daughters expectations were being negatively disconrmed to the point of causing extreme dissatisfaction because the service was the worst imaginable. Her mother died ten weeks after entering the home, allegedly owing to illnesses that were not detected because her mother was, according to the daughter, medicated to the point of being unconscious. Now, according to the daughter, she lives with her psychological trauma (and ongoing treatment) of knowing that she did not full the vow that she had taken with her mother. She felt that her mothers life was taken away from her owing to what she witnessed and described as horric care conditions. These included, according to the daughter, the mother not being warmly dressed, not taken to the toilet at night, not fed according to her visual impairment needs, not walked, hearing aid not being attended to, anxiety instructions not being listed to, issuing medication without authority and with misleading information. As stated above, it is alleged that medications led to the mothers death as she was not able to communicate any discomfort after suffering a heart attack, having kidney failure and pneumonia. This case can be divided into two components for analysis of expectations. The rst group of expectations that were not met were those dened above as expected (Ojasalo, 2001) or desired (Santos and Boote, 2003) expectations. These expectations, as dened above, are those that the customer can articulate when asked about what he or she wants. In this case, they were the expectations that were listed on the care plan that the care recipients daughter handed to the nursing home. At this stage, the daughter communicated these expectations and expected and them to be fullled. The second expectations group not met in this case were those relating to the alleged poor quality of care. These expectations are dened as must be needs (Ojasalo, 2001) or minimum tolerable (Santos and Boote, 2003) expectations, those that must be delivered no matter what. In aged care, these expectations refer to quality of care standards and principles set out in the Aged Care Act 1997. This case illustrates that both levels of expectations were not met. In line with the Santos and Boote (2003) model of positive/negative disconrmation, this service was at the level of the worst imaginable, which led to the affective state of dissatisfaction. The daughter naturally then lodged a complaint via the external complaints resolution scheme and is still pursuing a satisfactory settlement. Strategies for positively disconrming customer expectations in aged care The onset of the baby boomer generation entering aged care is increasing demand for services. Hence, providers need to create cultures for better practices in complaints handling (Thomas, 2006). As a mismatch of customer expectations and experiences are the beginning of the complaints process (Thomas, 2006), understanding the future customers needs and expectations will minimise the amount of time and money spent on complaints handling. One basic strategy already in place in many aged care facilities is to understand customer expectations through resident and family meetings or discussions. One-to-one interviewing could be used as an additional method for strengthening customer satisfaction and managing customer expectations (Halliday and Hogarth-Scott, 2000). Lim et al. (1999) discussed a method of increasing customer satisfaction called quality deployment function. This model goes through phases:
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(1) understanding who the customer is (in aged care, there are multiple parties that includes families, government, care recipient, etc.); (2) understanding their expectations through interviews; (3) ranking customers expectations; and (4) identifying quality management systems that address meeting those expectations. Finally, in aged care, providers should do pre-admission assessments to determine whether a potential resident is suited to that facility (Phillips, 2005). Had the nursing home in our case study paid attention to the written expectations and nursing instructions for the care recipient document they could have either brought the daughters expectations in line with the service provider, or given the daughter the choice of seeking a different provider that would have better suited her needs. As a result of not going through this process, the events described above occurred, resulting in the daughter taking action through the external complaint resolution scheme. Conclusion This article discussed expectation theory and how meeting customer expectations can lead to either conrmation or positive/negative disconrmation. Different types of expectations were identied. Services were highlighted as being distinct from products owing to their intangibility and delivery process requirements. Health care services were seen to add an additional layer of complexity in meeting customer expectations as there is the added element of quality of care that includes technical and interpersonal relationship dynamics between customers and service providers. Aged care services have been seen to be even more complex as the customers include multiple stakeholders such as immediate family that have their own interests, concerns and expectations to be met. A case study of negative disconrmation in aged care illustrated how it is the expectations of other stakeholders that are critical in understanding, and that to avoid complaints to the external complaint resolution scheme, it is vital to understand all stakeholders quality aged care expectations.
References ACAA (Aged Care Association of Australia) (2005), Handling complaints in Australias residential aged care facilities a report, Listening Post, Gordon, Sydney. Bendall, D. and Powers, T.L. (1995), Cultivating loyal patients, Journal of Health Care Marketing, Vol. 15 No. 4, pp. 50-2. Gilbert, F.W., Lumpkin, J.R. and Dant, R.P. (1992), Adaptation and customer expectations of health care options, Journal of Health Care Management, Vol. 12 No. 3, pp. 46-55. Halliday, S.V. and Hogarth-Scott, S. (2000), New customers to be managed: pregnant womens views as consumers of healthcare, Journal of Applied Management Studies, Vol. 9 No. 1, pp. 55-69. Helson, H. (1964), Adaptation Level Theory, Harper & Row, New York, NY. Lim, P.C., Tang, N.K.H. and Jackson, P.M. (1999), An innovative framework for health care performance measurement, Managing Services Quality, Vol. 9 No. 6, pp. 423-34. Ojasalo, J. (2001), Managing customer expectations in professional services, Managing Service Quality, Vol. 11 No. 3, pp. 200-12.
Olshavsky, R.W. and Kumar, A. (2001), Revealing the actual role of expectations in consumer satisfaction with experience and credence goods, Journal of Consumer Satisfaction, Dissatisfaction and Complaining Behavior, Vol. 14, pp. 60-73. Parasuraman, A., Zeithaml, V.A. and Berry, L.L. (1985), A conceptual model of service quality and its implications for future research, Journal of Marketing, Vol. 49 No. 4, pp. 41-50. Perucca, R. (2001), Customers with options, Nursing Management, Vol. 32 No. 9, pp. 20-4. Phillips, S. (2005), One size does not t all. Does your facility t your residents?, Health and Aged Care Brief, Summer, Russell Kennedy, Melbourne. Santos, J. and Boote, J. (2003), A theoretical exploration and model of consumer expectations, post-purchase affective states and affective behaviour, Journal of Consumer Behaviour, Vol. 3 No. 2, pp. 142-56. Thomas, L. (2006), Complaints: the right culture hears the message, National Health Care Journal, April-May, pp. 24-5. Corresponding author Leib Leventhal can be contacted at: LeibLeventhal@bigpond.com
IJHCQA 21,1
Patient claims and complaints data for improving patient safety

Pia Maria Jonsson and John vretveit
Medical Management Centre, MMC, Karolinska Institutet, Stockholm, Sweden
Abstract
Purpose The purpose of this paper is to describe patient complaints and claims data from Swedish databases and assess their value for scientic research and practical health care improvement. Design/methodology/approach The article rst describes previous research into patient claims and similar schemes. It then presents three types of data on patient claims and complaints in Sweden: data generated by the Patient Insurance Fund, the Medical Responsibility Board and the Patients Advisory Committees and considers methodological issues in using the data. Findings The databases value is problems related to spontaneous reporting, which makes it difcult to know how much the data correspond to general injury rates and health care patterns. Another issue is the balance between the size of study materials and the timeliness, e.g. when diagnosis-specic analysis requires data pooling over several years in order to reach adequate case numbers. Adjustment for confounders not present in the databases, e.g. data on hospital case-mix, may add to difculties using the data in comparative analyses of safety performance Research limitations/implications The databases safety analysis and quality improvement value depends on understanding their function, data collection method and their limitations as a source of data about the true incidence and prevalence of injuries and safety problems. Originality/value This is the rst thorough review of the possibilities and limitations associated with the use of claims and complaints data in health care research and improvement. Keywords Quality improvement, Safety, Patients, Measurement, Sweden, Complaints Paper type Research paper
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Received 14 August 2006 Revised 29 December 2006 Accepted 6 February 2007
Introduction Research shows signicant safety problems in health care in Sweden and abroad (Kohn et al., 2000; The National Board of Health and Welfare, 2004a). Empirical evidence about the number of adverse events for patients varies according to data collection methods. Similarly, empirical evidence about the causes of and conditions inuencing adverse events varies according to the investigation method. Better patient safety depends on better data about incidence and causes, both from research studies and from routine monitoring for timely action (Handler et al., 2000; Phillips et al., 2004). This means knowing more about the different systems advantages and disadvantages for reporting adverse events and for gathering safety data (Zhan and Miller, 2003; Thomas and Petersen, 2003). It is likely that a variety of data sources will be needed including patient claims databases, but little is known about the data, how they can be used, their strengths and weaknesses. We describe three main types of Swedish patient claims and complaints data: (1) data generated by Patient Insurance Fund activities; (2) Medical Responsibility Board; and (3) Patients Advisory Committees respectively.
In Sweden, all healthcare providers are obliged to have a medical malpractice insurance policy to cover indemnity for patient injuries. Patients can apply for injury compensation, which may have resulted from a healthcare episode without having to prove negligence (Patienforsakringen, n.d.). Data about these claims are available in an extensive database hosted by the Patient Insurance Fund. This organisation is nanced from tax revenue raised by the local government counties, and holds extensive claims data, which we describe later. Patients using private providers in the county can also apply for compensation to this publicly funded patient insurance fund. The Medical Responsibility Board investigates complaints against health services staff to examine whether there is a reason to impose disciplinary sanctions owing to negligence or malpractice (HSAN, 1996). Complaints data are registered in The National Board of Health and Welfares RiskDataBase. The county councils Patients Advisory Committees handle all types of patient complaints concerning health services (Patientnamnden, n.d.). The committees also host databases with complaints information. Can these data be used to monitor care safety and to highlight safety issues? What can we learn about patient safety from the experience of the Patient Insurance, the Medical Responsibility Board and the Patients Advisory Committees? Our purpose, therefore, is to: . outline the databases development and the information available; . present previous and current data analyses; and . discuss the value of patient complaints and claims data for research and practical improvement work. Research into patient claims The frequency of adverse events that occur when patients receive medical care has been reported in a number of studies, yet the precise prevalence and magnitude of medical error remains unknown (Weingart et al., 2000). The Harvard Medical Practice Study estimated that adverse events occurred in 3.7 per cent of hospitalisations and that 28 percent of these events were due to negligence (Brennan et al., 1991). Drug complications were the most common type of adverse event amounting to 19 per cent of all cases (Leape et al., 1991). The high proportion of patient management errors, 58 per cent of all adverse events, was regarded to suggest that many of the events would be preventable. The Quality in Australia Health Care Study reported that 16.6 per cent of hospital admissions were associated with an adverse event and 50 per cent were judged to have a high preventability score (Wilson et al., 1995). The Canadian Adverse Event Study estimated that the incidence of adverse events among hospital patients was 7.5 per cent (Baker et al., 2004). Among these cases, events judged to be preventable occurred in 36.9 per cent and death in 20.8 per cent. In Denmark, the hospital admissions with adverse events prevalence was estimated at 9 per cent of admissions and 40.4 per cent of the adverse events were judged to be preventable (Schioler et al., 2001). In Sweden, statistics compiled by the National Board of Health and Welfare show that approximately 203 per 100,000 men and 243 per 100,000 women in the general population were hospitalised owing to care complications in 2002 (The National Board of Health and Welfare, 2004b). Based on various databases and studies, The National Board of Health and Welfare (2004 a) estimated that adverse events contribute to
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around 1,800 deaths per year. However, systematic research into the epidemiology and aetiology of adverse events in the Swedish healthcare system has only just begun. Patient claims and complaints systems provide different types of data about health care adverse events. Can these data be used for patient safety research or routine monitoring and improvement? Patient claims data are collected under two different systems: (1) a legal claim under tort law, which allows patients to seek redress from a doctor for perceived negligence (e.g., USA, UK); and (2) a no-fault system, where patients do not have to prove negligence in a court of law (although they can use this route), but can have their claim assessed and compensation awarded through another system, usually administered by a government agency and tax funded (e.g., New Zealand and the Nordic countries). There are thought to be advantages and disadvantages to each. Under a tort system, compensation awards can be high. Insurance against claims is also high and medicine is practiced more defensively (Bovbjerg and Sloan, 1998). Legal redress may act as a deterrent against lower practice standards (Hiatt et al., 1989). Under a no-fault system, seeking compensation may be easier and less expensive, insurance costs are lower, and the total costs to society less, although there is no clear evidence. It also may be more likely that health care personnel report errors or near misses, which is thought to be important for effective safety reporting systems. One of the few empirical studies that contrasted the two systems considered preventable in-hospital medical injury under the no fault system in New Zealand (Davis et al., 2003). Although comparisons are difcult, the study claims that volume and type of medical injuries were signicantly different to those reported in other studies in countries with a tort law. How has data from both types of malpractice claims systems been used for research, and have data been used to study and improve care quality? One early review of empirical studies described the value of research into malpractice claims and called for better data (Zuckerman et al., 1986). A later study reviewed 64 serious obstetric accidents referred over ve years to the UK Medical Protection Society one of the three main UK litigation databases (Ennis and Vincent, 1990). Data suggested problem areas for attention that included supervision and foetal heart monitoring. This was one of the rst studies showing how these data help to predict and understand adverse events. Studies have examined the number of malpractice claims against physicians in the context of their credentials and found these to be strongly associated (Branney et al., 2000; Weycker and Jensen, 2000). Research also considered whether physician performance and type of speciality is related to malpractice claims, which found rates associated with both physician performance and specialty (Taragin et al., 1994). An unpublished UK study found standardised incidence ratio of error highest in the specialties, which traditionally produce the most claims accident and emergency, obstetrics and trauma and orthopaedics (Davy et al., 2004). The Physician Insurers Association of America (PIAA) database has been used as a surveillance tool for diabetes-related malpractice claims (Meredith et al., 1998). This study identied 906 claims from patients with diabetes where the total indemnity paid was almost $27 million. When compared to all claimants, diabetes patients were older and predominantly male. The proportion of diabetes claims was highest in
ophthalmology, internal medicine, general and family practice. A greater proportion of diabetes claims, as compared to all claims, was associated with the highest level of injury severity. The study concluded that the PIAA database can be a useful resource to monitor trends in diabetes-related malpractice. Prevention programs designed to reduce liability among high-risk specialties could also lead to improved care quality for patients with diabetes. Malpractice claims research has been used for nancial risk management and quality improvement. Goebel and Goebel (1999), for example, found evidence that malpractice lawsuits could be prevented by quality interventions such as clinical guidelines. Tsai et al. (2004) reported that medical experts considered that 83 per cent of 371 malpractice cases reviewed could be improved by quality management. Other studies found communication with patients and families to be a likely factor in precipitating claims and have proposed improving communications as an intervention to reduce claims (Vincent et al., 2001; Moles et al., 1998; Adamson et al., 1989). More studies are examining which type of patients le claims and why (Hickson et al., 1994; Lester and Smith, 1993; Levinson et al., 1997). Little research has considered the role of nursing or paramedic professions in patient claims. In 1989, one study reported a dramatic rise in the incidence of nurses as defendants in malpractice claims (McDonough and Rioux, 1989). Nurse negligence has been reported to be associated with 27 per cent of all USA claims and with 26 per cent in one Taiwan study (Beckman, 1996; Tsai et al., 2004). Claims databases have also been used to assess economic costs (Fenn et al., 2000; Persson and Svensson, 2005). The Swedish databases In Sweden the Patient Insurance Scheme, Medical Responsibility Board and the county councils Patients Advisory Committees represent instances to which patients (and sometimes their relatives) apply when they think they have been treated incorrectly, or that health care has not met their expectations. Table I displays the number of complaints and claims made to each body (1997-2004). Since the databases were developed at different times and for different purposes, they differ in the numbers of complaints as well as in the amount and character of information they contain.
Year 1997 1998 1999 2000 2001 2002 2003 2004
Patient insurance 8,174 8,552 8,129 8,871 9,003 9,395 8,717 8,938
Medical Responsibility Board 2,860 3,119 3,064 3,070 3,250 3,227 3,377 3,664
Patients Advisory Committees m. m. 16,239 18,546 19,995 22,572 m. 22,500
Sources: Statistics from the Patient Insurance Fund; Annual reports from the Medical Responsibility Board and The National Board of Health and Welfare
Table I. Number of complaints to the Patient Insurance Fund, Medical Responsibility Board and Patients Advisory Committees, 1997-2004
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Patient insurance scheme The county councils voluntary patient insurance scheme came into force in January 1975 and medical malpractice insurance was subsequently introduced for almost all Swedish public and private care. Indemnity for patient injury could be paid on objective grounds, irrespective of fault or negligence, when a treatment injury as described in the insurance conditions occurred. In January 1997 the voluntary insurance scheme was replaced by The Patient Injury Act (1996). Under the act, both public and private care providers are obliged to have a medical malpractice injury policy that covers patient indemnity. The conditions in the Act on Injury to Patients largely correspond to the conditions of the previous voluntary scheme. Indemnity for personal injury can be paid, if the injury concerned could have been avoided, if it was caused by faulty medical or dental equipment or by incorrect diagnosis, if infection has been transmitted in the course of treatment, in the event of accidents in connection with medical or dental care and in connection with incorrect prescribing. There is no indemnity in cases where the treatment simply has not led to the desired result or where (predictable) complications arise. Cases reported by the patients to the Patient Insurance Fund are scrutinised from a strictly medical point of view to establish whether the injury is of such a nature that compensation should be paid. Figure 1 shows the annual numbers of both applications for claims and compensated cases from the Patient Insurance Fund (1975-2003). Claims applications have increased to: . 9,400 claims in 2003; . 7,000 in 1993; . 5,000 in 1983; and . 3,300 in the rst year of operation in 1975.
Figure 1. Number of claims to the Swedish Patient Insurance Fund, 1975-2004
Overall 40-45 per cent led to a compensation payment. Regarding such injuries, data include: . injury year; . county council; . care giver type; . basic diagnosis; . injury cause and effect; and . since 1998, data about possible surgical interventions. Consequently, data can be analysed by: . care level; . medical specialty; . injury cause; . injury effects; and . patient consequences. Diagnosis and operation codes are used to analyse injuries to patient groups (diabetes, cardiovascular disease, cataract etc.) or patients undergoing a particular treatment (hip joint replacement, operation for short-sightedness, breast implant etc.). Previous studies addressed a range of clinical topics e.g. injuries related to certain clinical elds, to specic types of medical error or to the use of selected medical technologies (Cronstrom et al., 1998; Johansson and Raf, 1997; Raf and Claes, 1999). Specialties with many cases registered in the database include orthopaedics, surgery, gynaecology and obstetrics (Jonsson and Wahlberg, 1996; Ohrn et al., 2006). Over the years about 60 per cent of cases have concerned female patients (Pukk et al., 2003b). Gender-specic analyses have indicated differences between womens and mens injury patterns (Jonsson and Raf, 1997); e.g., there is a higher risk of women injured by radiological examinations, but a generally higher risk of lethal patient injury among men. Medical responsibility board The Medical Responsibility Board is an independent national authority, which investigates complaints against all registered health care professionals to examine whether there is cause for disciplinary action (Instruction to The Medical Responsibility Board, 1996). When taken, this action is usually an admonition or a warning, although a small proportion of cases involve withdrawing registration following notication from the National Board of Health and Welfare. Anyone who is or has been a patient can le a complaint to the Medical Responsibility Board. If the patient him/herself is incapable, the complaint may be submitted by a close relative. The complaints are reviewed by medical experts, after which the Board examines the case and decides. Certain cases are examined by the chairman alone. Apart from complaints about errors in medical treatment, there were previously also complaints about poor service or care quality. After 1994, cases solely concerning services a patient has received are referred to the Patients Advisory Committees. The numbers of complaints to the Medical Responsibility Board and the numbers of disciplinary
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actions in 1995-2004 are presented in Table II, which shows that a steady increase in the number of cases appears to be levelling off. Cases from the Medical Responsibility Board have been presented in the Swedish Medical Association Journal, but there have been few scientic analyses of the material. Recently, an exploratory study analysed factors and circumstances related to complaints in emergency medical dispatching, partly based on complaints to the Medical Responsibility Board (Wahlberg et al., 2003). The study identied second-hand information as an aggravating circumstance when assessing the urgency of care needs. Another study analysed all available complaints about stroke management made to the Medical Responsibility Board over a ve-year period (Johansson et al., 2004). Nearly all disciplinary actions against physicians concerned misdiagnoses (subarachnoid haemorrhage in particular). The most common reason for a nurse receiving a warning or an admonition was negligent handling of drugs. Hence, the survey identied two areas that educational programs could improve patient safety. Data from the Medical Responsibility Board have been used in regional comparisons (The National Board of Health and Welfare, 2002). Analysis showed large differences in Sweden between counties in number of claims per inhabitant in 1999/2000. Claims rates were appreciably higher in Stockholm, Uppsala, Goteborg and Bohus counties, in contrast to sparsely populated area rates, e.g. Kalmar and Kronoberg counties. The high claims rate in the Stockholm region applied to all types of activity, but was most prominent in dental care and general medicine. The Stockholm region also showed the highest number of disciplinary actions per inhabitant. Patients advisory committees The rst Swedish law about the Patients Advisory Committees was created in 1980. In January 1999, a new law came into force, in which committees tasks were specied more closely and the working eld was expanded to include all government-funded health care and certain social welfare problems experienced by older people (Law of the Patients Advisory Committee, 1998). The Patients Advisory Committees do not make medical judgements, have few direct sanctions and do not have disciplinary powers. They give advice to patients and provide a quasi-independent body for investigating dissatisfaction and mediating disputes
Complaints n 2,521 2,659 2,860 3,119 3,064 3,070 3,250 3,227 3,377 3,664 Disciplinary actions n 330 410 391 401 378 335 277 293 300 357 % 13 15 14 13 12 11 9 9 9 10
Year 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
Table II. Number of complaints received and disciplinary actions taken by the Medical Responsibility Board, 1995-2004
Source: Annual reports from The Medical Responsibility Board
between patients and health services or personnel. Complaints are often questions or criticisms that patients or relatives have tried to take up with healthcare personnel, but feel they have not been heard or respected. Sometimes, it is problems patients do not want to raise directly with personnel, because, for example, they feel they may suffer in the future as a result. The Committees aim is to solve problems quickly and in a non-bureaucratic way. It is also their task to refer patients to other agencies, for example, to le a malpractice claim. One of the Patients Advisory Committees duties is to prevent the same problems from occurring again by reporting the case statistics to the National Board of Health and Welfare, hospitals, public health care districts and other involved authorities. Reports to the National Board of Health and Welfare show that more than 22,000 complaints were led in 2002 (The National Board of Health and Welfare, 2003). Of these, 53 per cent concerned inpatient care, 24 per cent primary health care and 8 per cent mental health services. Table III shows the complaints distribution by one countys Patients Advisory Committee about different issues (Stockholm County Patients Advisory Committee, 2006). According to Committee representatives, feed-back sessions at local hospitals have been a popular way of sharing experience, but the effectiveness of using data in the prevention of patient injuries has not been studied systematically. Little research has used data from the Patients Advisory Committees. The previously mentioned study on emergency medical patching (Wahlberg et al., 2003) drew some data from one of the committees. In 2001, an analysis was made linking data about complaints to the Stockholm County Patients Advisory Committee with data from National Patient Register (Arnetz and Arnetz, 2002). The rates per specialty, calculated per 100,000 discharges, were compared with corresponding rates for the Medical Responsibility Board and the Patient Insurance Scheme. Results showed that, while applications and claims in specialities such as obstetrics and gynaecology were higher, the reverse was true, for example in the elds of neurology and geriatrics. Analysis also considered data from patient questionnaires in the same hospitals. The conclusion was that dissatisfaction about lack of information and patient participation was more likely to be detected by surveys, whereas complaints about care and treatment were more likely to be registered in the complaints to the Patients Advisory Committee. This analysis and the studies noted earlier show how each database provides a different picture, the importance of knowing the strengths and weaknesses of each and often the need to use multiple data sources.
Men Type of complaint Medical treatment Interaction, communication, information Organisation, resources Other complaints All n 555 204 787 197 1,743 % 32 12 45 11 100 n 967 431 1,255 298 2,951
Women % 33 15 43 10 100 Table III. Distribution of complaints to the Stockholm County Patients Advisory Committee, by gender, 2005
Source: Stockholm County Patients Advisory Board, Annual Report 2005
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Methodological concerns As the complaints and claims databases are so voluminous and the information in them relatively detailed, they seem to have a potential to help both quantitative and qualitative quality and safety of care analyses. However, researchers and quality improvement practitioners should use these data with caution and awareness of their limitations. The data might not be collected consistently over time, and only give a partial picture. Cases are registered in order to assess liability and damages or to solve patients problems, not for the purpose of assessing quality and its determinants. Most patients experiencing problems do not complain, let alone make a claim (vretveit, 1993). Some may make false claims. The problem of spontaneous reporting One special methodological problem analysing and interpreting data from the databases is that they are based on spontaneous reporting. A critical question is how far matters reported to different instances correspond to general dissatisfaction or injury patterns. The tendency in various patient groups to report shortcomings in service and treatment to The Medical Responsibility Board, the Patient Insurance etc., is important. The tendency to lodge a complaint may be affected by patients knowledge regarding the possibilities of applying to the various instances for support or compensation, and by healthcare providers attitudes and approach to informing, encouraging and assisting the complaints process. Regarding Patient Insurance, insurance practice over the years also affects material composition. The upward trends in patient complaints and claims have been interpreted by many observers as a consequence of better informed patients and more support from healthcare system in ling claims. In 1992, county councils were compared regarding claims numbers and compensated cases from the Patient Insurance Scheme (Rosen and Jonsson, 1992). It was noted that neither reporting nor compensation rates were constant, but there were variations regarding complaints per 1,000 inhabitants, number of complaints per 1,000 hospital discharges and number of injuries for which compensation was paid in relation to number of complaints. Similar differences may exist between various clinical specialities, different age groups and between women and men. Hence, in comparative studies, it may be advisable to relate the numbers of claims to the healthcare utilization rates. While this is possible for hospital inpatient care through links to the National Patient Register, there are great difculties in calculating rates in outpatient care owing to the lack of outpatient services national registrations. If we challenge the self-evident healthcare utilisation rates rather than focusing on how much harm the healthcare system does in the general population then rates calculated per inhabitant rather than per patient/discharge may need to be studied. Increased healthcare utilisation is likely to increase the magnitude of harm, but there may be cut-off points where the benet-harm ratio gets too low and the level of healthcare utilisation should be questioned. Analysing patient injury rates in the general population also permits comparisons of the safety problem magnitude across different society sectors, e.g. trafc safety. This may interest researchers when societal resources are allocated to prevent accidents. The ICD 10 classication Y-codes, used in Sweden since 1998, have been the basis for the production of this kind of statistic from the National Patient Register (The National Board of Health and Welfare, 2004b). One way of dealing with problems related to spontaneous reporting is to follow long-term
trends that reveal themselves in the proportions of total materials represented by, e.g. different specialties or patient groups. If we assume that better informed patients and more sovereign healthcare consumers is a mega trend permeating the healthcare system during the last few decades then analysing trends in proportions rather than in absolute numbers may be a good idea. However, this procedure does not deal with the differences in reporting tendency that may exist between men and women and different age groups. Adjustment for confounders Special difculties arise when the purpose of the analysis is to compare complaints or claims rates between hospitals or healthcare units. Adjustment for confounders has been an important topic when comparing the quality of hospital care based on data from the National Quality Registers in Sweden (Appelros et al., 2003). In the claims data, the variations between hospital case-mix that occur, e.g. owing to organisational factors, may be additionally aggravated by differences in reporting tendency. In a recent study involving data from the Patient Insurance Scheme, claims rates from departments of general medicine, gynaecology/obstetrics, orthopaedics and general surgery were compared with hospital managers perceptions care quality in their departments (Pukk et al., 2003a). No correlation was found between managers adverse events perceptions and the actual claims frequency from patients associated with the department. Although the study gives an indication of an important phenomenon that should be analysed further, we cannot exclude that results may be somewhat biased by lack of adjustment for confounders when comparing the claims rates from different departments. While adjustment for confounders such as age, sex and severity of illness is important when comparing clinical outcomes, the same logic does not necessarily apply to complaints about, e.g. lack of information and patient participation. High patient satisfaction should be one care target at all healthcare units, regardless of patient population composition. Responsiveness inherently means that service is adjusted to patients needs and expectations. Hence, there seems to be a weak case for comparing hypothetical standard populations instead of real-life patient ones. Size of materials and timeliness of study Although three databases contain large numbers of complaints regarding different medical specialties, selection by diagnosis and type of medical or surgical intervention easily reduces the volume of study materials. Size becomes even more critical if analysis is to deal with several confounders. A solution may be to pool data over several years to attain enough observations. This, however, needs to be balanced against the rapidity of change in medical practice. Owing to medical and technological development, the practice of medicine and safety of care may be different today compared to the early 1990s. Unfortunately, owing to few previous studies on risks and safety, it is difcult to know how much of a change is happening in different elds over time. The size of the study material is mainly a problem in quantitative research. The Patients Advisory Committees data, however, could also be used in qualitative analysis of problems that patients experience in health care. Here, it is not the number of observations but rather the quality of the short case stories registered beyond the numerical data that might set limits to the materials utility.
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Relationship to other sources of safety information As illustrated earlier the National Patient Register includes information about all hospital discharges in Sweden, including ICD 10 codes for medical and surgical treatment complications (The National Board of Health and Welfare, 2004b). The number of registered complications in 2002 was approximately 22,000. In comparison, Patient Insurance Fund claims, approximately 9,400 cases, are relatively few. To what extent this is due to patients underreporting problems, or that not all complications lead to injury entitled to compensation, is not possible to judge today. Correspondingly, the numbers of claims to the Medical Responsibility Board 3,200 claims in 2002 can be compared to the numbers of injuries coded as mishaps (approximately 3,500 cases in 2002). It should, however, be noted that claims data include all levels of care, while the Patient Register only covers hospital inpatient care. The Swedish Patient Register is in many ways comparable to hospital data sources in other countries. Hence, patient safety indicators constructed from administrative data and developed in, e.g. the USA and Canada and by the OECD Patient Safety Panel could be applied in overall safety analyses in Sweden (Agency for Health Care Research and Quality, 2006; Canadian Institute for Health Information, 2006; McLoughlin et al., 2006). Such analyses could also shed light on the extent patients claims and complaints reect safety problems grasped by purely medical-technical safety indicators. Serious injuries, diseases and risks in health care must, under certain circumstances, be reported to the National Board of Health and Welfare according to a special law, Lex Maria (named after an incident at Maria Hospital in Stockholm in the 1930s, when a number of patients died owing to malpractice). The obligation to report rests upon the person nominated by the health care principal, in practice, often the senior physician or the nurse with medical responsibility. Statistics regarding Lex Maria cases are collected in the Boards RiskDataBase, which contains information on cases since January 1992. Following analysis, the material can show, e.g. at what type of institution and in what medical service an injury or an incident occurred, and what consequences repeated events can have for the patients affected. In 2002, 1,000 cases were reported according to Lex Maria. As opposed to patient claims and complaints, the annual numbers of Lex Maria cases have not changed much since the mid 1990s. Tentatively, therefore, the risk of serious patient injury has not changed over time. However, the healthcare professionals reporting tendency has not been subjected to study. Conclusions The risk of adverse medical events and medical errors can never be entirely eliminated, but knowledge of risks gives care providers more opportunities for improving quality and helps care consumers choose care and treatment. This and other studies show the value of data on claims and complaints for providing information for researchers and practitioners, which is related to quality and is driven by patient and user perceptions. Analysis of existing data at a local and national level can provide valuable insights for quality interventions as well as for research. Changes are also possible to these databases and collection systems to make them even more valuable for quality improvement. We could not locate publications that systematically compared claims systems of different countries although trends comparisons have been made in medical malpractice in the USA, Canada, Australia and UK (Danzon, 1990). There is a case,
therefore, for using data from a number of sources to provide different perspectives on the rate and causes of safety and quality problems. Each system has its biases, but using a combination can provide a more objective picture.
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Fenn, P., Diacon, S., Gray, A., Hodges, R. and Rickman, N. (2000), Current cost of medical negligence in NHS hospitals: analysis of claims database, British Medical Journal, Vol. 320, pp. 1567-71. Goebel, R.H. and Goebel, M.R. (1999), Clinical practice guidelines for pressure ulcer prevention can prevent malpractice lawsuits in older patients, Journal of Wound, Osteotomy & Continence Nursing, Vol. 26 No. 4, pp. 175-84. Handler, J.A., Gillam, M., Sanders, A.B. and Klasco, R. (2000), Dening, identifying, and measuring error in emergency medicine, Academic Emergency Medicine, Vol. 7 No. 11, pp. 1183-8. Hiatt, H.H., Barnes, B.A., Brennan, T.A., Laird, N.M., Lawthers, A.G., Leape, L.L., Localio, A.R., Newhouse, J.P., Peterson, L.M. and Thorpe, K.E. (1989), A study of medical injury and medical malpractice: an overview, New England Journal of Medicine, Vol. 321 No. 7, pp. 480-4. Hickson, G.B., Clayton, E.W., Entman, S.S., Miller, C.S., Githens, P.B., Whetten-Goldstein, K. and Sloan, F.A. (1994), Obstetricians prior malpractice experience and patients satisfaction with care, Journal of the American Medical Association, Vol. 272 No. 20, pp. 1583-7. HSAN (1996), Halso- och Sjukvardens Ansvarsnamnd (Who can you turn to if you are dissatised with the care you receive?), Instruction to The Medical Responsibility Board, 1996: 571, available at: www.hsan.se Johansson, A., Lagerstedt, K. and Asplund, K. (2004), Mishaps in the management of stroke: a review of 214 complaints to a medical responsibility board, Cerebrovascular Diseases, Vol. 18 No. 1, pp. 16-21. Johansson, H. and Raf, L. (1997a), A compilation of diagnostic errors in Swedish health care. Missed diagnosis is most often a fracture (in Swedish), Lakartidningen, Vol. 94 No. 43, pp. 3848-50. Jonsson, P.M. and Raf, L. (1997b), Is quality of health care for women worse than for men? Two out of three insurance claims concern women, Lakartidningen, Vol. 94 No. 10, pp. 865-68 (in Swedish). Jonsson, P.M. and Wahlberg, C. (1996), Reported shortcomings and problems in health care from a gender perspective, Gender Equality in Health Care, The Swedish National Committee on Gender Disparities in Patient Care, Norstedts, Stockholm (SOU 1996:133), pp. 247-70 (in Swedish, English summary available). Kohn, L.T., Donaldson, M.S. and Corrigan, J. (Eds) (2000), To Err Is Human. Building a Safer Health System, National Academy Press, Washington, DC. Law of the Patients Advisory Committees (1998), Law of the Patients Advisory Committees (1998:1656). Leape, L.L., Brennan, T.A., Laird, N., Lawthers, A.G., Localio, A.B., Barnes, B.A., Hebert, L., Newhouse, J.P., Weiler, P.C. and Hiatt, H.H. (1991), The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II, New England Journal of Medicine, Vol. 324 No. 6, pp. 377-84. Lester, G. and Smith, S. (1993), Listening and talking to patients. A remedy for malpractice suits, The Western Journal of Medicine, Vol. 158 No. 3, pp. 268-72. Levinson, W., Roter, D.L., Mullooly, J.P., Dull, V.T. and Frankel, R.M. (1997), Physician-patient communication. The relationship with malpractice claims among primary care physicians and surgeons, Journal of the American Medical Association, Vol. 277 No. 7, pp. 553-9. McDonough, W. and Rioux, M. (1989), Increasing number of nurses named as sole defendants in malpractice suits, Forum, Vol. 10 No. 1, pp. 4-12.
McLoughlin, V., Millar, J., Mattke, S., Franca, M., Jonsson, P.M., Somekh, D. and Bates, D. (2006) Vol. 18, Selecting indicators for patient safety at the health system level in OECD countries, International Journal for Quality in Health Care, Vol. 18, Supp. I, pp. 14-20. Meredith, V., Cook, C.B. and Penman, A. (1998), Use of the Physician Insurers Association of America database as a surveillance tool for diabetes-related malpractice claims in the US, Diabetes Care, Vol. 21 No. 7, pp. 1096-100. Moles, D.R., Simper, R.D. and Bedi, R. (1998), Dental negligence: a study of cases assessed at one specialised advisory practice, British Dental Journal, Vol. 184 No. 3, pp. 130-3. (The) National Board of Health and Welfare (2002), Monitoring and Evaluation of the Health Services, Swedens Health Care Report 2001, Vol. 2001, pp. 69-90. (The) National Board of Health and Welfare (2003), Patients Advisory Committees reports to the National Board of Health and Welfare, The National Board of Health and Welfare, Stockholm (in Swedish). (The) National Board of Health and Welfare (2004a), Patient Safety and Safety Improvement An Overview, Stockholm (in Swedish). (The) National Board of Health and Welfare (2004b), Hospitalisation due to injuries and poisoning in Sweden 1998-2002, The National Board of Health and Welfare, (Statistics Health and Diseases 2004:2), Stockholm (in Swedish). Ohrn, A., Tropp, H., Scheer, J., Horn, B., Rutberg, H. and Elfstrom, J. (2006), Orthopaedic surgery the most common cause of patient injury, shows data from the Patient Insurance, Lakartidningen, Vol. 103 No. 8, pp. 534-9 (in Swedish). vretveit, J. (1993), Measuring Service Quality, Technical Communications Publications Ltd, Aylesbury. (The) Patient Injury Act (1996), The Patient Injury Act (1996:799). Patientforsakringen (n.d.), Patient Insurance, available at: www.patientforsakring.se Patientnamnden The Patients Advisory Committee (n.d.), The Patients Advisory Committee, available at: www.sll. se/w_ptn/19010.cs Persson, U. and Svensson, M. (2005), Prolonged national economic effects following patient injuries in Swedish health care. The single injury is expensive, but the total number of injuries is relatively low, Lakartidningen, Vol. 102 No. 42, pp. 3020-5 (in Swedish). Phillips, R.L., Bartholomew, L.A., Dovey, S.M., Fryer, G.E. Jr., Miyoshi, T.J. and Green, L.A. (2004), Learning from malpractice claims about negligent, adverse events in primary care in the United States, Quality and Safety in Health Care, Vol. 13 No. 2, pp. 121-6. Pukk, K., Lundberg, J., Gaffney, A., Penaloza-Pesantes, R. and Olsson, J. (2003a), Do health care managers know the comparative quality of their care?, Quality Management in Health Care, Vol. 12 No. 4, pp. 232-9. Pukk, K., Lundberg, J., Peneloza-Pesantes, R.V., Brommels, M. and Gaffney, F.A. (2003b), Do women simply complain more? National patient injury claims data show gender and age differences, Quality Management in Health Care, Vol. 12 No. 4, pp. 225-31. Raf, L. and Claes, G. (1999), Complications are frequent after surgery for excessive hand sweating. Patients should be informed about the risks, Lakartidningen, Vol. 96 No. 8, pp. 930-32 (in Swedish). Rosen, B. and Jonsson, P.M. (1992), Injuries reported to the Patient Insurance Scheme as a Basis for Injury Prevention. Project Report, The Swedish Institute for Health Services Development, Spri, Stockholm (in Swedish).
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Schioler, T., Lipczak, H., Pedersen, B.L., Mogensen, T.S., Bech, K.B., Stockmarr, A., Svenning, A.R. and Frolich, A. (2001), Incidence of adverse events in hospitals. A retrospective study of medical records, Ugeskrift for Laeger, Vol. 163 No. 39, pp. 5370-78 (in Danish). Stockholm County Patients Advisory Committee (2006), Annual Report 2005, Stockholm County Patients Advisory Committee, Stockholm (in Swedish). Taragin, M.I., Sonnenberg, F.A., Karns, M.E., Trout, R., Shapiro, S. and Carson, J.L. (1994), Does physician performance explain interspecialty differences in malpractice claim rates?, Medical Care, Vol. 32 No. 7, pp. 661-7. Thomas, E.J. and Petersen, L. (2003), Measuring errors and adverse effects in health care, Journal of General Internal Medicine, Vol. 18 No. 1, pp. 61-7. Tsai, W.C., Kung, P.T. and Chiang, Y.J. (2004), Relationship between malpractice claims and medical care quality, International Journal of Health Care Quality Assurance, Vol. 17 No. 7, pp. 7394-400. Vincent, C., Neale, G. and Woloshynowych, M. (2001), Adverse events in British hospitals: preliminary retrospective record review, British Medical Journal, Vol. 322, pp. 517-9. Wahlberg, A.C., Cedersund, E. and Wredling, R. (2003), Factors and circumstances related to complaints in emergency medical dispatching in Sweden: an exploratory study, European Journal of Emergency Medicine, Vol. 10 No. 4, pp. 272-8. Weingart, S.N., Wilson, R.M., Gibberd, W. and Harrison, B. (2000), Epidemiology of medical error, British Medical Journal, Vol. 320, pp. 774-7. Weycker, D.A. and Jensen, G.A. (2000), Medical malpractice among physicians: who will be sued and who will pay?, Health Care Management Science, Vol. 3 No. 4, pp. 269-77. Wilson, R.M., Runciman, W.B., Gibberd, R.W., Harrison, B.T., Newby, L. and Hamilton, J.D. (1995), The quality in Australian health care study, Medical Journal of Australia, Vol. 163 No. 9, pp. 458-71. Zhan, C. and Miller, M.R. (2003), Administrative data based patient safety research: a critical review, Quality and Safety in Health Care, Vol. 12, Supp. II, pp. ii58-ii63. Zuckerman, S., Koller, C.R. and Bovbjerg, R.R. (1986), Information on malpractice: a review of empirical research on major policy issues, Law & Contemporary Problems, Vol. 49 No. 2, pp. 85-111. Corresponding author Pia Maria Jonsson can be contacted at: pia.maria.jonsson@ki.se
Evaluating hospital service quality from a physician viewpoint

Peter Hensen, Meinhard Schiller, Dieter Metze and Thomas Luger
Dermatology Department, Munster University, Munster, Germany
Abstract
Purpose The purpose of this research is to show that referring physicians play a strategic role in health care management. This study aims to evaluate the perception of hospital services by referring physicians and clinicians for quality improvement. Design/method/approach Referring physicians in private practice and hospital clinicians at a large dermatology academic department providing inpatient and outpatient services at secondary and tertiary care levels were surveyed to determine their perceptions of service quality. A comparative questionnaire survey was established to identify improvement areas and factors that drive referral rates using descriptive and inferential statistics. Findings Referring physicians (n 53) and clinicians (n 22) survey results concordantly revealed that timely and signicant information about hospital stay as well as accessibility to hospital staff are major points for improvement. Signicant differences between both samples were found with respect to inpatient services and patient commendation. Clinicians tended to rate their services and offerings higher than referring physicians (p 0:019). Geographic range was correlated with the frequency of patient commendation (p 0:005) and the perception of friendliness (p 0:039). The number of referred patients was correlated with medical reports informational value (p 0:042). Research limitations/implications Although the study has a limited sample size it appears that surveying physicians perspectives is an essential tool for gathering information about how provided health care services are perceived. Originality/value Survey results should be useful for continuous quality improvement by regular measuring and reporting to executive boards. Hospitals should pay careful attention to their communication tools, particularly medical reports. Keywords Questionnaires, Customer services quality, Doctors, Hospitals, Germany Paper type Research paper
Evaluating hospital service quality 75

Received 5 October 2006 Revised 15 December 2006 Accepted 1 January 2007
Introduction Evaluating customers and stakeholders perceptions needs and expectations, well established in industrial markets, is of growing importance in the rapid changing health care market. In the German health care system, both specialists and general practitioners in private practice are responsible for most patient referrals to institutional providers and represent vital stakeholders for hospitals (Mackesy and Mulligan, 1990). Although Germany has a health care system that allows patients direct access to specialized care (Coulter, 1998; Rosemann et al., 2006), referring physicians act as de facto gatekeepers to hospitalization. They inuence the patients choice of where to be admitted and organize most of the pre- and after-care treatments (Braun and Nissen, 2005). Since referring physicians play a strategic role ensuring the survival of institutions providing health care services, mutually benecial
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partnerships between medical professionals in hospital and external physicians are essential and should be sought. Presently, patient questionnaires and customer complaint systems are widely applied for user orientation in health care systems and hospitals respectively (Castle et al., 2005). In contrast, surveying referral physician perspectives is not yet extensively established in the hospital care sector. Nevertheless, hospital clinicians should know exactly how the services they provide are perceived by referring physicians. Understanding factors that drive referral rates can help identify improvement areas and to anticipate future demands for hospital services. Several patient-specic characteristics, such as disease severity (Chan and Austin, 2003) or individual insurance coverage (Shea et al., 1999), and community-specic characteristics, such as socioeconomic status (Carr-Hill et al., 1996) or urban location (Chan and Austin, 2003), were shown to predetermine referrals from primary care physicians to specialists, but with a lack of consensus and with, to some extent, controversial results. Moreover, physician-specic inuences on the referral process were investigated equally, suggesting that referral patterns are related more strongly to the type of community than the supply of specialists (Chan and Austin, 2003). Variability in physician referral decisions is observable, but most remains unexplained (Franks et al., 1999; Stareld et al., 2002). Overall, satisfaction with services provided by health care institutions like hospitals is subject to referring physicians expectations and is a key factor for referrals (Piterman and Koritsas, 2005). In a large German dermatologic centre providing outpatient and inpatient care at a secondary and tertiary care level, a quality improvement process was initiated that focused on relationships between clinicians and referring physicians. The term clinician used in this study encompasses physicians at the clinical department including residents and attendings (i.e. senior and junior doctors). A questionnaire study using measurement and feedback was conducted to identify improvement areas from referring physicians perspectives, and to reveal associations between quality-related variables and physician-specic aspects. Our main approach was to compare our results with a corresponding survey regarding the same items from the clinicians point of view. Method We used a quantitative survey research design. Data collection We conducted our study at the University of Munster dermatology department. To accomplish our objectives, a questionnaire was developed containing 14 items suggested by previous research on physician referrals (Beltramini and Sirsi, 1992) and validated in internal audits among attending physicians. The questionnaire items enabled respondents to rate their perceptions in respect to each specied quality aspect. To increase feasibility and respond-rates, the questionnaire size was limited to a one-page-only design and the number of items was restricted to a reasonable quantity. Each item was carefully worded in a clear and precise manner. A six-point ordinal scale was used: 1 very good; 2 good; 3 satisfactory; 4 sufcient; 5 faulty; and 6 insufcient.
Our evaluation questions covered the following quality aspects: . cooperation with physicians in private practice; . clinicians medical expertise; . hospital services and staff accessibility in urgent cases; . time interval in which medical reports are supplied; . supplied medical reports signicance and informational value; . outpatient consultation availability; . outpatient services; . available hospital bed quantity and capacity; . inpatient services; . hospital staff friendliness; . education and training for external doctors; . commendations from recurring patients; . clinical departments perceived reputation; and . regular newsletter. Referring physicians were asked for their medical specialty, the number of referred patients per year, and the practices postal zip code. Over the years, names and addresses of miscellaneous specialists and general practitioners, who frequently referred patients to the dermatology department, were continuously stored in a database. Using these data, questionnaires were sent by mail to a total number of 304 external physicians in private practice including general practitioners and specialists. To avoid personal cost, respondents were free to use an accompanying stamped and pre-addressed envelope. Our survey was performed anonymously respondents personal data were recorded on the questionnaire. Reminding non-respondents, therefore, was difcult. No incentives for completion were offered. To get an image from hospital medical professionals, an unmodied questionnaire was sent to all dermatology department residents and attending physicians. The geographic range between private practice and the hospital were coded using: 1 city area, , 20 km; 2 regional area, 20-50 km; and 3 supra regional area, . 50 km. Equally, the annual number of referred patients was scaled (Table I) as follows: 1 0 2 5 patients; 2 6 2 20 patients; and 3 . 20 patients. Data analysis Statistical analysis was conducted using SPSS, release 13.0 (SPSS Inc., San Diego, CA). The Mann-Whitney U test was used to examine whether there were signicant differences in the average values between the referral physician and clinician subgroups. A chi-square test (Fishers exact test) was used to analyse signicance differences between deciency frequencies. Factor analysis was used to examine the relationships among the items to identify components that summarize evaluation questions. Bivariate correlation analysis was performed to study the association between descriptive variables, such as geographic range or annual number of referred patients, and the rated questionnaire items (Spearman correlation). Pearsons
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Characteristic Specialist status of respondents Dermatologist Not specied
n 51 2 9 9 32 3 9 6 32 6
% 96.2 3.8 17.0 17.0 60. 5.7 17 11.3 60.4 11.3
78
Number of referred patients per year 0-5 patients 6-20 patients .20 patients Not specied Geographic range between clinic and respondents City area (, 20 km) Regional area (20-50 km) Supra-regional area (. 50 km) Not specied
Table I. Data overview and characteristics of referring physicians who responded
correlation tested association among questionnaire items. The alternative hypothesis would be accepted at a p , 0.05 statistical signicance level. Results A total of 53 usable questionnaires were returned by referring physicians (response rate, 17.4 per cent). Nearly all respondents declared to be dermatologists (n 51, see Table I) but two respondents did not answer this question. Regarding the referring dermatologist subgroup, a 21 per cent response rate was obtained. A total of 22 useable questionnaires, representing nearly the complete physician staff in the clinical department, were returned from the subsequent internal survey. The overall Cronbachs alpha for the questionnaire was 0.845. Identifying improvement areas Means and standard deviations were calculated to obtain an average rating for items 1-14. Response rates and the average ratings divided into referring physicians and clinicians along with the comparative statistical results (Table II). Moreover, the proportions of referring physicians ratings of each questionnaire item were displayed (Figure 1). Value 1 very good and 2 good frequencies were summed to a conjoint variable indicating an acceptable quality level without need for action. Under the assumption that a potential quality problem is indicated by lower ratings from 3 to 6, these values were combined to a conjoint deciency variable that represents poorer quality needing action. The absolute deciency frequencies in our study were used to show areas of improvement. Absolute frequencies also containing missing values are more predictive for the given population in small samples than relative ones. In short, a deciency frequency of 80 per cent and higher can be considered to indicate urgent improvement areas; a frequency of 60 per cent to 79 per cent is suitable for detecting areas of improvement with lower priority. The calculated deciency frequencies and a ranking of priority are shown in Table III. Physician medical expertise was highly ranked by referring specialists. In contrast, external physicians estimations of patient commendations were low. The length of
No. 50 51 52 51 94.3 96.2 98.1 96.2 2.72 ^ 1.03 1.98 ^ 0.65 2.96 ^ 1.03 3.84 ^ 1.22 22 22 21 20 100 100 95.5 90.9
Variable (item)
Referring physicians n 53 % Mean (^ SD) n 2.64 ^ 0.73 1.73 ^ 0.63 3.00 ^ 0.78 3.95 ^ 1.10
Clinicians n 22 % Mean (^ SD)
p-value *
1. 2. 3. 4. 5.
0.014 0.002 , 0.001
6. 7. 8. 9. 10. 11. 12. 48 51 41 90.6 96.2 77.4 3.77 ^ 1.15 2.43 ^ 0.81 2.46 ^ 0.81 19 22 20
51 49 49 45 46 47 51
96.2 92.5 92.5 84.9 86.8 88.7 96.2
2.76 ^ 0.86 2.80 ^ 1.10 2.27 ^ 0.93 2.49 ^ 0.92 2.28 ^ 0.81 2.53 ^ 0.98 2.29 ^ 0.86
19 22 22 22 22 22 22
86.4 100 100 100 100 100 100 86.4 100.0 90.9
2.26 ^ 0.56 2.41 ^ 1.10 1.95 ^ 0.65 1.77 ^ 0.69 1.55 ^ 0.60 2.05 ^ 0.84 2.23 ^ 0.87 2.42 ^ 0.90 2.05 ^ 0.84 2.00 ^ 0.80
, 0.001 0.032
13. 14.
Cooperation with physicians in private practice Medical expertise of the clinicians Accessibility of hospital services in urgent cases Time interval in which medical reports are supplied Signicance and informational value of supplied medical reports Availability of outpatient consultations Amount of outpatient service offerings Quantity of available hospital beds Amount of inpatient service offerings Friendliness of hospital staff Education and training offerings for externals Frequency of commendations from recurring patients Reputation of the clinical department Provided regular mail newsletter
Notes: SD, standard deviation; * Mann-Whitney U test, two-tailed
Table II. Questionnaire items, item response rates, mean values, and comparative statistics
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Figure 1. Referring physicians ratings proportions of each item
No. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.
Variable * Cooperation Medical expertise Accessibilitya, b Medical reports: Timea, b Medical reports: Informational valuea Outpatient consultations Outpatient service offerings Bed capacities Inpatient service offerings Friendliness Education and training Commendationa Reputation Newsletter
Referring physicians Clinicians Def. Def. Rank of frequation Rank of frequation priority % priority % p-valuec 5 14 4 2 3 7 11 8 12 9 13 1 10 6 58.5 15.1 64.2 84.9 66.0 56.6 39.6 52.8 39.6 47.2 35.8 86.8 45.3 58.5 3 13 2 1 5 6 11 12 14 6 8 4 8 8 50 9.1 77.3 95.5 40.9 36.4 18.2 13.6 4.5 36.4 27.3 45.5 27.3 27.3
0.002 0.002 ,0.001 0.022
Table III. Rank of priority, deciency frequencies, and statistical results
.60 per cent are indicated; a detected by referring physicians; b detected by clinicians; c Fishers exact test, two-tailed
Notes: Def. frequation , deciency frequency; * Areas of improvement with a deciency frequency
time in which medical reports were provided following hospital treatment (85 per cent deciency frequency) and their informational value for referring specialists (66 per cent) were the most common insufciencies. Moreover, referring physicians criticised staff accessibility in urgent cases (64 per cent). Our ndings suggest these three improvement areas.
Comparative evaluations As seen in Table II and III, there were disagreements between the way referring physicians and the way in which clinicians themselves rated some items. An average mean value for all 14 quality items was calculated for each subgroup: . referring physicians: 2.69, SD: 0.54; and . clinicians: 2.29, SD: 0.61 revealing a statistically signicant difference (p 0:019). There were signicant differences concerning average rating values and deciency frequencies. Lack of patient commendation had the highest deciency frequency (87 per cent) and the second lowest rating in the referring physicians group. However, this aspect was supposed to be much higher from the clinicians viewpoint ( p , 0.001). Furthermore, clinicians rated newsletters signicantly higher than referring specialists ( p , 0.032, p , 0.022). Differences were also been found with inpatient resources and inpatient services. Average rating values and deciency frequencies reveal that clinicians ratings were remarkably distinct from those referring physicians scores (mean, p 0:002; deciency frequency, p 0:002, p , 0.001). There were no signicant differences between referring physicians ratings and those made by clinical department physicians concerning: . cooperation; . medical expertise; . accessibility in urgent cases; . time interval in which medical reports are supplied; . outpatient consultations; . outpatient services; . hospital staff friendliness, and the; and . clinical departments perceived reputation. Quality features interaction Factor analysis revealed two components that explained nearly 52 per cent of the variability in the original 14 variables. Varimax rotation was used to determine what the components represented. The rst component, which explains nearly 37 per cent of the variance, is highly correlated with the following variables: . cooperation; . medical expertise; . friendliness; and . reputation.
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The second component is highly correlated with inpatient bed capacities and inpatient service offerings. The rst component represents a construct with generic attributes that improvement activities cannot inuence directly. Correlating quality items representing a generic quality perception, such as cooperation and reputation, were calculated. Table IV shows that most variables were highly correlated with these two items. An equally important nding is that inpatient capacities and service offerings were not correlated. A further interesting point was to test for correlation between questionnaire items and both geographic range and annual number of referred patients (Table V). Signicant negative correlations were found between geographic range and hospital staff friendliness (p 0:039), and the frequency of patient commendations (p 0:005). Moreover, the number of referred patients was signicantly negatively correlated to medical reports informational value (p 0:042). Discussion Our study described and evaluated the way referring physicians and clinicians rated several quality items from their individual perspectives. Although the study response is low, in former studies dealing similar questions, equal or even lower response rates have been observed from physician samples (MacDowell and Perry, 1990; Beltramini and Sirsi, 1992). It may be speculated that there is a lack of motivation and incentive for private practice physicians to participate. This may be caused by a lack of quality management sense. However, we considered the response rate acceptable, particularly when we did not remind respondents or offered an incentive for completion. This survey is limited to: . sampling referring physicians via the manually maintained databank; . one geographical region; and . the medical specialty of which the majority of responses were received.
Cooperation Reputation Responses Pearson Responses Pearson (n) correlation p-value * (n) correlation p-value * 50 49 50 50 50 47 47 44 44 45 48 46 49 40 1.000 0.539 0.342 0.301 0.601 0.639 0.532 0.067 0.059 0.615 0.348 0.364 0.594 0.428 , 0.001 0.015 0.034 , 0.001 , 0.001 , 0.001 , 0.001 0.015 0.013 , 0.001 0.006 46 47 51 50 50 49 49 45 46 47 49 48 51 41 0.594 0.547 0.369 0.595 0.528 0.471 0.505 0.149 0.054 0.647 0.251 0.514 1 0.465 ,0.001 ,0.001 0.008 ,0.001 ,0.001 0.001 ,0.001 ,0.001 ,0.001 0.002
No. Variable 1. 2. 3. 4. 5. 6. 7. Table IV. Correlation analysis of generic quality perceptions represented by reputation and cooperation with other quality items, sample of referring physicians 8. 9. 10. 11. 12. 13. 14. Cooperation Medical expertise Accessibility Medical reports: Time Medical reports: Informational value Outpatient consultations Outpatient service offerings Bed capacities Inpatient service offerings Friendliness Education and training Commendation Reputation Newsletter
Note: * Two-tailed test of signicance
No. Variable 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. Cooperation Medical expertise Accessibility Medical reports: time Medical reports: Informational value Outpatient consultations Outpatient service offerings Bed capacities Inpatient service offerings Friendliness Education and training Commendation Reputation Newsletter
Geographic range Number of referred patients Responses Spearman Responses Spearman (n) correlation p-value * (n) correlation p-value * 44 45 46 45 45 43 43 39 40 42 45 42 45 37 20.174 20.079 20.001 20.253 20.059 20.157 20.150 20.102 20.120 20.320 20.007 20.421 20.231 0.131 48 48 49 48 48 46 46 42 43 44 48 45 48 38 20.189 20.032 0.148 0.055 20.295 20.262 20.207 0.161 20.037 20.029 20.083 20.183 20.075 20.219 0.042
0.039 0.005
Note: * Two-tailed test of signicance
Table V. Correlation of geographic range and number of referred patients with quality items, sample of referring physicians
Nevertheless, our survey questionnaire provides a ready-to-use instrument that identies crucial improvement areas. Critical deciency frequencies indicating relevant areas, such as 80 per cent and more, can be chosen individually for each item and should be monitored over time. Using this approach, major improvement areas demanding urgent action could be identied. For interpretation, it is important to distinguish between variables that can be directly inuenced by management activities, such as providing medical reports and newsletters, and those variables, which are less tangible, such as reputation and cooperation. The present ndings suggest that timely and signicant information about: . hospital stay; . discharge; . proposed procedures; and . medications. are major points for satisfaction and perception of adequate cooperation. The high importance attached to timely and adequate communication back to referring physician was previously reported in other studies (Cummins et al., 1980; Curry et al., 1980; Elija and Marja-Leena, 2005). Moreover, accessibility in urgent cases, which represents a further tangible communication and cooperation aspect, has been found to be improvable. In conclusion, hospital administrators and clinicians should pay careful attention to communication tools, such as medical reports and newsletter articles, and should address this problem by investing in systematic communication improvement programs. Not only do patients expect a seamless healthcare system and continuity of
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care between services but also the physicians who refer patients to higher-level health care institutions. Referring physicians expect management to be shared with their cooperating medical partners. Although we found statistically signicant disagreements, comparative analysis allowed us to conclude that the majority of quality problems are perceived in a similar manner by referring physicians and clinicians. However, in general, clinicians tend to rate quality higher than referring physicians. We note that the frequency of patient commendation, estimated by clinicians, was signicantly higher, proposing a strong positive self-image in terms of services they provide. Although the validity of this latter item remains doubtful, the frequency of patient commendation was found to be associated with the geographic range. If the distance between referring specialists and hospitals is great then patient commendations decline. This may be subject to rather infrequent contact, which makes it difcult for referring physicians to give a valid rating. Another meaningful nding is that if only a small number of patients are referred then the referring physicians rate medical reports informational value signicantly higher. One may speculate that physicians, who refer only a few patients to the clinical department, are much more interested in reading and understanding medical reports than physicians who refer a greater number of patients. An assumable cause may lie in a few but important referrals from the viewpoint of the referring physician. Private practice and clinician specialists providing health care services at a secondary or tertiary care level have different roles and may often see problems from different perspectives. Working in separate medical realities may diminish understanding for the concerns of others (Kvamme et al., 2001). This situation is particularly important in the German health care system, which is separated into inpatient and outpatient care sectors with spending caps (Altenstetter, 2003). Not competition between specialists, but good working relations across all boundaries is required. Recommendations We cannot have an accurate understanding of how our services are perceived by others without asking them. Health care provider images and satisfaction with those providers vary among consumers, physicians and the public (Scammon and Kennard, 1983). Before customer satisfaction can be addressed, therefore, hospitals need to understand stakeholder needs, expectations and satisfaction. Surveying referral physician perspectives is an essential method for gathering information on health care service perception. A second step, utilizing survey results, is equally important. Regular measurement and reporting to hospital staff members and the executive board is mandatory for a quality improvement process. The long-term strategic challenge lies in building creative and sustainable referral networks that promote professional partnership among physicians, care levels and care sectors (Javalgi et al., 1993).
References Altenstetter, C. (2003), Insights from health care in Germany, American Journal of Public Health, Vol. 93 No. 1, pp. 38-44.
Beltramini, R.F. and Sirsi, A.K. (1992), Informational inuences on physician referrals, Journal of Hospital Marketing, Vol. 6 No. 2, pp. 101-26. Braun, G.E. and Nissen, J. (2005), Die Bedeutung der Einweiserzufriedenheit fur Krankenhauser und ihre erfolgreiche Messung, Gesundheitsokonomie und Qualitatsmanagement, Vol. 10 No. 6, pp. 376-84. Carr-Hill, R.A., Rice, N. and Roland, M. (1996), Socioeconomic determinants of rates of consultation in general practice based on fourth national morbidity survey of general practices, British Medical Journal, Vol. 312, pp. 1008-12. Castle, N.G., Brown, J., Hepner, K.A. and Hays, R.D. (2005), Review of the literature on survey instruments used to collect data on hospital patients perceptions of care, Health Services Research, Vol. 40 No. 6, pp. 1996-2017. Chan, B.T.B. and Austin, P.C. (2003), Patient, physician, and community factors affecting referrals to specialists in Ontario, Canada. A population-based, multi-level modelling approach, Medical Care, Vol. 41 No. 4, pp. 500-11. Coulter, A. (1998), Managing demand at the interface between primary and secondary care, British Medical Journal, Vol. 316, pp. 1974-6. Cummins, R.O., Smith, R.W. and Inui, T.S. (1980), Communication failure in primary care. Failure of consultants to provide follow-up information, Journal of the American Medical Association, Vol. 243 No. 16, pp. 1650-2. Curry, R.W. Jr., Crandall, L.A. and Coggins, W.J. (1980), The referral process: a study of one method for improving communication between rural practitioners and consultants, The Journal of Family Practice, Vol. 10 No. 2, pp. 287-91. Eija, G. and Marja-Leena, P. (2005), Home care personnels perspectives on successful discharge of elderly clients from hospital to home setting, Scandinavian Journal of Caring Sciences, Vol. 19 No. 3, pp. 288-95. Franks, P., Zwanziger, J., Mooney, C. and Sorbero, M. (1999), Variations in primary care physician referral rates, Health Services Research, Vol. 34 No. 1, pp. 323-9. Javalgi, R., Joseph, W.B., Gombeski, W.R. Jr. and Lester, J.A. (1993), How physicians make referrals, Journal of Health Care Marketing, Vol. 13 No. 2, pp. 6-17. Kvamme, O.J., Olesen, F. and Samuelson, M. (2001), Improving the interface between primary and secondary care: a statement from the European Working Party on Quality in Family Practice (EQuiP), Quality in Health Care, Vol. 10 No. 1, pp. 33-9. MacDowell, N.M. and Perry, R. (1990), Factors inuencing physician choice of an outpatient surgery and testing facility, Journal of Health Care Marketing, Vol. 10 No. 3, pp. 67-74. Mackesy, R. and Mulligan, A.T. (1990), Establishing an effective referring physician network, Journal of Health Care Marketing, Vol. 10 No. 2, pp. 54-8. Piterman, L. and Koritsas, S. (2005), Part II. General practitioner-specialist referral process, Internal Medicine Journal, Vol. 35 No. 8, pp. 491-6. Rosemann, T., Wensing, M., Rueter, G. and Szecsenyi, J. (2006), Referrals from general practice to consultants in Germany: if the GP is the initiator, patients experiences are more positive, BMC Health Services Research, Vol. 6 No. 5, available at: www.biomedcentral. com/1472-6963/6/5 Scammon, D. and Kennard, L. (1983), Improving health care strategy planning through assessment of perceptions of consumers, providers and administrators, Journal of Health Care Marketing, Vol. 3 No. 4, pp. 9-17.
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Shea, D., Stuart, B., Vasey, J. and Nag, S. (1999), Medicare physician referral patterns, Health Services Research, Vol. 34 No. 1, pp. 331-48. Stareld, B., Forrest, C.B., Nutting, P.A. and von Schrader, S. (2002), Variability in physician referral decisions, The Journal of the American Board of Family Practice, Vol. 15 No. 6, pp. 473-80. Corresponding author Peter Hensen can be contacted at: hensenp@mednet.uni-muenster.de
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The inuence of service quality and patients emotions on satisfaction

Maria Helena Vinagre
Instituto Superior de Ciencias do Trabalho e da Empresa (ISCTE), Montijo, Portugal, and
The inuence of service quality
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Received 2 November 2006 Revised 13 April 2007 Accepted 3 May 2007
Jose Neves
Instituto Superior de Ciencias do Trabalho e da Empresa (ISCTE), Lisboa, Portugal
Abstract
Purpose The purpose of this research is to develop and empirically test a model to examine the major factors affecting patients satisfaction that depict and estimate the relationships between service quality, patients emotions, expectations and involvement. Design/methodology/approach The approach was tested using structural equation modeling, with a sample of 317 patients from six Portuguese public healthcare centres, using a revised SERVQUAL scale for service quality evaluation and an adapted DESII scale for assessing patient emotions. Findings The scales used to evaluate service quality and emotional experience appears valid. The results support process complexity that leads to health service satisfaction, which involves diverse phenomena within the cognitive and emotional domain, revealing that all the predictors have a signicant effect on satisfaction. Research limitations/implications The emotions inventory, although showing good internal consistency, might be enlarged to other typologies in further research needed to conrm these ndings. Practical implications Patients satisfaction mechanisms are important for improving service quality. Originality/value The research shows empirical evidence about the effect of both patients emotions and service quality on satisfaction with healthcare services. Findings also provide a model that includes valid and reliable measures. Keywords Customer satisfaction, Portugal, Service levels Paper type Research paper
Introduction Service quality and customer satisfaction are a major goal in modern organizations. Public services cannot detach from this general concern, mostly because they act on the socio-economic level and serve individuals and organizations that need adequate, timely and effective responses (Vinagre and Neves, 2002). Public Sector importance, especially as a service provider, forces managers and practitioners to address quality and client satisfaction issues as a priority. These services have, however, specic characteristics, such as intangibility, heterogeneity and inseparability. Their production, distribution and consumption are simultaneous processes and they are
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not storable. They are created in buyer-seller interactions and they are essentially activities or processes, in which customers participate in the production (Gronroos, 2000). Consequently, the customer perceives a service in all its production processes and not merely as the result of that production. Therefore, the features of these services make it difcult to adopt service quality and customer satisfaction evaluation criteria. Service experiences are the outcomes of the interactions between organizations, related systems/processes, service employees and customers (Bitner et al., 1997). Customer satisfaction and customer perceptions are therefore often inuenced by those interactions (Bitner et al., 1994; Surprenant and Solomon, 1987). The wide diversity of services constitutes another factor that poses measurement difculties. We may need separate criteria to differentiate services mainly on the basis of the sort of experience users have with a particular service. Transactions can thus be open or closed; the degree of involvement can vary as well as the duration of consumer experience. Services can also differ in the degree of technical knowledge and skill required. Despite the generalized acknowledgment of these differences among service types, there is a rather limited body of knowledge on the effects that these different types of services have upon consumer satisfaction. Traditionally, in order to explain service quality and satisfaction, only cognitive measures were considered such as disconrmation or the perceived service performance (Liljander and Strandvik, 1997). Departing mainly from Westbrooks (1987) and Westbrook and Olivers (1991) work, several empirical studies revealed that service use has potential to elicit a complex variety of emotional and cognitive responses. Both studies proved the DESII scales validity and reliability in consumption settings and show that a number of different positive and negative emotions can be related to satisfaction. Considering healthcare services consumers differing needs, we assume that we can also nd differing evaluations of the degree of importance (involvement) attached to the service among the patients. Some studies found a signicant relationship between involvement and the level of emotions concerning service experience (e.g., Bloemer and Ruyter, 1999; Price et al., 1995). Having this in mind, involvement seems a variable to be considered in patient satisfaction and emotional response analysis. Focusing on consumer satisfaction with a public healthcare service (in this study we considered patient as a health service consumer); we intend to know the service quality dimensions perceived by patients and the relationship between emotion, expectations, service experience and involvement. From an empirical study in six healthcare centres, we intend to evaluate service quality dimensions, the emotions linked to service experience and the complementary effect of expectations and involvement on patient satisfaction. Theoretical framework Despite seemingly alike, perceived service quality and consumer satisfaction are distinct constructs that may be dened and evaluated in different ways. Oliver (1997) identied a few major elements that differentiate service quality and satisfaction, he suggests that quality is a judgment or evaluation that concerns performance pattern, which involves several service dimensions specic to the service delivered. Quality is believed to be determined more by external cues (e.g., price, reputation). Satisfaction, however, is perceived as a global consumer response in which consumers reect on their pleasure level. Satisfaction is based on service delivery predictions/norms that depend on past experiences, driven by conceptual cues (e.g., equity, regret). Although
perceived service quality may be updated at each specic transaction or service experience, it tends to last longer than satisfaction, which is understood as being transitory and merely reecting a specic service experience (Martinez-Tur et al., 2001). In short, researchers dispute the relationship between perceived service quality and satisfaction (Ting, 2004). In this study, we suggest that service quality should be one patient satisfaction antecedent. Service quality Quality has been used to describe diverse phenomena. Service quality studies at the consumer level have a decisive impact on the type of research that has been developed (Gronroos, 1998). Quality is no longer analysed and measured from an internal focus; it is now conceived from the exterior (or consumers) point of view. Among consumer satisfaction theories, different authors (Parasuraman et al., 1985, 1988; Zeithaml et al., 1990) dened service quality as a degree and gap between service perception and consumer expectations. Based on the disconrmation paradigm the Gap Model developed by Parasuramans team in the 1980s is fundamentally a model of service quality analysis and evaluation. Conclusions drawn from their exploratory study helped them to develop an evaluation and service quality measurement known as SERVQUAL an instrument that has been improved (Parasuraman et al., 1991; Zeithaml et al., 1990; Parasuraman et al., 1985, 1988) and validated (e.g. Wisniewski and Wisniewski, 2005; Cook and Thompson, 2000; Donnelly, 1995; Gabbie and ONeill, 1996). The SERVQUAL model includes ve service quality dimensions reliability, assurance, tangibles, empathy and responsiveness that consumers are assumed to use in a systematic way to perceive services provided. Some authors criticise SERVQUAL. Buttle (1995) synthesized some of these criticisms regarding: disconrmation (disconrmation paradigm rather than an attitudinal paradigm); the appropriateness or utility of expectations in SERVQUAL (the meaning of expectations, the meaning of P-E gaps and the contribution of the expectation scores); and service quality dimensionality (the universality of the ve dimensions are not always conrmed). Regarding expectation criticisms, Parasuraman et al. (1991) acknowledged that normative expectations (what services should be) lead to unrealistic expectations. Accordingly, they redened expectation in predictive terms what a client may expect from an excellent service. Subsequently, they suggest that expectations have a tolerance zone between desired service and adequate or minimal acceptable service level (Berry and Parasuraman, 1991). Regarding dimensionality, some studies conrmed service quality dimensional variability (e.g., Mostafa, 2005; Vinagre and Neves, 2002; Cook and Thompson, 2000). As an alternative to the universal SERVQUAL ve-factor structure, we consider a contingent approach in which dimension numbers vary according to, among others, service type (contextualized dimensionality). Nevertheless, SERVQUAL is considered a useful and valid instrument to measure service diversity, although it requires an adaptation to the organization under evaluation (Curry, 1999), which implies subsequent renement of quality dimensions relevant to each service. Expectations Consumer expectations are central to satisfaction studies. Although there is general agreement about the inuence of customers expectations in overall service quality and
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customer satisfaction, considerable work remains to be done regarding the exact way this process takes place (Coye, 2004). It is assumed that consumers create expectations prior to their service experience against which performance is evaluated. Perception can disconrm expectation (either for worse or better) or conrm it (neutral comparison). Several studies found a separate effect of expectations and disconrmation on satisfaction (e.g., Andreassen, 2000; Oliver, 1980). Oliver and DeSarbo (1988) mention theoretical support for those effects. They state that expectations cause an assimilation effect while discrepancy causes a contrast effect. Assimilation effect corresponds to a narrowing of the gap (leading to an assimilation of expectations with perceptions) while the contrast effect is the opposite. When the consumer acknowledges a gap, he or she attempts to reduce this space. However if disconrmation is too strong then the consumer may strengthen his or her negative perception thus widening the gap. In this latter case, contrast effect occurs. According to the assimilation theory, individuals tend to respond according to their expectations because they are reluctant to admit wide discrepancies. Consequently, if the discrepancy between the consumers expectations and perception is small then perceptual judgment will reduce this difference. However, if the discrepancy is too large then we need to obtain a contrasting perception (Bridges, 1993). The role of expectations as an assimilation agent provides, therefore, the mechanism by which expectations may inuence satisfaction directly (Oliver, 1997). Emotions and consumer experience Emotions refer to a set of responses occurring especially during consumer experience (Westbrook and Oliver, 1991). High levels of satisfaction may include positive and negative emotions (Arnould and Price, 1993), which implies that we should consider examining positive and negative emotion effects separately (Babin et al., 2005; Dube and Menon, 2000; Price et al., 1995). Different scales have been used in consumer emotion studies. Izards (1977) Differential Emotions Scale (DES), originally conceived to measure an individuals emotional state, is used to measure emotional experience or emotional reactions perceived by the individual during a time period. The DESII instrument is a discrete emotions inventory, self-administered, designed to measure basic emotions or combinations of emotions experienced by the individual. It comprises ten subscales with three items each representing the frequency with which individuals express each of ten basic emotions, measured on a ve-point Likert-scale. Generically, DES is a measure of emotional state intensity, while DESII is a measure of emotional experience frequency at a given period and is often used in consumer-experience research. However, as Richins (1997) highlights, because these are measures developed in other contexts, difculties may arise when DESII is used for consumer behavior research, as emotions are context specic, some emotions experienced in the context of interpersonal relationships may be different from those experienced during a consumption experience. Involvement Involvement is linked to studies on consumer satisfaction. Within consumer psychology, involvement is viewed as a motivational construct that inuences subsequent consumer behaviour (Dholakia, 2001). Although involvement represents a more complex construct (Kim, 2005), we assume that a patient is involved when the
service is relevant according to the services characteristics and the patients needs, values and interests (Zaichkowsky, 1985). In this respect, involvement is similar to importance, interest, attachment and/or motivation. However, these may be considered distinct. For example, an individual may be interested in a service or activity even though that service or activity may not be important to him or her. Involvement has also been operationalized distinctly (e.g., Bridges, 1993; Zaichokowsky, 1985) and despite involvement semantic distinctions, it corresponds to a products or services perceived importance (Mittal, 1995). In our study, we depart from the more restricted conception of involvement: the degree of importance attributed to the service by the patient. Despite studies that relate involvement with satisfaction, or that conceive involvement as a mediator of disconrmation (e.g., Bridges, 1993), the involvement effect is insufciently explored compared to other satisfaction predictors. Satisfaction predictors: theoretical model of analysis Acknowledging that consumer experience is complex, especially at the service level, calls attention to the important role emotions may play when associated with other cognitive variables that explain these phenomena. Usually, service quality is considered mostly a cognitive construct while satisfaction has been considered a more complex concept that includes cognitive and affective components (Oliver, 1997). However, considering the interaction between the two in service experience, perceived service quality can also include dimensions that are mostly relational. Therefore, these relational dimensions are permeable to a strong emotional inuence; opposing the purely cognitive nature of service quality evaluation. The mere possibility that emotions can be present across all interactions between consumers and service providers makes it difcult to separate emotions from service quality evaluations (Liljander and Strandvik, 1997). Some researchers argue that emotional versus cognitive saliency depends on the type and nature of service transactions. Services with more qualied or more credential properties imply that a consumers capacity and ability to evaluate the service provided is reduced. In these cases, there should be a greater tendency to evaluate aspects relating to attention received during the interaction established along the service experience (Shemwell et al., 1998) and emotional aspects. Acknowledging potential expectation effects, service quality and emotions on satisfaction, we hypothesized that: H1. Service quality has a positive effect on patient satisfaction. H2. Positive emotions have a positive effect on patient satisfaction. H3. Negative emotions have a negative effect on patient satisfaction. H4. Expectations have a positive effect on patient satisfaction. The diversity of emotional experiences is explained as a function of emotion-cognition interactions resulting in cognitive-affective structures (Izard, 1992). Consequently, we assume an interrelation between cognitive variables in forming emotions and satisfaction (Westbrook and Oliver, 1991). Within this context, it is foreseeable that expectations are related to the frequency with which patients experience positive or negative emotions. Therefore:
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H5. Expectations have a positive effect on positive emotions. H6. Expectations have a negative effect on negative emotions. We presume that service involvement motivates patients to initiate a more positive service-interaction. Consequently, we expect that in a healthcare service there is a high level of involvement given the degree of importance it has for the patient and in which there is a direct relation between the degree of involvement, satisfaction and other predictors such as expectations and emotions. These assumptions led us to make the following predictions: H7. Patient involvement has a positive effect on expectations. H8. Patient involvement has a positive effect on positive emotions. H9. Patient involvement has a negative effect on negative emotions H10. Patient involvement has a positive effect on patient satisfaction. The research model and the expected effects are represented in Figure 1. Methodology Sample We used a convenience sample composed of individuals attending targeted healthcare centres during approximately one month in each. We obtained 317 valid responses from patients in six healthcare centres. A self-administered form instructed patients to ll in the questionnaire in two phases: their expectations before experiencing the service and their perceptions after the service had been provided. These variables and measures were adopted:
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Figure 1. Research model
Service quality. Following recommendations in the literature (e.g., Babakus and Mangold, 1992; Carman, 1990; Kilbourne et al., 2004, Vandamme and Leunis, 1992) to measure expectations and perceptions, we used an adapted SERVQUAL scale (Parasuraman et al., 1988) for the particular healthcare sector contexts. We used a ve-point Likert scale ranging from completely disagree (1) to completely agree (5). This instrument includes 28 items for the expectations scale and 28 items for the perceptions scale. Service expectations quality scale. Patients were asked, before consultation, what they thought on the basis of their experience what could be expected from services provided in a healthcare unit. Examples include (E3) Staff would have good appearance; (E5) They would full their promised service at the time they promise to do so; (E15) My doctor instils me with condence (E19) Nurses would be always courteous with me; (E21) My doctor would have a good professional preparation; (E24) The doctor would give me personal attention. Service perceptions quality scale. Using the same 28 items, this scale asked patients how they considered services that were provided. Examples include: (P4) Materials and documents are clear and visually appealing; (P8) They provide services at the promised time; (P16) I feel safe in my relationship with my doctor; (P17) I feel safe in my relationship with nurses; (P18) I feel safe in my relationship with the auxiliary staff; (P26) My doctor understands my specic needs Satisfaction measure. Consumer satisfaction is the main dependent variable in our study. We considered the existing measures diversity in the literature. We chose to use a satisfaction scale composed of four items (assertions) measured in a ve-point Likert-scale format from completely disagree (1) to completely agree (5). This scale was developed by adapting Donavan and Hocutts (2001) and Dube and Menons (2000) items on the relationship between patients emotions during hospitalization and their satisfaction, taking into account a series of hospital service characteristics. This scale consists of ve items and includes: Generally I am satised with my doctor; Generally I am satised with the nurses; Generally I am satised with the services of support; Generally I am satised with the level of services performed; Generally I am satised with this healthcare centre. Emotions. In order to obtain the users emotional reactions to the services provided, we adapted Izards (1977) Differential Emotions Scale DESII used and validated in consumer studies (e.g., Westbrook, 1987; Westbrook and Oliver, 1991) but not particularly in healthcare services. We included positive and negative emotions scales but we excluded the surprise item owing to its ambiguity. The scale contains 27 adjectives that present the frequency with which patient experienced each of nine considered basic emotions over service healthcare experience (how often do you have these feelings in your relationship with this healthcare centre) on a ve-point scale from (1) never to (5) very often. Expectations. Following Olivers (1981, 1997) proposal, we used a satisfaction expectation measure focusing on the service to be provided. We asked respondents to predict the degree of anticipated satisfaction (what would you expect from this service: to feel satised with this medical consultation, to feel satised with the service performance and to feel physically better) in a Likert ve-point format from completely disagree (1) to completely agree (5).
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Involvement. Was measured in a direct way with a single item that intended to identify the degree of service importance to the patient by the healthcare centre (The services given in this healthcare centre are very important for me in a Likert ve-point format). Questionnaire pre-testing An initial questionnaire draft was submitted to a critical analysis to three professors and academic investigators on service quality or quality in healthcare services that analysed the questionnaires construction and language clarity. Then, the revised questionnaire was pre-tested on a sample of healthcare public service users in order to test its consistency. Measures showed a good internal consistency with Cronbachs alpha around 0.90 for the expectations scale and 0.97 for the emotions scale. Data analysis Psychometric measure validation followed the recommended procedures: . Internal consistency analysis (Cronbachs alpha). . Factorial structure identication with an exploratory factor analyses performed on the items for each scale (according with the procedures adopted by Mano and Oliver, 1993; Liljander and Strandvik, 1997; and Verbeke and Bagozzi, 2000), adopting theoretical criteria for retaining factors with Eigenvalues higher than 1, applying Varimax Rotation and deleting items not satisfying the following criteria: loadings equal or above 0.6 in the dominant factor and cross-loadings below 0.4 in the remaining factors. . Internal consistency analysis of the factor structure found. Our analysis was done using structural equation modelling (SEM) by means of AMOS 4.0. Following Hoyle and Panters (1995) recommendation, we used the estimation method of free parameters in structural equations employing Maximum Likelihood (ML) that presents better performance in less favourable analytical conditions (e.g., sample size, or no normality), with means and intercepts estimate owing to missing data and indication of the saturate and independent model measures of t. In this model, the service quality factors (i.e. positive and negative emotions) are treated as observed components of the respective constructs. Once the models were specied and estimated, results were analysed. The rst step consisted of verifying the models t to the data through t-measure analysis. In a second step, the signicance of the structural model parameters were analysed (path coefcients). Given the controversy regarding the indices that one should use in evaluating the model t in SEM, it is cautious to use more than a single index when substituting the chi-square. Considering Hoyle and Panters (1995) recommendations, suggesting that indices characteristics depend on data, sample size and selected estimation method, we adopted the Incremental Fit Index (IFI) type 2 index, which is less sensitive to sample size and non-normality and Tucker-Lewis Index (TLI) also a type 2; the Comparative Fit Index (CFI), a type 3 index and the Root Mean Square Error of Approximation (RMSEA). Results Service quality measure According to extant literature, a service is considered to be quality whenever perceptions exceed users service expectations. Thus dened, service quality results
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in the gap between user perceptions and respective expectations. From this point of view, it seems justiable that service quality construct dimensionality is focused on the gap between perceptions and expectations (Vinagre and Neves, 2002; Babakus and Mangold, 1992; Vandamme and Leunis, 1992; Parasuraman et al., 1991). In order to identify variables concerning service quality, we used the SPSS compute variable function to calculate 28 new variables representing the result of the numerical expression (perception expectation) for each item. The scale presented a high internal consistency (a 0:97). Considering the constructs multidimensional nature, we intended to identify service quality scale structure through Principal Component Analysis (PCA). Using Kaisers criterion (Eigenvalue . 1), we extracted four components that explained 67.01 per cent of total variance. By analysing the saturation matrix after Varimax rotation (Table I), we eliminated 11 items owing to cross-loading. The extracted factors are interpretable and allow us to identify four service quality dimensions: (1) Reliability. With factor loadings ranging from 0.77 to 0.64, it integrates all items from the Reliability factor plus two more from the Response Capacity factor in the original scale. (2) Physicians assurance. With factor loadings ranging from 0.84 to 0.69, it integrates all items concerning medical performance, comprehending simultaneously in the same factor the Assurance regarding their professional competency and empathy towards the patients. (3) Employees assurance. With factor loadings above 0.68, it integrates items from the Assurance factor concerning Nurses and Auxiliary staff. (4) Tangibles. With factor loadings ranging from 0.72 to 0.76, it groups two items from the physical elements. Regarding the theoretical model, we fused Reliability and Response Capacity. The Empathy and Assurance dimensions, both concerning specically the relation with the service provider, are disaggregated in two groups corresponding to distinct occupational groups: physicians, nurses and auxiliary staff. Although with fewer items, the Physical Elements dimension was kept. The scales showed a good internal consistency. Cronbach alpha varied from 0.67 for the Physical Elements scale (which also has fewer items) to 0.97 for Reliability. The global service quality scale presented a Cronbach alpha of 0.95. Nunnaly (1978) indicated 0.7 to be an acceptable reliability coefcient but lower values as 0.60 are also used in the literature (e.g., Wright, 2007; Aspy et al., 2004; W So, 2002). Alpha coefcient is dependent not only on the magnitude of correlations among items but also on the number of items in the scale, so alpha could be lower in scales with fewer items. Measure of emotions in service experience The DESII scale showed high internal consistency for all 30 items (a 0:91). Considering that the scale comprehends differing and opposite valences, we checked subscale validity and consistency, grouped by valence (positive and negative emotions within the emotional experience).
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Statement number code QS5
Text
Reliability 0.77 0.76 0.73 0.73 0.72 0.66 0.64 0.17 0.22 0.31 0.14 0.22 0.15 0.37 0.27 0.3 0.22 23.09 0.93
Components Physicians Employees assurance assurance 0.22 0.25 0.22 0.23 0.27 0.37 0.27 0.84 0.82 0.75 0.73 0.69 0.33 0.15 0.34 0.21 0.06 18.69 67.01 0.88 0.95 0.82 0.3 0.24 0.33 0.21 0.28 0.27 0.35 0.21 0.12 0.11 0.33 0.32 0.77 0.73 0.68 0.21 0.35 14.56
Tangibles 0.23 0.3 0.23 0.37 0.17 0.23 0.18 0.13 0.12 0.19 0.26 0.08 0.28 0.15 0.25 0.76 0.72 10.7 0.67
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Table I. Service qualitys factor structure: rotated component matrix (Varimax)
They full their promised service at the time they promise to do so QS8 They provide me the services at the promised time QS10 They give accurate information as to when services will be provided QS7 They perform the service right the rst time QS6 When I have a problem, they show sincere interest in solving it QS11 They give me a prompt service QS9 They insist on error-free records QS15 My doctor instils me condence QS26 My doctor understands my specic needs QS24 The doctor gives me personal attention QS16 I feel safe in my relationship with my doctor QS21 My doctor has a ne professional training QS17 I feel safe in my relationship with the nurses QS19 Nurses are always courteous with me QS18 I feel safe in my relationship with the auxiliary staff QS4 Materials and documents are clear and visually appealing QS3 Staff has good appearance % Explained variance (with rotation) % Explained variance (with rotation) Factor internal consistency (Cronbach alpha) Factor internal consistency all items (Cronbach alpha)
Positive emotions Our PCA of two DESII positive valence subscales matched factors in the theoretical model (Varimax rotation with Kaiser criterion) explaining cumulatively 79.88 per cent of total variance. The internal consistency analysis showed a Cronbach alpha of 0.83 for Interest and 0.90 for Enjoyment (in Izards, 1977 study, Cronbach alpha for these subscales was 0.76 and 0.87 respectively) and 0.84 for the total scale. Negative emotions Our PCA on the seven DESII negative valence subscales revealed four interpretable components (Varimax rotation with Kaiser criterion) explaining cumulatively 78.28 per
cent of total variance. Seven items had to be discarded in the rotated matrix owing to unacceptable cross-loading (Table II). Our results indicated that items composing Aversion and Despise factorise into a single factor. Factor Shame absorbs one factor item that had disappeared (namely, the second item in Guilty). All the remaining factors were maintained. Factors extracted allowed us to identify four negative emotions: disgust, shame, distress and fear. The subscales we found presented, good internal consistency with alpha values ranging from 0.87 to 0.96 for the subscales and 0.92 for the total scale. Satisfaction measure In order to verify the measures one-dimensional character we developed a PCA with ve composing items. By applying the Kaiser criterion we extracted a single factor that accounted for 71.84 per cent of total variance with a Cronbach alpha of 0.90, thus conrming our global satisfaction scales one-dimensionality hypothesis. Satisfaction expectation scale Three items composing this measure revealed a high Cronbach alpha of 0.88. Structural model Following Anderson and Gerbings (1988) recommendations regarding Structural Equation Modelling, we started with the measurement model factorial structure analysis as well as its adjustment to data, in order to validate the latent variables. In a second phase, the hypothesized model was evaluated. The measurement model was estimated without mistakes or warnings (from the program built in control processes) and presented good t indices. However, imposing two co-variances has shown to improve the t indices (x2 106:89, df 51, p , 0.001, IFI 0:99; TLI 0:99,
Components Shame Distress 0.03 0.12 0.14 0.18 0.12 0.16 0.18 0.25 0.39 0.40 0.81 0.83 0.85 0.66 17.60 78.28 0.96 0.87 0.92 0.89 0.90 0.77 0.84 0.79 0.27 0.24 0.11 0.10 0.22 0.20 0.24 0.22 0.27 0.16 -0.25 15.57
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Items Downhearted Sad Discouraged Feeling of distaste Disgusted Feeling of revulsion Contemptuous Scared Fearful Afraid Sheepish Bashful Shy Guilty % Of explained variance (with rotation) % Of explained variance (with rotation) Factor internal consistency (Cronbach alpha) Factor internal consistency all items (Cronbach alpha)
Disgust 0.08 0.23 0.27 0.86 0.86 0.85 0.84 0.37 0.29 0.21 0.13 0.08 0.09 0.34 31.23
Fear 0.33 0.19 0.07 0.16 0.19 0.30 0.37 0.73 0.72 0.74 0.27 0.24 0.21 0.19 13.88
Table II. Negative emotions factor structure: rotated component matrix (Varimax)
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CFI 0:99 and RMSEA 0:052). As the measurement model revealed good t, indicating that latent variables were actually depicting different constructs, we proceeded to analyse the structural model (that integrates the measurement model) and the causal relations between the variables that depicted the hypotheses under analysis. Results showed that the structural model has good t (x2 134:46, df 54, p , 0.001, IFI 0:99; TLI 0:99, CFI 0:98 and RMSEA 0:061). All estimated parameters were signicant. Figure 2 presents the estimated structural model with the respective parameter values. The estimated structural model corroborated our hypotheses. Results showed that the model explains 61 per cent of the satisfaction variance (R 2 0:61). The predictors we considered had a direct effect on patient satisfaction. The perceived service quality,
Figure 2. Estimated structural model
the expectation and the emotions (especially the positive ones) all predicted satisfaction. Expectations had a direct effect (b 0:37, p , 0.001) and an indirect effect (b 0:12, p , 0.001). The involvement also had a direct effect on satisfaction (b 0:15, p , 0.001) and an indirect effect (b 0:28, p , 0.001). We thus veried that positive and negative emotions were partially mediating the effect of expectations and involvement on satisfaction. Conclusions and recommendations In our initial discussion, we considered that the service quality construct is multidimensional. We departed from the assumption that this multidimensionality was equivalent to ve quality dimensions proposed by Parasuraman et al. (1988): reliability, responsiveness, assurance, empathy and tangibles. However, considering several studies developed by other researchers, we acknowledged that these dimensions lacked stability as well as the possibility that variations may occur depending on the characteristics of each service. This phenomenon is surely related to the required modications made in the original instrument in order to adapt it to the specic type of service as Parasuraman et al. (1991) acknowledged. These modications may have, somehow constrained the possibility of replicating the study and, therefore, lowered the likelihood of nding similar results. In our study, SERVQUAL was minimally altered to guarantee its adaptation to Portuguese public healthcare centres context, considering that the evaluations done by individuals should comprise a multiplicity of levels (the organizations and the individuals) as well as a multiplicity of service providers (physicians, nurses, auxiliary staff, administrative staff) and consequently, a multiplicity of events of service and interactions. From the PCA we identied four dimensions: Reliability, Physicians assurance, Employees assurance and Tangibles. Regarding the dimensions proposed by Parasuraman et al.(1988), two dimensions were clearly kept: reliability and tangibles. The remaining two dimensions seemed to be specic to this type of service, as they relate directly to the service providers occupational level: physicians aggregate Assurance and Empathy dimensions for this professional group and all the other occupations aggregating respective items from Assurance dimension. As Sureshchandar et al. (2002) highlighted, the interaction/intervention elements importance has been acknowledged by many researchers. Service quality measures have shown that with the exception of physical elements, all the remaining measures refer to the human element linked to service performance. This study provides further support for the idea that service quality construct dimensions vary (Vinagre and Neves, 2002) and that it is necessary to adopt a contingency approach in which the number of dimensions varies according to, among others, the type of the service. We believe that this approach is preferable to the idea of the ve-factor universal structure present in the SERVQUAL scale. As predicted, given the healthcare services credential, patients have no skill to evaluate exactly the services technical reliability, so the interaction dimensions gained greater saliency: assurance and empathy with the physician, assurance with the nursing and auxiliary staff. This result is also consistent with Donabedians (1980, 1989) statement that patients often are in no position to assess care process technical quality and they are sensitive to interpersonal relationships.
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The scale used to evaluate the emotional experience appears valid. The pattern of emotions associated with service experience showed the coexistence of diverse emotions linked to the service experience. Results also supported the process complexity that leads to satisfaction with a service, which involves diverse phenomena within the cognitive and emotional domain. Our study highlights the importance of relational and emotional aspects in patient satisfaction. Satisfaction also varied with the involvement seen as the importance level of the service to the patients. The higher the individual involvement, higher the tendency to feel satised with the service provided. The involvement also had a direct and signicant effect on emotions: the more important the service is to the individuals the higher the number of positive emotions and the lower the number of negative emotions they experience. Expectations also have a direct effect on emotions: the higher the expected satisfaction the more individuals tend to experience positive emotions and, the less they tend to experience negative emotions. These results support the assimilation effect of expectations. Therefore, the results showed that individuals experience pleasant or unpleasant emotional states following expected levels of satisfaction, operating like a self-fullling prophecy. Our study highlighted the effect of emotions, mainly positive ones, on the patients satisfaction. From a management view point, one should keep in mind that besides seeking to provide high standards in terms of service quality, it is necessary to take into account relational aspects between the service provider (physicians, nurses and auxiliary) and the patients and the goodness of interpersonal skills in patient patients satisfaction (Donabedian, 1980). Even when performance is perceived as high quality, satisfaction levels may be affected if the providers of these services disregard the patients emotions and if, consequently, they do not know how to manage those emotions. Some limitations have to be considered in our study. The emotions inventory we used, although showing good internal consistency, is not extended to typologies proposed by other authors. Future research could develop the idea of dimension variability regarding the service quality dimensions and test whether emotions experienced in specic service contexts (e.g., more or less qualied, a more open or closed transaction, greater or lesser degree of involvement) are also operating within these dynamics.
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Sureshchandar, G.S., Rajendran, C. and Anantharaman, R.N. (2002), Determinants of customer-perceived quality: a conrmatory factor analysis approach, Journal of Services Marketing, Vol. 16 No. 1, pp. 9-34. Surprenant, C.F. and Solomon, M.R. (1987), Predictability and personalization in the service encounter, Journal of Marketing, Vol. 51, pp. 86-96. Ting, D.H. (2004), Service quality and satisfaction perceptions: curvilinear and interaction effect, International Journal of Bank Marketing, Vol. 22 No. 6, pp. 407-20. Vandamme, R. and Leunis, J. (1992), Development of a multiple-items scale for measuring hospital service quality, International Journal of Service Industry Management, Vol. 4 No. 3, pp. 30-49. Verbeke, W. and Bagozzi, R.P. (2000), Sales call anxiety: exploring what it means when fear rules a sales encounter, Journal of Marketing, Vol. 64 No. 3, pp. 88-101. Vinagre, M.H. and Neves, J.G. (2002), Medicao da qualidade de servicos em autarquias locais, in Colibri (Ed.), Percursos da investigacao em Psicologia Social e Organizacional, Vol. 1, Lisboa, pp. 271-90. Westbrook, R.A. (1987), Product/consumption-based affective responses and post-purchase processes, Journal of Marketing Research, Vol. 24, pp. 258-70. Westbrook, R.A. and Oliver, R.L. (1991), The dimensionality of consumption emotion patterns and consumer satisfaction, Journal of Consumer Research, Vol. 18, pp. 84-91. Wisniewski, M. and Wisniewski, H. (2005), Measuring service quality in a hospital colposcopy clinic, International Journal of Health Care Quality Assurance, Vol. 18 Nos 2/3, pp. 217-28. Wright, B.E. (2007), Public service and motivation: does mission matter?, Public Administration Review, Vol. 67 No. 1, pp. 54-64. W So, D. (2002), Acupuncture outcomes, expectations, patient-provider relationship, and the placebo effect: implications for health promotion, American Journal of Public Health., Vol. 92 No. 10, pp. 1662-7. Zaichkowsky, J.L. (1985), Measuring the involvement construct, Journal of Consumer Research, Vol. 12, pp. 341-52. Zeithaml, V.A., Parasuraman, A. and Berry, L.L. (1990), Delivering Quality Service: Balancing Customer Perceptions and Expectations, Free Press, New York, NY. Corresponding author Maria Helena Vinagre can be contacted at: helenavinagre@gmail.com
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The relative importance of service dimensions in a healthcare setting

Rooma Roshnee Ramsaran-Fowdar
Faculty of Law and Management, University of Mauritius, Reduit, Mauritius
Abstract
Purpose The paper aims to focus on an augmented SERVQUAL instrument that was used to measure private patients service expectations and perceptions. Design/method/approach A questionnaire was administered to 750 and 34 per cent responded. Findings A new service quality instrument called PRIVHEALTHQUAL emerged from the study, based on factor and reliability analysis. The reliability and fair and equitable treatment factor was found to be the most important healthcare service quality dimension. Originality/value Adds to the existing body of research on service quality and demonstrates that SERVQUAL is not a generic service quality measure for all industries. Keywords Health services, Private hospitals, Service levels, Mauritius Paper type Research paper
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Received 28 November 2006 Revised 23 April 2007 Accepted 12 May 2007
Introduction Ensuring services benet not only patients but also healthcare providers are important. Patients who perceive they are content with services are likely to exhibit favourable behavioural intentions that are benecial to the healthcare providers long-term success. Zeithaml and Bitner (2000) described how customers express such intentions in positive ways: . praising the rm; . preferring the company over others; . increasing their volume of purchases; or . agreeing to pay a price premium. Retaining customers may be more protable than attracting new ones. Clancy and Schulman (1994) calculated the cost of attracting new customers to be approximately ve times that of keeping current customers happy. On the other hand, customer dissatisfaction may lead to unfavourable behavioral intentions such as negative word-of-mouth, doing less business or switching to alternative service providers. Therefore, healthcare providers have much to gain if they can understand what patients expect since this assists them by serving their patients better and building long-term relationships. If a healthcare service provider is to maintain itself as a viable entity in todays competitive market then great care must be taken to not only identify patients needs and wants but also ensure that these needs and wants are satisfactorily met. Human needs are states of felt deprivation such as physical needs for food, clothing and safety, social needs for belongingness and affection and individual needs
for knowledge and self-expression. Wants are the form taken by human needs as they are shaped by culture and individual personality. Exactly what are consumers needs and wants in a healthcare context? By and large, healthcare can be considered a credence good an offering that consumers will never be able to evaluate owing to a lack of medical knowledge (Bloom and Reeve, 1990). Given healthcares credence, patients are likely to look for cues or signals that are redolent of treatment quality they are likely to receive (or do receive) from a provider. Ofce aesthetics, staff appearance, relationship between patient and doctors and the punctuality of appointment among others may be medical care quality indicators. These service quality surrogate indicators can be used by patients to assess service provider efcaciousness. The most widely accepted measurement scale for service quality is SERVQUAL (Parasuraman et al., 1988), which consists of ve essential service quality dimensions: (1) tangibles; (2) reliability; (3) responsiveness; (4) assurance; and (5) empathy. Within each dimension there are several items (22 in total) measured on a seven-point scale from strongly agree to strongly disagree. Although SERVQUAL proved to be a robust service quality measure, it has been subject to criticisms conceptually and methodologically (Babakus and Mangold, 1989; Brown et al., 1993; Carman, 1990; Cronin and Taylor, 1992; Spreng and Singh, 1993; Teas, 1993a, 1993b). One of these criticisms is SERVQUALs inappropriateness as a generic measure for all service settings. There is research that service quality is contingent upon service type (Babakus and Mangold, 1989). Since SERVQUAL was generated outside healthcare and has limited examination in the healthcare literature, additional research is necessary to gauge its applicability to healthcare services. Specically, there is a need to test if SERVQUAL is a comprehensive patient evaluation of healthcare service quality measure or if additional dimensions are needed. In their popular measuring service quality framework, Parasuraman et al. (1988) used a single expectation standard, desired expectations as a comparison against which service performance is assessed. Recently, researchers proposed that multi-expectation standard approaches may be more appropriate for service quality models (Boulding et al., 1993; Zeithaml et al., 1993; Parasuraman et al., 1994). This model proposes that service expectations can be separated into an adequate standard and a desired standard (Zeithaml et al., 1993). Between these two expectation levels lies tolerance zones that represent a performance range consumers consider acceptable. It also illustrates the difference between perceived service and desired service known as the Measure of Service Superiority (MSS) and the difference between perceived service and adequate service labeled as the Measure of Service Adequacy (MSA). This framework not only provides better comprehension of the multiple expectations that consumers use in evaluating services but also gives practitioners an opportunity to optimise resource allocation when attempting to meet/exceed customer expectations (Walker and Baker, 2000). However, research on consumers multi-expectations,
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tolerance zones, MSS and MSA is in the exploratory stage. Consequently, private medical services were identied as a suitable study setting to explore professional service quality and its evaluation from the clients perspectives. Private general practitioners (GPs) were selected because they deal with patients on a long-term basis. The Mauritius healthcare system The Republic of Mauritius has a total area of 720 square miles and a population of 1.2 million residents (Central Statistics Ofce, 2003). Compared to other African countries, Mauritius has made remarkable progress addressing citizens healthcare needs. In the past thirty years the average life expectancy has increased from 63 years to 71 years while infant mortality fell from 64 to 14 deaths in the rst year of life for every 1,000 live births. Although Mauritius is doing well, in comparison to developing countries, new measures are needed to improve its performance to reach the levels achieved by places such as New Zealand, Singapore and other developed countries where average life expectancy is above 75 years and infant mortality rates is below seven. One reason for this difference in health status may be the relative level of investment in the health services in different countries. Presently, Mauritius spends about 2.8 per cent of its Gross Domestic Product on health compared to 3.3 per cent in Singapore, 5.9 per cent in Seychelles, 8 per cent in New Zealand, 8.9 per cent in Belgium, 9.8 per cent in France and 13 per cent in the USA (Ministry of Health and Quality of Life, 2002). Mauritian medical care is freely provided by the state and there is also a well-established private sector. The total number of beds in government institutions was 3,716 at the end of 2001; that is, one bed for 315 inhabitants or 3.2 beds per 1,000. The public sector employs over 690 doctors (including about 245 specialists) and around 2,700 nurses. The private sector, which absorbs 32 per cent of the countrys total health expenditure, employs over 400 doctors and provides primary and secondary services in 14 private clinics. The private sector has 588 beds of which 283 are single rooms (Ministry of Health and Quality of Life, 2001, 2002). Healthcare service performance is also relatively low in Mauritius compared to other countries because of stafng differences. Indeed, the number of doctors and nurses employed per 100,000 population in Mauritius is signicantly below that found in countries with better levels of health. At the end of 2001, for instance, there were 1,107 doctors in Mauritius, representing one doctor for every 1,089 inhabitants. The number of doctors registered has declined over the years since these professionals prefer to work overseas where they are better remunerated. Similarly, many nurses have migrated. Given the physician shortage, the government allows public doctors to practise privately as part of its staff retention strategy. Nevertheless, there is a serious demoralisation problem among hospital employees resulting from cumbersome workload, poor remuneration, low working life quality, inability to take initiatives and poor leadership. All impede patient service delivery in the public sector. Often, patients have to wait in long queues in the public hospitals. Consequently, the public healthcare system is perceived negatively by the general population and some people prefer private physicians and services who charge fees ranging from US$6 to US$25 depending on the doctor and his/her medical expertise. People at the bottom of the socioeconomic ladder obviously cannot access paid services. Furthermore, the majority of people consuming private health care services are fully self-paying patients and very few are covered either partially or fully by their private employers or by private
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insurance. Our purpose, therefore, was to conduct empirical research on service quality frameworks. Addressing the major issues discussed above, we seek to accomplish the following specic objectives: . to measure service quality in a private healthcare setting; and . to identify the most important service quality dimension in a healthcare setting. Literature review Different theoretical perspectives on service quality were developed during the 1980 s. Groonroos (1982), for example, distinguished two types of service quality: (1) technical quality refers to core service delivery or service outcome (i.e. what is offered and received); while (2) functional quality refers to service delivery processes or the way in which the customer receives the service (i.e. how the service is offered and received). Technical quality can relate to the surgeons performance, while functional quality may consist of the doctors waiting room, doctors ofce hours and secretarys behaviour. Lehtinen and Lehtinen (1982), on the other hand, discussed three kinds of quality: (1) physical; (2) interactive; and (3) corporate. Physical quality includes structural aspects associated with services such as the reception area, examination room and medical equipment. Interactive quality involves contact between the customer and service personnel. Corporate quality includes image and reputation. From these earlier writings, it can be seen that service quality notions arise from a comparison of what customers feel a seller should offer (i.e. customers expectations) with the sellers actual service performance (Parasuraman, 2000). This idea was supported by exploratory research conducted by Parasuraman et al. (1985) using twelve consumer focus-groups in four industries (banking, credit card, securities brokerage, product repair and maintenance). Topics discussed with focus group members included the meaning of quality in the services context, service quality characteristics and the criteria used by customers when assessing service quality. The study revealed that customers used the same general criteria to arrive at an evaluative judgement regarding service quality. Consequently, Parasuraman et al. (1985) dened service quality as an overall evaluation, similar to but not the same as an attitude, which refers to the degree and direction of discrepancy between customers perceptions and expectations. The researchers also identied two inter-related service quality dimensions, outcome quality and process quality, which correspond to the dichotomy proposed by Gronroos (1982) and to the physical and interactive quality characteristics identied earlier by Lehtinen and Lehtinen (1982). Along the same line, Zeithaml (1988) later dened service quality as the consumers assessment of overall excellence or superiority of the service. Olshavasky (1985) also viewed quality as a form of overall service evaluation similar in many ways to attitude. Parasuraman et al.s. (1985) study was the most extensive research carried out into customer service
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quality perceptions. The 22-item SERVQUAL instrument, developed by Parasuraman and his colleagues, included ve service quality dimensions described above. Parasuraman et al. (1985) dened service quality as the difference between what a service company should offer and what it actually offers or the discrepancy between expectations and perceptions of the service performance. Zeithaml et al. (1990) reported, in their study of credit-card, repair and maintenance, long-distance telephone and retail banking services, that customers rated all ve SERVQUAL dimensions important. Respondents considered reliability as the most important and tangibles the least important dimension. This nding consistently cropped up in other studies such as Zeithaml et al. (1990). In a study of 1936 customers in two banks, two insurance companies and a long-distance telephone company, Zeithaml et al. (1990) reported service reliability as the most critical dimension perceived by customers, followed by responsiveness, assurance, empathy and tangibles. However, other studies (Carman, 1990; Mowen et al., 1993) demonstrated that service encounter situational characteristics such as customers prior experience, time or day of the week or whether customers are given an expectation about waiting time may affect the relative importance of various quality dimensions. Turner and Pol (1995) also reported that quality dimensions are not equally important. They suggest that environment, customers physical or emotional status and other non-medical characteristics can inuence customers service quality perceptions. The SERVQUAL instrument is described by Parasuraman et al. (1991) as a reliable and valid service quality measure with relatively stable dimensions that apply across many service industries. Despite its widespread use, the instrument has been criticised conceptually and methodologically. One main criticism is the applicability of the ve SERVQUAL dimensions to different service settings. That is, replication studies by other investigators failed to support the ve-dimensional factor structure obtained by Parasuraman et al. (1988). For example, Groonroos (1982) conceptualised service quality as a two dimensional construct comprising technical and functional quality. On the other hand, Lehtinen and Lehtinen (1982), dened service quality as three constructs: interactive, physical and corporate quality. McDougall and Levesques (1994) study also did not support Parasuraman et al.s (1985) ve service quality dimensions. They revealed only three underlying elements: tangibles, contractual performance (outcome) and customer-employee relationships (process). Moreover, research indicates the possibility of two public utility sector dimensions (Babakus and Boller, 1992) and up to nine (Carman, 1990) in a dental school patient clinic, business school placement centre, motor care tire centre and acute care hospital, which underpin service quality. Because some service quality determinants are perceived generically, while others are industry- or situation-specic, Babakus and Mangold (1989) argue that SERVQUALs dimensional instability results from the type of service sector under investigation. In Parasuraman et al.s (1985) well-known SERVQUAL model, a single expectation standard, desired expectations (what the consumer feels a service provider should offer) was used as a comparison against which service performance was assessed. Lately, however, some researchers such as (Boulding et al. (1993) and Parasuraman et al. (1993, 1994) suggest that multi-expectation standard approaches may be more appropriate in service quality models. Attempting to capture the essence of various comparison standards, Zeithaml et al. (1993) pooled insights from past expectation
conceptualisations with ndings from a multi-sector focus-group study to develop an integrative customers service expectation model. This service quality framework combines adequate, desired and predicted expectations along with perceived performance. The new model separates expectations into an adequate standard (which is inuenced by predicted expectations) and a desired standard that customers use to evaluate service quality. A desired service is dened as the level representing what customers hope to receive or a combination of what customers believe can be and should be provided. However, most customers are realistic and understand that company staff cannot always deliver the preferred service level. Hence, customers also have an expectation threshold, termed adequate service, or the minimum level of service customers are willing to accept without dissatisfaction. Separating these two expectation levels is a tolerance zone that represents a service performance range a customer would consider satisfactory. A performance below the tolerance zone (or below the adequate service level) will engender customer frustration and dissatisfaction and decrease customer loyalty (competitive disadvantage). A performance level above the tolerance zone (or above the desired service level) will surprise and create customer delight and strengthen their loyalty (customer franchise), (Berry and Parasuraman, 1991). On the other hand, customers will be satised if performance falls within their tolerance zone (competitive disadvantage). In other words, the tolerance zone is a service range within which customers do not pay explicit attention to performance. The tolerance zone thus not only improves multiple expectation comprehension that consumers may use in service evaluations but also provides practitioners better opportunities to optimise resource allocations in their continual attempt to meet or exceed customer expectations (Walker and Baker, 2000). Moreover, Parasuraman et al. (1994) found that tolerance zone measures had convergent and predictive validity. Convergent validity is the extent to which the scale correlates positively with other measures of the same construct. Predictive validity is assessed by comparing data on the scale at one point in time and data on the criterion at a future point in time. If the correlation between two measures is high then the initial measure is said to have predictive validity. The tolerance measures were also less susceptible to response errors compared to single expectation measures. Additionally, the tolerance zone provides detailed and probably more accurate managerially diagnostic information and thus better strategy decisions (Teas and DeCarlo, 2004). The latest SERVQUAL modication, therefore, incorporates this expanded expectation conceptualisation. For each SERVQUAL attribute, three values (on a nine-point scale) are measured: (1) customers desired service level; (2) service level adequacy; and (3) a specic companys perceived service. As mentioned earlier, Parasuraman et al. (1994) modied SERVQUALs structure to capture the MSS and MSA gaps. They also developed three alternative service quality measurement formats among which the three-column format seemed most useful and demonstrated where appropriate improvement efforts should be made if identifying critical service deciencies is the principal objective. The three-column format (Table I) involved obtaining separate desired, adequate and perceived service ratings using
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When it comes to. . . 1 2 3 4 5 6 7 8 9 1
Modern-looking equipment
Table I. Three-level format Column 3 My perception of XYZs service My minimum service level is: My desired service level is: performance: Low High Low High Low High No opinion 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 N Column 1 Column 2
three identical, side-by-side scales. The perceived desired and perceived adequate differences were used to calculate MSS and MSA respectively. The perception-only ratings (Column 3) were found to have the most predictive power. Parasuraman et al. (1994) concluded that if the primary goal was to maximise the variance explained in overall service ratings then the perceptions-only scale appeared to be the best. However, one practical problem with the three-column format is that it calls for three separate ratings that respondents may nd more time-consuming. Healthcare sector service quality Previous SERVQUAL tests in health care settings yielded mixed ndings. Babakus and Mangold (1992) found the instrument reliable and valid in hospitals. Bowers et al. (1994), on the other hand, reported two major additional dimensions not captured by SERVQUAL: caring and patient outcomes. The caring dimension implied a personal, human involvement, with emotions approaching love for the patient and an outcomes dimension that included pain relief, life saving, anger or disappointment with life after medical intervention. On the other hand, research conducted by Haywood-Farmer and Stuart (1988) suggested that SERVQUAL was inappropriate for measuring professional service quality since it excluded core service, service customisation and knowledge of the professional dimensions. Additionally, Brown and Swartz (1989) identied professional credibility, professional competence and communications as factors signicant for both physicians and patients in service quality evaluation. Peyrot et al. (1993) separated service attributes into three factors using factor analysis: (1) staff behaviour (friendliness, helpfulness, explanation); (2) pre-examination comfort (e.g. waiting room, waiting time, user-friendly forms); and (3) examination comfort (physical comfort and time in the examination room). Using principal components analysis and Varimax rotation, Gabott and Hogg (1994) reported six factors that affect consumer satisfaction: (1) service range (e.g. specialists, facilities for disabled); (2) empathy (e.g. receptionists manner, bedside manner, home visits); (3) physical access (e.g. parking, access by public transport; appointment time convenience); (4) doctor specic (e.g. age, sex, number of doctors); (5) situational (e.g. waiting room facilities, decoration); and (6) responsiveness (time spent with doctor and time spent in waiting room). A GP (1) (2) (3) (4) satisfaction study by Drain (2001) yielded four factors: care provider; access to care; ofce visit; and personal issues.
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Dean (1999) identied four stable dimensions using SERVQUAL to compare service quality dimensions in two different healthcare settings (medical centre, maternal and child health centres): (1) assurance; (2) tangibles; (3) empathy; and (4) reliability and responsiveness. Loaded together these dimensions accounted for approximately 68 per cent of the variance in both settings. Kilbourne et al.s (2004) study also showed that SERVQUAL captures service quality multidimensionality: . tangibles; . responsiveness; . reliability and empathy; as well as an . overall (second order) service quality factor. Recently, using factor analysis, Morrison et al. (2003) identied ve main service attributes that explain peoples GP service preferences: (1) communication; (2) doctor-patient relationship; (3) same gender as the patient; (4) advising; and (5) empowering patients to make decisions. However, few studies including Babakus and Mangold (1992), Lam (1997) and Taylor (1994a, 1994b) reported that SERVQUAL was a consistent and reliable one-dimensional scale. Therefore, research indicates that perceived service quality is contingent upon service type, which implies that one generic service quality measure is inappropriate for all services. In short, studies show that SERVQUAL does not cover all healthcare services dimensions that are important to patients. However, there has been limited recent published work on service quality dimensionality after the mid 1990s. Most important dimension in healthcare service quality In many quality studies the reliability dimension the ability to perform services dependably and accurately stands out as the most important customer service quality perception determinant. A different argument is proposed for consideration in a healthcare environment, however. Although Berry and Parasuraman (1991) argued that the SERVQUAL reliability dimension is the outcome of service performance representing the core service, it is believed that the core medical outcome is not part of the reliability dimension and represents the most important criterion patients look for when visiting a GP. Therefore, it is hypothesized that: H1. Core outcome is the most important healthcare service quality dimension.
Method We used a cross-sectional quantitative research design. Our questionnaire was designed taking preliminary considerations such as the research questions, hypothesis, target respondents, response format, question wording and questionnaire sequence into consideration (Kinnear and Taylor, 1996). Consequently, our questionnaire consisted of three sections: (1) Section A included 47 statements on different aspects of GP services. Respondents circled the appropriate number on a seven-point scale from Low (1) to High (7). Their choice best reected their desired and minimum service level expectations, and their GP service ratings. (2) Section B consisted of a question that measured respondents overall service quality evaluation. (3) Section C covered respondent demographics, including gender, age, ethnicity, address, occupation, education level, marital status, monthly household income and private healthcare payment mode. Our modied SERVQUAL-type questionnaire for use in the healthcare sector was constructed by retaining some items from the updated SERVQUAL dimensions: tangibles; reliability; responsiveness; empathy and assurance from Parasuraman et al. (1994). Selected items were rened and paraphrased in both wording and contextual applications as appropriate to suit our research purposes. Next, after carrying out in-depth interviews on healthcare quality with patients, each item investigated was checked once again before verbally and structurally being changed to reect our research needs. The in-depth interviews were conducted with twelve patients over a period of three weeks to probe their needs and the benets they hoped to obtain from private GPs. A convenience sample was used by choosing people working at the Mauritius University, their friends and other associates. Respondents were chosen to achieve age, gender, residence, occupational status, personal income and marital status diversity. Respondents were subjected to a set of open-ended questions on their quality perceptions of services provided by private GPs. Detailed notes were taken during interviews and these were eventually compiled into a report. All items were phrased positively as suggested by Parasuraman et al. (1994). All service quality items were ordered alphabetically to later identify the underlying quality dimensions and those items that are highly related to the same dimension using factor analysis. Parasuraman et al.s (1994) three-column format was used with three identical desired, adequate and perceived service scales. These scales add strong diagnostic value and the three-column format possesses comparable reliability and validity to other formats studied. Additionally, the 47 service quality items measured on a seven-point scale from low to high, respondents were asked to rate the overall quality of GP service on a seven-point Likert scale. This separate question for measuring overall service quality using the average measured gap helped to measure multi co-linearity, and used the regression purposes. The list below summarises the questionnaires 47 service quality items. Service quality questionnaire items (1) Ability to get an appointment at a convenient time to me. (2) Appealing materials such as pamphlets, magazines, newspapers, posters and so on.
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(3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19) (20) (21) (22) (23) (24) (25) (26) (27) (28) (29) (30) (31) (32) (33) (34) (35) (36) (37) (38)
Availability of prescribed medicines at the pharmacy. Careful diagnosis of the patients problems. Convenient hours of operation. Convenient clinic location. GP accessibility at odd hours in case of emergencies. GP accessibility by phone. Maintaining accurate and neat records of the patients medical history. Modern medical equipment. Physician compliance with hygienic and other precautions. Physician reputation. Prescription of affordable medicines. Professional appearance/dress of the GP. Professional appearance/dress of the support staff. Prompt service without an appointment. Punctuality of appointment. Reliability in handling the patients problems. Uniform fees and other charges for all patients. Visually attractive and comfortable physical facilities (e.g. waiting room, chairs, tables and amenities). Willingness to help patients. Ability of GP to inspire trust and condence in patient. Ability of support staff to inspire trust and condence in patient. Clear display of GPs qualications. Courteous and friendly doctor. Courteous and friendly support staff. GP having patients best interest at heart. GP making patient feel good emotionally and psychologically. GPs emphasis on patient education. GPs emphasis on prevention of health problems. GPs familiarity with latest advances in medical eld/products. GPs medical qualications. GPs readiness to respond to the patients questions and worries. GPs willingness to listen carefully to patients. Highly experienced GP. Honesty and integrity of physician. Knowledgeable and skilled GP. Knowledgeable and skilled support staff.
(39) (40) (41) (42) (43) (44)
Maintenance of patient condentiality. Personal conduct and manners of the GP. Physicians willingness, if necessary, to refer the patient to a specialist. Physicians making patients feel safe and relaxed during their visits. Positive medical outcome of treatment. Quality of GPs referral contacts (i.e. contacts with specialists, hospitals, pharmacies, laboratories). (45) Reassuring the patient about the recovery. (46) Remembering names and faces of patients. (47) Thoroughness of explanation of medical condition and treatment. Sample The study population was dened as all patients 18 years or older and who had visited a private GP at least once within the past year for their own or family needs. This allowed recollections of their visit experience in order to be able to remember and answer the purchase and post-purchase situations and feelings appropriately. We used a convenience sample. A total of 750 questionnaires were distributed and administered in two stages. First, 600 questionnaires in batches of two were distributed to Mauritius University undergraduate and postgraduate students. Questionnaires were also sent to workplaces, schools, families and friends. The latter were instructed to administer the questionnaires to one male and one female (since the 2000 census enumerated the sex ratio at all ages to be 981 males per 1,000 females (Central Statistics Ofce, 2003). They were asked to ensure that each was an immediate family member, neighbour, other relative or associate. Respondents must also have visited a private GP during the preceding year and be over 18 years of age. Second, 150 questionnaires were hand-delivered to the receptionists in ve randomly selected private GPs. Completion instructions were given to each receptionist. They were requested to ask visiting patients to ll in the questionnaire when waiting for the doctors consultation. Completed questionnaires were then collected by the researcher over a period of two months. Thus, every attempt was made to randomise the data collection process. Owing to the relatively large University and other contact commuter base, the sample was considered to represent the population and was large enough to accommodate the number of variables in the study as well as cell sizes involved. Response rate From 750 questionnaires distributed over a period of ve months in 2003, a total of 260 were completed and returned. Of these, three were omitted from our data analysis owing to incomplete or missing information a nal response rate of 34 per cent. Sommers (1999) reports that for scientic validity, a survey must achieve a rate of response that includes at least 30 per cent of the patients whose opinion was sought. Moreover, our 34 per cent response bettered the Mauritian 15-25 per cent national response-rate average. Basilevsky (1994) and Hair et al. (1999) suggest that, as a rough guideline, there should be at least four or ve times as many observations (sample size) as there are variables. Since there is a maximum of 47 items, a sample size of 188 to 235 respondents would have been appropriate. Therefore, the response rate achieved was
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considered adequate for the study. The resulting respondent prole was deemed to be encompassing and fairly well distributed. Table II provides a summary of the respondents demographics. Data analysis We examined dimensionality using factor analysis. Factor structure reliability was tested for internal consistency after items were grouped. Raw data were initially organised into MSS and MSA. Both MSS and MSA scores from 47 service quality items were factor analysed using Parasuraman et al.s (1994) recommendation. In the initial stage of factor extraction, principal component analysis was used to extract the maximum variance from our data. The Varimax rotation technique, with maximum likelihood method, was chosen for our factor analysis second stage. Factor rotation maximises the loadings variance on each factor thus minimising factor complexity (Tabachnick and Fidell, 1989). Only factors with Eigenvalues greater than one were retained and a decision rule of factor loadings in excess of 0.40 was considered. To test instrument scale validity, a regression analysis was performed to assess the questionnaires convergent and predictive properties. Three different regressions were done. Overall service quality ratings were used as the dependent variable, while MSS (sum of MSS means of 44 service statements retained from MSS construct divided by 44), MSA (sum of MSA means of all 46 service statements retained from MSA construct divided by 46) and perceptions-only ratings (overall) from the dimension factor means were used as independent variables. Results are illustrated in Table III. Findings and discussion Table III shows that the perceptions-only scale had higher R 2 value than the other two measures, empirically supporting the superior predictive power of this scale compared to the difference-score measures (Babakus and Mangold, 1992; Cronin and Taylor, 1992; McDougall and Levesque, 1994). Although MSS and MSA scores produced fairly low R 2 values, it does not mean that these constructs are unrelated to overall service quality. There could be a nonlinear relationship between them that is not captured by R 2. According to Table III, MSS scores explained 19.3 per cent of the variation in overall service quality and MSA scores 9.8 per cent. We can, therefore, conrm the service quality scales convergent and predictive validity. A comparison of two possible formats is needed to determine which should be used to decide the factor structure for further analysis. Table IV summarises two factor analysis results derived from MSS and MSA scores based on: . the total variation explained; . eigenvalues; and . Cronbach alphas. Based on the total variance explained, the factors derived from the MSA construct were slightly superior to the MSS score format. Comparing individual factor Eigenvalues revealed that results were relatively equivalent. The same conclusion was reached when comparing the Cronbach alphas. Nevertheless, MSS scores explained the item loadings in a better and sound conceptual way. Moreover, MSS convergent and predictive validity were superior compared to the MSA format (Table IV) by the higher R 2. Therefore, the MSS format was found to be superior.
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Frequency Gender Male Female Age 18-29 years old 30-49 years old 50 to 64 years old 65 years or older Ethnic group Hindu Muslim Chinese Other Place of residence Rural region Urban region Occupational status Unemployed/student/housewife/retired Clerical/factory worker/and other white collar jobs Executive/managerial/professional (teacher, lawyers, doctors, etc.) Self-employed Others Highest level of education completed CPE (cert. of primary education) O level/SC A level/HSC/diploma Degree Postgraduate Others Marital satus Single Married without children Married with children Widowed/divorced/separated Gross monthly household income Below Rs 10,000 Rs 10,001-20,000 Rs 10,001-20,000 Rs 30,001-40,000 Rs 40,001-50,000 Above Rs 50,000 Mode of payment for private healthcare Fully self paying patient Self-paying patient through private insurance Self-paying patient covered partially by employer Self-paying patient covered fully by employer 128 129 133 83 38 3 157 41 23 36 113 144 105 66 62 16 8 10 52 131 45 18 1 126 29 94 8 88 114 31 14 8 2 187 21 39 10
% 49.8 50.2 51.8 32.3 14.8 1.1 61.1 16.0 8.9 14.0 44 56 40.9 25.7 24.1 6.2 3.1 3.9 20.2 51.0 17.5 7.0 0.4 49.0 11.3 36.6 3.1 34.2 44.4 12.1 5.4 3.1 0.8 72.8 8.2 15.2 3.9
Table II. Respondents demographic prole
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Proposed service quality scale for private healthcare Table V compares service quality dimensions generated from the MSS format we used with Parasuraman et al.s (1988) SERVQUAL dimensions. From our comparisons it can be said that an augmented and modied SERVQUAL instrument can be used in a private healthcare context. Although some dimensions were relatively equivalent, there were two additional dimensions with high Eigenvalues and Cronbach alphas, which largely explain the total variance: Core Medical Services/Professionalism/Skill/Competence and Information Dissemination, which were obtained using factor and reliability analyses on data from private healthcare settings. Fairness and treatment equity was also associated to the reliability dimension. Consequently, we named our new service quality instrument PRIVHEALTHQUAL. Our study adds to the large body of service quality research, which demonstrates that SERVQUAL is not a service quality generic measure for all industries. We also show a need to examine current tools that measure service standards in the professional services domain. Moreover, our study provides evidence that expectations drive service quality diagnostic evaluations by consumers and, therefore, managers should not continue to ignore consumer expectations. Clearly, an understanding of both adequate and desired expectations is necessary to avoid service shortfalls and achieve better resource allocations. One way to test core outcome ` dimension importance (vis-a-vis other service quality dimensions) is to examine its
Independent variable used Table III. Proportion of variance in overall service quality (dependent variable) Perceptions-only (overall) MSS (overall) MSA (overall)
R2 0.340 0.193 0.098
Adjusted R 2 0.337 0.189 0.094
F 102.092 47.294 21.545
df 1 1 1
Sig. 0.000 0.000 0.000
MSS format 63.7% Total variance explained Dimensions Assurance/empathy Core medical services/professionalism/ skill/competence Responsiveness Responsiveness/tangibility Tangibility/image Image/fair and equitable treatment Reliability/fair and equitable treatment Reliability Equipment and records Information dissemination No. of items 13 8 9 4 Eigenvalues 6.2 6.1 4.9 4 Cronbach Alpha 0.95 0.91 0.87 0.76 4 5 2 2 4.2 1.8 1.5 0.81 2 0.75 0.72 No. of items 19 5 15
MSA format 65.4% Eigenvalues 9.2 4 7.6 3.4 3.6 Cronbach Alpha 0.97 0.9 0.94 0.8 0.72
Table IV. Comparison between MSS and MSA score formats
SERVQUAL dimensions 1. Tangibility physical facilities, equipment and appearance of personnel
Service quality dimensions in private healthcare (PRIVHEALTHQUAL) 1. Tangibility/image physical facilities, image and appearance of GP Reliability/fair and equitable treatment ability to perform the service dependably, accurately, fairly and equitably Responsiveness willingness to help customers and provide prompt service Assurance/empathy the ability of the physician and staff to inspire trust and condence and courtesy displayed by the physician; caring, individualised attention provided to patients by physicians Core medical services/ professionalism/skill/ competence the central medical aspects of the service: appropriateness, effectiveness and benet to the patient; knowledge, technical expertise, amount of training and experience Equipment and records physical equipment used by physician and accurate records of medical history Information dissemination provision of information by physician
2.
2 Reliability ability to perform the expected service dependably and accurately
3.
Responsiveness willingness to help customers and provide prompt service
3.
4.
4. Assurance courtesy and knowledge of staff and their ability to inspire trust and condence
5.
Empathy caring, individualised attention provided to customers
5.
6.
7.
Table V. SERVQUAL Dimensions versus service quality dimensions generated from factor and reliability analyses
correlation with a global measure of service quality and satisfaction. The Pearson product-moment correlation coefcient (r) indicates the degree that quantitative variables are linearly related in a sample. The signicance test of r evaluates whether there is a linear relationship between two variables in the population. The square of the correlation gives the proportion of criterion variance that is accounted for by its linear relationship with the predictor. Here, we shall use the PRIVHEALTHQUAL scale derived from the MSS scores. Table VI lists the results.
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MEDETAN Pearson correlation Sig. (two-tailed) n Pearson correlation Sig. (two-tailed) n Pearson correlation Sig. (two-tailed) n Pearson correlation Sig. (two-tailed) n Pearson correlation Sig. (two-tailed) n Pearson correlation Sig. (two-tailed) n Pearson correlation Sig. (two-tailed) n
What is your evaluation of the overall service quality you receive from your GP? 0.097 0.122 255 0.247 * 0.000 255 0.098 0.119 255 0.210 * 0.001 255 0.213 * 0.001 255 0.175 * 0.005 255 0.100 0.113 255
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MEDEREL
MEDERES
MEDEASS
MEDECORE
MEDEEQUI Table VI. Correlations between service quality dimensions, overall service quality evaluation and satisfaction
MEDEINFO
Note: * Correlation is signicant at the 0.01 level (two-tailed)
From Table VI, we conclude that core outcome is not the most important dimension in health care service quality. In fact, the dimension Reliability/Fair and Equitable Treatment is the most important, followed by the core outcome, assurance/empathy and equipment and records dimensions. Hypothesis H1 given earlier, therefore, is not supported consistent with many studies including Zeithaml et al. (1990), Berry and Parasuraman (1991). Reliability includes careful diagnosis of the patients problems, GPs medical qualications, and physicians willingness to refer patients to a specialist if necessary. However, a new dimension Fair and Equitable Treatment, consistent with Sureshchandar et al.s (2002) and Hellier et al.s (2003) studies, was associated with the Reliability dimension. This new dimension included items such as uniform fees and other charges for all patients. This reected patients views that everyone should be treated alike by their GP. Our study supports Carmans (1990) argument that SERVQUAL scale items/dimensions need to be modied to suit particular industry settings. Consequently, we suggest that seven service quality dimensions are applicable to private healthcare. Thus, our research adds to the large body of previous research on service quality, which demonstrates that SERVQUAL is not a generic service quality measure for all industries and that reliability is the most important dimension in a healthcare context.
Recommendations A number of issues limit our ndings generalisabilty. The sample, for instance, consisted of university students, their friends and relatives, patients and their friends and neighbours at a few private GPs medical clinics. There is a risk, therefore, that our sample might not represent the population served by private Mauritian GPs. However, a counterargument is that our sample was geographically spread since university students came from all over the island. Therefore, results might be generalized for the whole island. Nevertheless, our reesults may not be replicable outside Mauritius in that patients cultures, private GP practices abroad and other factors including the healthcare system are likely to be different. The sample size (257 usable responses) can be argued to be moderate. However, this number more than satised the criterion laid out by Basilevsky (1994) and Hair et al. (1999). Another limitation is that a longitudinal study would provide greater diagnostic value than our cross-sectional design. Changes in perceptions and expectations could thus be tracked over time. This research was also limited to the Mauritian private healthcare sector. Further research, therefore, could also focus on studying other service settings.
References Babakus, E. and Boller, G.W. (1992), An empirical assessment of the SERVQUAL scale, Journal of Business Research, Vol. 24, pp. 253-68. Babakus, E. and Mangold, W.G. (1989), Adapting the SERVQUAL scale to health care environment: an empirical assessment, in Bloom, P., Weitz, B., Winer, R., Spekman, R.E., Kassarjian, H.H., Mahajan, V., Scammon, D.L. and Leay, M. (Eds), AMA Summer Educators Proceedings: Enhancing Knowledge Development in Marketing, American Marketing Association, Chicago, IL. Babakus, E. and Mangold, W.G. (1992), Adapting the SERVQUAL scale to hospital services: an empirical investigation, Health Services Research, Vol. 26 No. 6, pp. 767-86. Basilevsky, A. (1994), Statistical Factor Analysis and Related Methods: Theory and Applications, John Wiley, New York, NY. Berry, L.L. and Parasuraman, A. (1991), Marketing Services: Competing through Quality, The Free Press, New York, NY. Bloom, P.N. and Reeve, T. (1990), Transmitting signals to consumers for competitive advantage, Business Horizons, Vol. 33, July-August, pp. 58-66. Bowers, M.R., Swan, J.E. and Koehler, W.F. (1994), What attributes determine quality and satisfaction with healthcare delivery?, Health Care Management Review, Vol. 19 No. 4, pp. 49-55. Boulding, W., Karla, A., Staelin, R. and Zeithaml, V.A. (1993), A dynamic process model of service quality: from expectations to behavioural intentions, Journal of Marketing Research, Vol. 30 No. 1, pp. 7-27. Brown, S.W. and Swartz, T.A. (1989), A gap analysis of professional service quality, Journal of Marketing, Vol. 53 No. 4, pp. 92-8. Brown, T.J., Churchill, G.A. Jr. and Peter, J.P. (1993), Improving the measurement of service quality, Journal of Retailing, Vol. 69 No. 1, pp. 127-39. Carman, J.M. (1990), Consumer perceptions of service quality: an assessment of the SERVQUAL dimensions, Journal of Retailing, Vol. 66, Spring, pp. 33-55. Central Statistics Ofce (2003), Housing and Population Census 2000, Ministry of Economic Development, Financial Services and Corporate Affairs, Port-Louis, April.
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Clancy, K.J. and Schulman, R.S. (1994), Breaking the mold, Sales and Marketing Management, pp. 82-4. Cronin, J.J. Jr. and Taylor, S.A. (1992), Measuring service quality: a reexamination and extension, Journal of Marketing, Vol. 56 No. 3, pp. 55-68. Dean, A.M. (1999), The applicability of SERVQUAL in different health care environments, Health Marketing Quarterly, Vol. 16 No. 3, pp. 1-15. Drain, M. (2001), Quality improvement in primary care and the importance of patient perceptions, Journal of Ambulatory Care Management, Vol. 14 No. 2, pp. 30-46. Gabott, M. and Hogg, G. (1994), Uninformed choice, Journal of Health Care Marketing, Vol. 14 No. 3, pp. 28-34. Gronroos, C. (1982), Strategic Management and Marketing in the Service Sector, Swedish School of Economic and Business Administration, Helsinki. Hair, J.F. Jr., Anderson, R.E., Tatham, R.L. and Black, W.C. (1999), Multivariate Data Analysis, 5th ed., Prentice Hall, Upper Saddle River, NJ. Haywood-Farmer, J. and Stuart, F. (1988), Measuring the quality of professional services, in Johnston, R. (Ed.), The Management of Service Operations, Proceedings of the Third Annual International Conference of the UK Operations Management Association, University of Warwick, Coventry. Hellier, P.K., Geursen, G.M., Carr, R.A. and Rickard, J.A. (2003), Customer repurchase intention a general structural equation model, European Journal of Marketing, Vol. 37 Nos 11/12, pp. 1762-800. Kilbourne, W.E., Duffy, J.A., Duffy, M. and Giarchi, G. (2004), The applicability of SERVQUAL in cross-national measurements of health care quality, Journal of Services Marketing, Vol. 18 No. 7, pp. 524-33. Kinnear, T.C. and Taylor, J.R. (1996), Marketing Research: An Applied Approach, 5th ed., Mc-Graw-Hill, New York, NY. Lam, S.K. (1997), SERVQUAL: A tool for measuring patients opinions of hospital service quality in Hong Kong, Total Quality Management, Vol. 8 No. 4, pp. 145-53. Lehtinen, U. and Lehtinen, J.R. (1982), Service quality: a study of quality dimensions, unpublished research report, Science Management Group, Helsinki. McDougall, G.H.G. and Levesque, T.J. (1994), A revised view of service quality dimensions: an empirical investigation, Journal of Professional Services Marketing, Vol. 11 No. 1, pp. 189-209. Ministry of Health and Quality of Life (2001), Ministry of Health and Quality of Life Health Statistics Annual, Ministry of Health and Quality of Life, Port Louis. Ministry of Health and Quality of Life (2002), Ministry of Health and Quality of Life White Paper on Health Sector Development and Reform, Ministry of Health and Quality of Life, Port-Louis. Morrison, M., Murphy, T. and Nalder, C. (2003), Consumer preferences for general practitioner services, Health Marketing Quarterly, Vol. 20 No. 3, pp. 3-19. Mowen, J.C., Licata, J.W. and McPhail, J. (1993), Waiting in the emergency room: how to improve patient satisfaction, Journal of Health Care Marketing, Vol. 13 No. 2, pp. 26-33. Olshavasky, R.W. (1985), Perceived quality in consumer decision making: an integrated theoretical perspective, in Jacoby, J. and Olson, J. (Eds), Perceived Quality, Lexington Books, Lexington, MA.
Parasuraman, A. (2000), Superior customer service and marketing excellence: two sides of the same success coin, Vikalpa, Vol. 25 No. 3, pp. 3-13. Parasuraman, A., Berry, L.L. and Zeithaml, V.A. (1991), Renement and reassessment of the SERVQUAL scale, Journal of Retailing, Vol. 67 No. 4, pp. 420-50. Parasuraman, A., Berry, L.L. and Zeithaml, V.A. (1993), More on improving service quality measurement, Journal of Retailing, Vol. 69 No. 1, pp. 140-7. Parasuraman, A., Zeithaml, V.A. and Berry, L.L. (1985), A conceptual model of service quality and its implications for future research, Journal of Marketing, Vol. 49, Fall, pp. 41-50. Parasuraman, A., Zeithaml, V.A. and Berry, L.L. (1988), SERVQUAL: A multi-item scale for measuring consumer perceptions of service quality, Journal of Retailing, Vol. 64, Spring, pp. 21-40. Parasuraman, A., Zeithaml, V.A. and Berry, L.L. (1994), Alternative scales for measuring service quality: a comparative assessment based on psychometric and diagnostic criteria, Journal of Retailing, Vol. 70 No. 3, pp. 201-30. Peyrot, M., Cooper, P. and Schnapf, D. (1993), Consumer satisfaction and perceived quality of outpatient health services, Journal of Health Care Marketing, Vol. 13 No. 1, pp. 24-33. Sommers, P.A. (1999), Consumer Satisfaction in Medical Practice, The Haworth Press, Binghamton, NY. Spreng, R.A. and Singh, A.K. (1993), An empirical assessment of the SERVQUAL Scale and the relationship between service quality and satisfaction, in Cravens, D.W. and Dickson, P. (Eds), Enhancing Knowledge Development in Marketing, Vol. 4, pp. 1-6. Sureshchandar, G.S., Rajendran, C. and Anantharaman, R.N. (2002), Determinants of customer-perceived service quality: a conrmatory factor analysis approach, Journal of Services Marketing, Vol. 16 No. 1, pp. 9-34. Tabachnick, B.G. and Fidell, L.S. (1989), Using Multivariate Statistics, 2nd ed., Harper Collins Publishers Inc., New York, NY. Taylor, S. (1994a), Waiting for service: the relationship between delays and evaluations of service, Journal of Marketing, Vol. 58 No. 2, pp. 56-69. Taylor, S.A. (1994b), Distinguishing service quality from patient satisfaction in developing health care marketing strategies, Hospital and Health Services Administration, Vol. 39 No. 2, pp. 221-36. Teas, R.K. (1993a), Consumer expectations and the measurement of perceived service quality, Journal of Professional Services Marketing, Vol. 57 No. 4, pp. 18-24. Teas, R.K. (1993b), Expectations, performance, evaluation and consumers perceptions of quality, Journal of Marketing, Vol. 57, pp. 18-34. Teas, R.K. and DeCarlo, T.E. (2004), An examination and extension of the zone-of-tolerance model- a comparison to performance-based models of perceived quality, Journal of Service Research, Vol. 6 No. 3, pp. 272-86. Turner, P.D. and Pol, L.G. (1995), Beyond patient satisfaction, Journal of Health Care Marketing, Vol. 15 No. 3, pp. 45-53. Walker, J. and Baker, J. (2000), An exploratory study of a multi-expectation framework for services, Journal of Services Marketing, Vol. 14 No. 5, pp. 411-31. Zeithaml, V.A. (1988), Consumer perceptions of price, quality and value: a means-end model and synthesis of evidence, Journal of Marketing, Vol. 52, July, pp. 2-22. Zeithaml, V.A. and Bitner, M.J. (2000), Services Marketing: Integrating Customer Focus Across the Firm, 2nd ed., McGraw-Hill, New York, NY.
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Zeithaml, V.A., Berry, L.L. and Parasuraman, A. (1993), The nature and determinants of customer expectations of service, Journal of the Academy of Marketing Science, Vol. 21 No. 1, pp. 1-12. Zeithaml, V.A., Parasuraman, A. and Berry, L.L. (1990), Delivering Quality Service: Balancing Customer Perceptions and Expectations, The Free Press, New York, NY. Further reading Zeithaml, V.A., Berry, L.L. and Parasuraman, A. (1996), The behavioural consequences of service quality, Journal of Marketing, Vol. 60, pp. 31-46. Corresponding author Rooma Roshnee Ramsaran-Fowdar can be contacted at: rooma@uom.ac.mu
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News and views

Edited by Jo Lamb-White
News and views
World Health Organization

New guidelines to improve psychological and social assistance in emergencies
Keywords Human rights, Community healthcare, Effective healthcare outcomes
International humanitarian agencies have agreed on a new set of guidelines to address the mental health and psychosocial needs of survivors as part of the response to conict or disaster. The Inter-Agency Standing Committee (IASC) Guidelines on Mental Health and Psychosocial Support in Emergency Settings clearly state that protecting and promoting mental health and psychosocial well-being is the responsibility of all humanitarian agencies and workers. Until now, many people involved in emergency response have viewed mental health and psychosocial well-being as the sole responsibility of psychiatrists and psychologists. These new IASC guidelines are a signicant step towards providing better care and support to people in disaster- and conict-affected areas worldwide, said Dr Ala Alwan, Assistant Director-General for Health Action in Crises at the World Health Organization. Recent conicts and natural disasters in Afghanistan, Indonesia, Sri Lanka and Sudan among many others involve substantial psychological and social suffering in the short term, which if not adequately addressed can lead to long-term mental health and psychosocial problems. These can threaten peace, peoples human rights and development. Yet, when communities and services provide protection and support, most individuals have been shown to be remarkably resilient. While this is increasingly recognised, many actors identied the need for a coherent, systematic approach that can be applied in large emergencies. The guidelines address this gap. The guidelines have been published by the IASC, a committee that is responsible for world-wide humanitarian policy and consists of heads of relevant UN and other intergovernmental agencies, Red Cross and Red Crescent agencies, and NGO consortia. The guidelines have been developed by staff from 27 agencies through a highly participatory process. Drafting the guidelines has been a joint effort of a broad range of key actors in the diverse sectors of humanitarian aid and we are happy to see the synergy and commitment, said Mr Jim Bishop, Vice President for Humanitarian Policy and Practice of InterAction, the consortium of USA-based international NGOs. The guidelines lay out the essential rst steps in protecting or promoting peoples mental health and psychosocial well-being in the midst of emergencies. They identify useful practices and ag potentially harmful ones, and clarify how different approaches complement one another.
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The new guidelines present a major step forward to much better protect the mental health and psychosocial well-being of displaced persons using an integrated approach in collaboration with all partners said Ms Ruvendrini Menikdiwela, Deputy Director, Division for International Protection Services at the Ofce of the United Nations High Commissioner of Refugees. The guidelines have a clear focus on social interventions and supports. They emphasize the importance of building on local resources such as teachers, health workers, healers, and womens groups to promote psychosocial well-being. They focus on strengthening social networks and building on existing ways community members deal with distress in their lives. The guidelines include attention to protection and care of people with severe mental disorders, including severe trauma-induced disorders, as well as access to psychological rst aid for those in acute distress. The guidelines stress that the way in which humanitarian aid is provided can have a substantial impact on peoples mental health and psychosocial well-being. Treating survivors with dignity and enabling them to participate in and organize emergency support is essential. Coordination of mental health and psychosocial support is difcult in large emergencies involving numerous agencies. Affected populations can be overwhelmed by outsiders, and local contributions to mental health and psychosocial support are easily marginalised or undermined. Dr Bruce Eshaya-Chauvin, Head of the Health and Care Department at the International Federation of Red Cross and Red Crescent Societies, remarked: Achieving improved psychosocial support for populations affected by crises requires coordinated action among all government and non-government and humanitarian actors. These guidelines give sensible advice on how to achieve that. These guidelines now need to be transferred from paper into concrete action at the eld level so that those affected by disasters and conict will benet from the work done on them. NGOs can play a major role in this regard. said Ms Manisha Thomas, acting Coordinator of the International Council of Voluntary Agencies. For further information: www.who.int
Europe
Future oncology healthcare strategy on the agenda of the Portuguese EU council presidency
Keywords Healthcare strategy, Quality healthcare, Healthcare improvement
The European Society for Medical Oncology (ESMO) is proud to announce that it is collaborating closely with the Portuguese EU Presidency on a key European meeting on health care issues, where cancer will be an important part of the agenda. The Round Table on Health Strategies in the European Union is one of the most important initiatives launched by the EU Portuguese Presidency within the context of the EU strategy on health policy, focusing on the topic of health and migration. ESMO
has been invited by Dr Joaquim Gouveia, National Coordinator of Oncological Diseases in Portugal, to be a key partner in this meeting for aspects related to cancer. Under the broad theme of creating a European Health Strategy, this Round Table will address crucial issues in terms of the EU health agenda, such as facing specic health problems, health determinants, health services and patient mobility. The selection of such topics reects the importance politicians place on assuring best quality healthcare, a service that touches the lives of every single EU citizen, as well as newcomers, said Pascale Blaes, Director of the ESMO Political Ofce in Brussels. The Round Table session on cancer will be chaired by Dr Joaquim Gouveia, with prominent participation of Dr Marija Seljak, Slovenian Public Health Director, and Mr Alojz Peterle, member of the MAC (Members of the European Parliament Against Cancer). The meeting will open with a welcome address by Professor Hakan Mellstedt, ESMO President. The impact of this meeting will inuence the future oncology healthcare strategy throughout the European Union, he said. Cancer is one of the major causes of disease, morbidity and mortality worldwide. Although great scientic progress has been achieved in oncology and continues to be achieved, cancer remains a huge public health challenge and a tremendous threat. ESMO is convinced that it is time to send a strong political signal for a broad alliance and concerted actions for the benet of patients in Europe and worldwide and considers this event a tangible means for the Portuguese Presidency in this direction, said Professor Mellstedt. The Portuguese representatives, ESMO, the experts and the key forces gathering in Lisbon will call upon the European institutions to put cancer on the political agenda as a priority and will request the national governments to develop policies, including a comprehensive overall strategy, for the prevention and control of cancer. The common objective of the meeting will be to create capacity building for developing and implementing effective policies and programs. Only by sharing expertise and exchanging best practices in Europe, and by advocating together to get support and the appropriate political commitment, we will be able to achieve the expected relevant outcome: survival, better quality of life, and patient satisfaction, Professor Mellstedt said. Appropriate tools will need to be identied for the proposed policies to be effectively implemented. As a main actor in the eld, with a wide expertise, ESMO, together with the Portuguese Presidency, will stress the following instruments: . comprehensive cancer control plans consisting of a variety of activities and strategic approaches, which are built on large coalitions and involve the necessary sectors; . population-based cancer registries; and . screening programs. It will certainly be complicated but is highly challenging, acknowledged Professor Mellstedt. ESMO is proud to be associated with the Portuguese Presidency Workshop on Cancer and we are sure that it will contribute to the development of a framework for health benets in Europe, Professor Mellstedt continued. The interactive format of the meeting, and its connections with other specic and global issues under discussion,
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will guarantee a high value contribution to the global debate on cancer and health in Europe. ESMO will continue to support the Portuguese efforts to make this initiative a turning point in the ght against cancer in Europe and the rst step towards the hoped for recognition by the national and European authorities of the recommendations agreed upon by the experts gathered together for this meeting. For further information: www.medicalnewsblog.info/
UK
Quality improvement: patient-reported outcomes and experiences now integrated with clinical data for the rst time
Keywords Patient feedback, Healthcare standards, Quality improvement measures
UK hospitals can now combine their clinical data with both patient-reported health outcomes and a measurement of patient experience, for the rst time. The new service, Patient Driven Quality, is being developed jointly by CHKS, the leading independent provider of healthcare information, and the Picker Institute, the charity which is a leading authority on capturing patient and staff feedback and using it to improve services. Hospitals will be able to measure the three sets of indicators, applied to particular clinical specialties, over time, and judge them against national benchmarks. Paul Robinson, external relationship manager at CHKS, said: There is considerable interest within the health service in the potential of PROMs patient-reported outcome measures. We intend to make PROMs directly useful to clinicians and managers in their efforts to gain continual quality improvement and to achieve the developmental standards in Standards for Health. Clinicians will be able to see how their own activity compares to the health outcomes reported by patients, and what patients say about their experience of receiving that care and treatment. Kay Usher, business manager at the Picker Institute, said: This combination will provide a patient-focused picture of the quality and effectiveness of the service provided by a clinical specialty over time. By staging the measurements hospitals will be able to judge the impact of quality improvement measures through the litmus test of what difference they are making for patients. The data tools included are: CHKS admitted patient care data set; the EQ5D patient-reported outcome measure compared to a major new normative database; and bespoke patient experience questionnaires developed to national standards by the Picker Institute. The combination of performance data, outcome data and patient experience data gives UK hospitals the ability to: . correlate activity performance data with patient health and patient experience; . target and evaluate quality improvement initiatives;
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demonstrate efforts to meet standards for better health; and benchmark their own performance and reputation against the national data set.
News and views
For further information: www.pickereurope.org
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Patients give vote of condence in overall care provided by NHS hospitals in largest national survey
Keywords Patient satisfaction, Performance standards, Quality improvements
Patients have given a vote of condence in the overall care provided by NHS hospitals with nine out of ten people surveyed by the Healthcare Commission rating it as excellent, very good or good. Just 2 per cent of patients said the overall care they received in hospital was poor. And compared with the Commissions previous inpatient survey in 2005, more people responded positively to questions about cleanliness and efforts to control infection through handwashing. The results also highlighted considerable variation in the performance of acute trusts on a range of issues relating to dignity in care. These include the standard of food, mixed-sex accommodation, answering calls for help, and assistance with eating. The survey highlights include: . There were encouraging signs on cleanliness with 93 per cent of patients saying their room or ward, was very clean or fairly clean. This compares with 92 per cent in the 2005 survey. . More patients said they waited six months or less for planned admissions, 84 per cent in this survey compared with 78 per cent in 2005. . Of the patients who indicated that they needed help eating, 20 per cent said they did not get enough. Among trusts, these gures varied between 2 per cent and 42 per cent. . There were 30 trusts where one in ve, or more, patients rated the food as poor. But in most other trusts, few patients rated the food as poor just 2 per cent in one trust. . There was variation in how trusts scored on single-sex accommodation. Looking at planned admissions only and excluding those who stayed in critical care units, 11 per cent of patients nationally said they shared a room or bay with a patient of the opposite sex. The ndings are from the Commissions inpatient survey, the biggest test of the experiences of patients in NHS hospitals in England. In autumn 2006, 80,000 patients at 167 acute and specialist trusts responded to the survey, coordinated on behalf of the Commission by the Picker Institute. Anna Walker, Chief Executive of the Healthcare Commission, said: We all hear a lot of negative comment about the NHS, but we must never forget that most patients
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have consistently rated the overall quality of their care as good or excellent. Staff should remember this as it shows that patients value the good work they do. The results also suggest that we need a fresh drive to tackle a set of issues related to treating patients with dignity. But, where there are problems it seems as if there are a minority of trusts that are letting the rest down. Patients have the right to expect all hospitals to get the basics right, like offering help with eating and answering calls for assistance. It is also clear that for a signicant minority of patients, the NHS is performing below standards on segregated accommodation. Looking at waiting times, trusts need to improve the patients journey through all parts of the hospital, from arrival at A&E to discharge. For example, too many patients still say they wait a long time while being admitted. There may be scope to reduce this by looking at delays in admissions units. The Commission will feed the results of the inpatient survey into its annual assessment of NHS trusts, which uses information to target inspections and ultimately leads to an annual performance rating. The independent watchdog is also preparing a national report on dignity in care for older people, to be published later in the year. As part of this, it has inspected 23 trusts where performance data raised particular questions. For further information: www.healthcarecommission.org.uk
Patient satisfaction surveys made easy: Department of Health

Keywords Clinical governance, Patient experience, Continuous improvement
Under the new community pharmacy contract in England and Wales, all contractors will be asked to complete an annual patient satisfaction survey, which will form one of the Clinical Governance requirements. Completion will therefore be mandatory. PSNC and the Department of Health are deciding on the ner detail of the survey and an announcement is expected soon, but as yet there is no compulsion to conduct such a survey. Results should be fed in to PCTs by the end of the nancial year therefore the rst set will be due by March 2008. The NPA will have member support ready as soon as the announcement is made. There are likely to be two or three options available to contractors. (1) Print, implement and evaluate the survey yourself. (2) Print and implement your own survey and outsource the analysis of results and reports. (3) Outsource the print, implementation, evaluation and reporting of results. Options (1) and (2) would only be recommended if a contractor had the time, expertise and resource in-house to cope with a survey. When the requirement is introduced, the National Pharmacy Association (NPA) will be offering its members three levels of support to match these options.
The STANDpoint system from Customer Research Technologies conducts all the research electronically and provides speedy analysis results. CRT simply delivers the device to the pharmacy and collects it two weeks later. Results are returned to contractors within the next ve days. (CFEP) UK Surveys, an independent company that specialises in producing patient feedback surveys for healthcare professionals, provides pharmacy contractors with a validated questionnaire which focuses on the ve domains of patient experience as dened by the Department of Health. The completed questionnaires will be analysed and the results fed back to the contractor. The entire survey process, from encouraging patients to complete the questionnaire to the analysis and actions arising from the results, will be validated. The service includes the supply of an appropriate number of questionnaires, available in various languages, sealable envelopes to ensure patient condentiality, in-store materials to explain the survey to patients, a ballot box, pens and a large self-addressed envelope in which to return the completed questionnaires. A high quality report of the results, including benchmarked data and patient comments will then be produced. The NPA has also commissioned CFEP to produce a resource pack to guide its members through the complex area of patient surveys. This is a practical guide showing how to design, implement, analyse and evaluate the results of the survey. NPA Commercial Director, Simon Ellison, says: A resource pack will be available to members free of charge. However, we are aware that members may need different levels of support and the NPA is committed to providing services to meet those needs as precisely as possible. We are condent that these three levels of service will provide every member with what they need to meet their obligations under the pharmacy contract. More than that, we are condent that the feedback members will gain from their patients will mean that they gain a high return on their investment. Raina Jordan, NPA Commercial Manager adds: Patient surveys are completely new to community pharmacy so the NPA wants to ensure that the route members choose when carrying out a patient satisfaction survey suits their needs. If you would like advice on which level of support may be best for your needs or to register your interest in readiness for the announcement, please contact us on r.jordan@npa.co.uk.
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NHS web site aims to boost choice

Keywords Patient choice, Healthcare standards, Patient empowerment
Patients are being given more choice over where they are treated. A new web site is being launched in an attempt to strengthen patient choice. The 3.6m NHS Choices web site will include information on issues as varied as waiting times, hospital ratings and general cleanliness. It is aimed at helping patients choose where they want to be treated when they need non-emergency surgery. Ministers also hope it will lead to detailed data on clinical outcomes being published to date only heart surgeons reveal performance statistics.
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Patients have been given a choice of where they can go to be treated for non-emergency treatment since last year. At the moment, patients are given a choice of at least four local hospitals and the top-performing foundation trusts. Later in the year people needing hip and knee operations will be able to choose from any hospital. And that will be extended to all specialities by April next year. The multi-media web site has sections giving advice on healthy lifestyles and also allows users to carry out an online health check. It has detailed information on 40 of the most common diseases and also uses data compiled by the Healthcare Commission on hospital performance, including ratings and MRSA rates. Health Secretary Patricia Hewitt said: We know patients and the public are thirsty about getting information on health. One of the problems with the internet is that some of the information about health is top quality and some of it is rubbish. What NHS Choices will do is give the public access to the best information about health. Ms Hewitt is also hoping the web site will push doctors into releasing information about the results of treatment. The web site includes death rate data from individual heart units, which was already available via a Healthcare Commission web site. Other specialities have been reluctant to follow suit because of concerns over case mixes the most experienced surgeons and doctors tend to take on the most difcult cases and therefore crude data could suggest they have the worst outcomes. The health secretary said: We now have to do this with other procedures. . .with the internet age resisting progress is fruitless. For further information: www.nhs.uk
Signposting the way to better out of hours services for patients

Keywords Healthcare information, Service delivery, Healthcare assessment
Doctors leaders have produced a ten point plan to help patients navigate their way through the maze of out-of-hours (OOH) services. The Royal College of General Practitioners says that services are confusing, fragmented, of highly variable quality and that urgent action is needed to restore condence in out-of-hours services. It is publishing the plan in direct response to concerns from members and patients and in advance of a Department of Health Review of urgent care services. The RCGP plan recognises the pivotal role of GPs and includes across-the-board recommendations for the Department of Health, Primary Care Trusts (PCTs), GP practices and health organisations to improve urgent care services for patients. Patients and doctors say out of hours services have been a cause of confusion since 2004 when the new GMS contract was introduced and PCTs took over responsibility for commissioning out of hours care in England. While the RCGP recognises that good quality urgent care exists in some areas, it highlights a clear need for better signposting as patients are often unable to determine
the most appropriate service to access. It has also identied concerns about variation in quality of out of hours services. To address this, and to kickstart action in improving urgent care services, the RCGP will shortly launch a national Out of Hours Clinical Audit Toolkit, which will enable PCTs to monitor clinical outcomes. RCGP Chairman Professor Mayur Lakhani, a practising GP in Leicester, said: We are concerned that GPs are being blamed unfairly for the state of out-of-hours services when the responsibility for commissioning and providing OOH services resides with primary care trusts and not GPs. Nonetheless we acknowledge that this has been a difcult issue for the profession and that many GPs agonised over their decision to opt out of 24 hour contractual responsibility. GPs are still involved in OOH rotas and a large proportion of OOH is still provided by GP co-operatives. PCTs must make efforts to engage and involve GPs in out of hours care: some PCTs have already managed to do this effectively. The RCGP ten point action plan recommends that services are designed around the clinical needs of patients who should expect to receive a consistent and rigorous assessment of their needs and an appropriate and prompt response to that need regardless of who is administering their care. The action plan calls for: (1) Care to be congured around the needs of patients with better signposting for access. (2) All GP practices to have a system for responding to and dealing with urgent care during surgery hours. Athough no longer contractually responsible for out of hours work, they should champion optimal levels of urgent care for their patients and practices must have systems in place for alerting urgent care providers to patients with complex healthcare needs. (3) PCTs to develop Urgent Care Networks comprising GP practices, walk-in centres and minor injury units to foster integration and co-ordination of care between providers. (4) Quality standards including clinical outcomes to be monitored and enforce. (5) Engagement with local GPs and recognition of their key role in leadership, planning and support for urgent care and out of hours services. (6) Stronger multidisciplinary urgent care teams whose members have been trained to nationally agreed standards, and training opportunities in urgent care for GP Registrars. (7) The Department of Health to make urgent care a priority and set a clear national strategy, emphasising the necessity for high clinical standards. (8) Emergency care practitioners to be trained to a dened national standard including an assessment of competence. (9) The Healthcare Commission to ensure that the quality and safety of urgent care is monitored and to make recommendations for improvement based on their ndings. (10) Primary care educators to ensure that the quality of urgent care training receives a high priority and establish a systematic approach to the training of
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GP Registrars. Urgent care competencies should also be incorporated within GP appraisal and CPD. Professor Lakhani said: A step change in policy is needed. Being ill in the middle of night is frightening experience and patients need to be sure the NHS will be there for them. The majority of care is still provided by GPs. As the proven experts in providing urgent care, it is important that GPs have a strong inuence on urgent care. Any attempt to downgrade the role of GPs will lead to further diminution of quality and put pressure on other parts of the NHS. We are aware of excellent service provision in some areas but also have signicant concerns about fragmentation of care and a lack of signposting to services. We urge that PCTs be held to account for the quality of their out of hours services. Some PCTs have managed to get it right so why not others? The Out of Hours Toolkit will help to ensure that the spotlight remains on high standards of patient care measurement of clinical quality is essential. It is imperative that primary care providers work together to address these problems access to good quality urgent care should be the preserve of all, not the lucky few. Ailsa Donnelly, Chair of the RCGP Patient Partnership Group, said: Patients are very confused and bewildered about which services may be available to them outside GP surgery appointments. Clear signposting to appropriate care is essential, and this plan will go a long way towards demystifying the maze that currently exists. For further information: www.medicalnewstoday.com
Americas
Outsourcing improves patient satisfaction
Keywords Patient experience, Financial management, Healthcare environment
The Hospital Consumer Assessment of Healthcare Providers and Systems survey shows better management of environmental services yields improved patient satisfaction with the hospital experience Cleanliness may be next to Godliness, but it is also turning out to be a Godsend to hospital administrative staff who seek to strengthen the position of their hospitals for the upcoming publication of the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey results in 2007. Through an increased reliance on management companies who provide environmental services (EVS) to help enhance the patient experience, hospitals can improve survey responses. Such high-percentile marks can help increase census counts and ultimately the nancial position of the hospital as patients patronise those facilities that they perceive to provide the best care. Everyone has struggled with patient satisfaction and the surveys in general, but we see HCAHPS as an opportunity, says Laura Fortin, Chief Nursing Ofcer and
Chief Operating Ofcer at the 1.2 million ft2 St Joseph Medical Center in Houston, Texas,USA. There are studies out there that show a denite correlation between patient satisfaction and your bottom line, and EVS plays a key role in patient satisfaction. Composed of 27 items that encompass critical aspects of the hospital experience such as the responsiveness of hospital staff, quietness, and cleanliness of the hospitalthe HCAHPS survey provides a standardised instrument and data collection methodology for measuring patients perspectives on hospital care. At that point, an increasingly astute patient population will be able to make direct comparisons between competing acute care facilities and subsequently exercise their inuence in selecting the facility that will render services to them. Any hospital that wishes to remain in the running must act now to position itself as a leader among survey respondents. Given such a short timeline, many administrators and operating ofcers are opting for quick solutions, and upping the cleanliness factor is an effective means of enhancing the perception of competency. Patients can denitely assess how clean their room is, and how nice the person was who cleaned their room these are things they can easily quantify on a survey, so housekeeping denitely has a role, states St Josephs Fortin. EVS is an important part of the patients experience in the hospital, agrees Marilyn Schock, Assistant Administrator at McKee Medical Center in Loveland, Colorado. Celebrating its 30th birthday, McKee is part of the Phoenix, Arizona-based Banner Health organization, which encompasses 20 hospitals and other facilities that offer an array of medical services. Cleanliness is an important part of the healing and caring environment, continues Schock. Clean areas invoke a sense of condence and a positive feeling about the people and services. Dirty places tend to trigger a sense of doubt, uncertainty and a feeling of scepticism about the people and services being provided. EVS plays a crucial role in meeting the patients expectations of excellent patient care. The challenge of improving EVS Coupled with the typically low retention rate of EVS employees and hospitals traditionally lacking systematised processes for this department, accomplishing gains in EVS often proves elusive. In response, administrators at some hospitals are increasingly turning to management companies and consultants who, by virtue of the fact that they specialise only in healthcare EVS, can transform that facet of hospital operations into a high-scoring asset when surveys get lled out. St Joseph was one hospital who chose this route. I believe each facility is unique, and management has to seek out what is best for their operation, comments Fortin. It made sense for us to go with Medi-Dyn because we share a similar vision and value system with them, so we work really well together. Founded in 1979 and based in Englewood, Colorado, Medi-Dyn is a privately held corporation providing environmental and laundry management services exclusively to the healthcare industry. Typically, a contract management rm like Medi-Dyn will offer a range of services so that administrators can tailor the available services to t the needs of their particular facility.
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In a management-only structure, the contractor provides the on-site management needed to effectively lead daily operations. In other situations, both managers and all direct labor staff are employed by the contractor under a full-service option. Intermediate levels of integration also exist. We only utilise Medi-Dyn for its management services the employees are our own but they report directly to the Medi-Dyn manager, notes Schock. Typically, EVS staff represents a tough population for retention. Medi-Dyns expertise combined with our culture of excellence ensures a seamless teamwork approach. In the selection of any vendor, the key is to get the right management person, Fortin reiterates. The Medi-Dyn Director here, Bill Walles, is phenomenal. He is very involved in patient satisfaction, exposing new hires to our goal of improving the patient experience. really believes in this and understands what we are trying to accomplish within our EVS department. When you have that, you cant fail. At the same time, it is the EVS worker who frequently comes into direct contact with patients, so effective training in meeting patients expectations must extend to all levels of the department. This allows hospital administration to concentrate on other facets of patient care and improving the facilitys ratings. When EVS shines, so do HCAHPS surveys Early positive returns on patient surveys from hospitals that rely on EVS management experts prove hard to ignore. At the McKee Medical Center, for example, Press Ganey scores in third quarter of 2006 for courtesy and cleanliness were in the 99th percentile, maintaining EVS as the hospitals top-scoring department. That was up from the 70th percentile on courtesy and the 65th percentile on cleanliness when Medi-Dyn began the contract in June 2003. The attainment of such successes hinges on proven quality control systems. Through such feedback mechanisms as: patient interviews, department head inspections, physician questionnaires, administrative reporting procedures and nancial accountability, the level of quality can consistently improve over time. We started a competition between departments: nursing competes against each other on scores each month, as well as ancillary departments, says Fortin, and housekeeping has blown all other departments off the map, so they are doing something right. Other hospitals that chose the same option as St Joseph and McKee include Memorial Hermann Hospital in The Woodlands, Texas, where patient satisfaction scores for EVS are consistently above the 95th percentile; and, Natchez Community Hospital in Mississippi, where more than 99 percent of patient responses have ranked EVS services as good or excellent since 2001. One of the lesser-known benets of turning to an EVS management expert to help enhance HCAHPS results, is the fact that it can yield a return on investment that is often superior to managing the department from within. Under the guidance of Medi-Dyn, one particular hospital reduced its full-time-equivalent EVS staff from 72 to 46, and its managerial staff from eight to four, saving over US$350,000 per year while improving quality of service. Gains in EVS management can even possibly inuence capital outcomes.
When our hospital was up for sale, every person that came in that was interested in buying the hospital could not believe how clean it was, recalls Fortin. The cleanliness denitely affected their overall impression of our facility. As of August 2006, St Josephs became a part of Hospital Partners of America, a Charlotte, North Carolina based healthcare services company that owns and operates general acute care hospitals in partnership with leading physicians throughout the USA. Perception is everything, and the face that you want to put out there is one of cleanliness, agrees Schock. EVS plays a key role in how your hospital is rated, but the customer-service gains you achieve, does not end with just good H-caps scores, it improves the possibility a patient will return or recommend your services. For further information: www.healthservicetalk.coml
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Recent publications
Please note that unless expressly stated, these are not reviews of titles given. They are descriptions of the books, based on information provided by the publishers.
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Using Patient Experience in Nurse Education Edited by Tony Warne and Susan McAndrew Palgrave Macmillan ISBN 9781403934017 Keywords Healthcare policy, Patient involvement, Professional education
Current health policy places an emphasis on the greater involvement of health service users and carers in all aspects of their care, including planning, provision and evaluation. However, the focus is usually on after the event accounts - i.e. when individuals have become consumers of health care services. There is little patient involvement in before the event experiences such as planning to meet health care needs, or in the training of health care practitioners. This book lls that gap, and meets a growing demand for educational approaches that address the perspectives of patients and carers. Contents include: . Nursing, education and professionalisation in a contemporary context; A. Warne and S. McAndrew. . The person as a life expert: this is not a love song; D. Skidmore. . Beyond the tick box: providing a strategic direction to patient involvement in education; F. ONeill. . Nursing policy paradoxes and education implications; S. Stark and I. Stronach . Patients as teachers: utilising patients in classroom teaching; J. Costello and M. Horne. . Using patients experiences in medical education: rst steps in inter-professional training?; S. Kilminster, P. Morris, E. Simpson, J. Thislethwaite and B. Ewart. . A long term affair; G. Samociuk and S. McAndrew. . Patient-centred, student-centred learning in community and primary care nursing; J. Canham. . Looking back- stepping forward; A. Warne, S. McAndrew, H. Hepworth, E. Collins and S. McGregor.
Bringing User Experience to Healthcare Improvement: The Concepts, Methods and Practices of Experience-based Design Paul Bate and Glenn Robert Radcliffe Oxford ISBN 10 1 84619 176 9; ISBN 13 9781846191763 Keywords Patient experience, Healthcare improvement, Quality standards
Experience Based Design (EBD) is a new way to bring about improvements in healthcare services by being user-focussed. Facilities, healthcare professionals, carers,
family and friends are all involved in the patient experience and systems and policies need to adapt to take this into consideration. By exploring the underlying concepts, methods and practices of EBD, this exciting guide offers a unique approach to healthcare customer satisfaction. It offers recommendations for the future and many interesting points for discussion. It will be of great interest to health and social care management, particularly directors of service improvement in hospitals and directors of nursing, health and social care policy makers and shapers, and quality improvement and organisational development specialists in healthcare. Patient groups and national organisations, too will nd the book inspirational. Can you imagine what it would be like if we moved from a health service that does things to and for its patients to one which is patient-led? Where the service has been specically designed by patients and staff together so that it provides the best experiences you could hope for. This compelling book illustrates a new approach to redesigning health systems so that they truly meet the needs of patients and staff, the very people who are experiencing them. This is a must for all health care staff. Lynne Maher. Contents include: . Bringing the user experience to health care. . Concepts: a quiet revolution in design. So whats different? . The intellectual roots of experience design. . Methods: becoming a disciple of experience. . Using stories and storytelling to reveal the users-eye view of the landscape Patterns-based design: the concept of design principles. . Experience-based design: tools for diagnosis and intervention. . Practices: The how of experience-based design: a case study for practitioners Evaluating patient experience and experience-based design (and a brief word about patient satisfaction surveys. . .). . Future directions for experience-based design and user-centred improvement and innovation.
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Improving Patient Satisfaction Now: How to Earn Patient and Payer Loyalty Anne-Marie Nelson Jones & Bartlett ISBN 0834209225 Keywords Healthcare evaluation, Patient expectations, Patient satisfaction
In todays health care environment, having satised patients just is not enough you are now being judged by payers and compared to other providers; patient satisfaction is a big part of that evaluation. Improving Patient Satisfaction Now: How to Earn Patient and Payer Loyalty explains why understanding and meeting patient expectations is not only nice to know, its need to know! It gives you action steps in all areas of the practice. Through anecdotes and real-life examples from practicing physicians, you will learn
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how to develop higher patient satisfaction, more compliant patients, a more productive and committed staff, and practical techniques to increase patient satisfaction in this updated edition. Contents include: . Winning practices for loyal patients. . How to earn raves from patients and payers. . Lighting and leading the way. . Some things change, but patient expectations remain the same. . Eighteen ways to learn what patients want. . The diversity imperative hits health care. . Want to communicate better? Listen well. . How do you rate when youre face to face with your patient? . Empower your patients with knowledge. . Want compliant patients? Communicate and educate. . Success is a team effort. . Motivation: it takes more than a paycheck. . Empowerment? Its just plain old trust! . For practice administrators and managers only: how to gain physician participation. . Set standards for a great rst and last impression. . The telephone connection. . Create a schedule that satises everyone! . Making wrongs right. . Where does clinical quality t in the picture? . Now is the time to create loyal patients and winning practices.

Quality Assurance

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ISSN 0952-6862

Volume 21 Number 1 2008

Health Care Quality Assurance

International Journal of Health Care Quality Assurance

ISSN 0952-6862 Volume 21 Number 1 2008

Access this journal electronically

The role of understanding customer expectations in aged care

Patient claims and complaints data for improving patient safety

Evaluating hospital service quality from a physician viewpoint

The influence of service quality and patients emotions on satisfaction

The relative importance of service dimensions in a healthcare setting

CENTRE SECTION News and views __________________________________________ Recent publications ______________________________________

How to access this journal electronically

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Key features of Emerald electronic journals

Emerald Customer Support

EDITORIAL ADVISORY BOARD

Erdogan Haktan Ekiz

Salih Turan Katircioglu

Service quality in public and private hospitals 9

Service quality in public and private hospitals 11

Service quality in public and private hospitals 13

Table I. Sample demographics

Public hospital Exp. Per. Gap FL Gap

Private hospital Exp. Per.

Service quality in public and private hospitals

Public hospital Exp. Per. Gap FL

Private hospital Exp. Per.

Food 45. 46. 44. 43. 48. 47.

Service quality in public and private hospitals

Service quality in public and private hospitals 19

Service quality in public and private hospitals 21

Service quality in public and private hospitals 23

Measuring the three process segments 25

Figure 1. Overall satisfaction model

Figure 2. Retention model

Measuring the three process segments 27

Measuring the three process segments 29

Signicance testing Predictive relevance

Bootstrapping: 500 samples Bootstrap t-tests Stone-Geisser Q2

Table IV. Structural model test criteria

Figure 3. Overall satisfaction model

Indicator OAA_1 OAA_2

Weights 0.078 0.079

Measuring the three process segments 31

Table VI. Overall satisfaction model loadings/cross loadings of items

Overall Overall Stage 1 Stage 2 Stage 3 0.924 0.898 0.954 0.875

Stage 1 0.996 0.891 0.843

Measuring the three process segments 33

Measuring the three process segments 35

Measuring the three process segments 37

Pessimism and hostility scores

Ross A. Dierkhising and Kenneth P. Offord

Pessimism and hostility scores

Pessimism and hostility scores

Questionnaire item 83 83 83 83 100 83 100 88 89 86 86 62 62 62 64 61 59 57 56 43 51 88 70 64 61 59 52 71 65 63 89 71 75 66 65 68 64 64 67 62 61 65 60 55 61 59 72 75 67

Pessimism and hostility scores

Model 3c (0.79-1.08) (0.80-1.10) (0.74-1.01) (0.73-1.00) (0.74-1.00) (0.75-1.02) (0.80-1.28)

Pessimism and hostility scores

Pessimism and hostility scores

The role of understanding customer expectations in aged care

Understanding customer expectations 51

Understanding customer expectations 53

CENTRE SECTION News and views ____ Recent publications