International Journal of Health Care Quality Assurance

Measuring patient-perceived hospital service quality: a conceptual framework

YOGESH P PAI Satyanarayana T Chary
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 Measuring patient-perceived hospital service quality: a conceptual framework

Introduction
A service has been defined as ‘any activity or benefit that one party can offer to another that
is essentially intangible and does not result in the ownership of anything…’ (Kotler et al.,
2013 p.322). Service characteristics such as intangibility, inseparability, heterogeneity and
perishability make services distinct compared to goods (Zeithaml et al., 1985). These are also
referred as the SHIP model (simultaneity, heterogeneity, intangibility, perishability) (Hollins
and Shinkins, 2006). It is this fundamental belief that services are dissimilar to goods that
leads to a service discipline requiring innovative thoughts, methods and strategies (Berry and
Parasuraman, 1993). For services, the process is the product (Fitzsimmons and Fitzsimmons,
2006 p.31); and in any service process, customers are inputs who interact with the service
system. It is important to understand this distinction in a service compared to manufacturing;
thus negating manufacturing’s closed system owing to customer presence in the service
process (Fitzsimmons and Fitzsimmons, 2006).
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Although traditional services such as hotels, catering and housecleaning dominate the
service sector, these are increasingly supplemented by amenities such as banking, insurance,
computing, communication, etc., (Eichengreen and Gupta, 2009). Healthcare is the fastest
growing service among developed and developing countries (Dey et al., 2006). Therefore, it
is important that hospitals provide services that are appropriate to the population’s health
needs (Rechel et al., 2009). Only those consumers who are satisfied with their healthcare
providers will return when they need care again (Otani et al., 2010). Managers need to
understand that even though the process is performed exactly as designed by them; service
quality is low if they do not meet customer requirements. Accordingly, if service
performance does not address individual customer requirements then customers will not use
the service (Sampson, 1999). Assessing healthcare quality and understanding how patients
perceive quality are crucial in such a rapidly changing and increasingly competitive market
(Braunsberger and Gates, 2002). Therefore, meeting patient needs and creating healthcare
standards are imperative to achieving high quality (Ramachandran and Cram, 2005),
consequently identifying and understanding what quality dimensions are important to
customers are fundamental to service quality. Hence, studying healthcare quality is as natural
as it is for any other service. Practitioners and academics are struggling to find an appropriate
healthcare system that satisfies different stakeholders such as patients, providers, practitioners
and insurers. As a result, understanding service quality dimensions has become more
important over the years.

Understanding and measuring healthcare quality

Healthcare is considered a credence purchase (Butler et al., 1996). Additionally, healthcare is
considered a need rather than a want, which is characteristically personal and has several
dissimilar characteristics compared to other services such as patients not controlling entry and
exit, surrendering confidentiality, collaboration between patient and physician (Berry and
Seltman, 2008; Pai and Chary, 2013). It is important to understand these differences as they
pose important questions (Parasuraman et al., 1985, 1988):

1. How do we measure service quality in healthcare settings?

2. What’s the best way to define service quality?
3. What’s the best way to measure service quality?

These questions have been debated by academics over three decades (Martinez and Martinez,
2010). There are different service quality definitions in the literature. However, we consider
 only two: ‘the outcome of an evaluation process where the consumer compares his
expectations with the service he has received’ (Gronroos, 1984 p.37) and ‘a customer’s
judgement about a product’s excellence or superiority’ (Zeithaml, 1988 p.3). The healthcare
industry has gone through service delivery changes in response to higher service expectations
from patients, technology advancements, superior access to health information through the
internet and digital media, and a holistic approach to health and well-being concerns (Francis,
2010). Although patient opinions are an important tool in healthcare evaluation (Polluste et
al., 2000), healthcare quality has been studied largely from a clinical perspective, excluding
the patient’s service quality perception (Gill and White, 2009). Despite an extensive quality
determinants literature (Badri et al., 2005), quality indicators cannot be determined
adequately using existing service quality measures (Butler et al., 1996) and currently, few
tools exist for assessing and managing healthcare quality (Chow-Chua and Goh, 2002). Pai
and Chary (2013) concluded that researchers need to look for healthcare dimensions rather
than adopting any available instrument, thus highlighting the need for an instrument for
measuring hospital service quality. Hence we propose a conceptual framework to measure
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service quality addressing this gap in the literature to provide academics and practitioners
measurement alternative.

Service quality literature

The service quality literature includes numerous models by different researchers such as: (i)
Nordic (Gronoos, 1984); (ii) SERVQUAL (Parasuraman et al., 1985, 1988); (iii) three-
component (Rust and Oliver, 1994) and (iv) hierarchical (Dabholkar et al., 1996).
Understanding these conceptual models is important because ‘a model attempts to show the
relationships that exist between salient variables’ (Ghobadian et al., 1994, p.56). Seth et al.
(2005) reported 19 conceptual service quality models developed between 1984-2003 and
advocate that each model represents different service viewpoints. Accordingly, identifying
the underlying service quality dimensions and their relative importance in consumer
evaluation situations is the first step to defining service quality. Pai and Chary (2013)
acknowledged the manner in which studies measure hospital service quality using three
databases (Ebsco, Emerald Insight, ABI/Inform) and identify SERVQUAL’s application with
or without modification. SERVQUAL, a generic instrument considered to measure service
quality, developed by Parasuraman et al. (1988), including 22 items as five factors, remains a
popular service quality measure for researchers and practitioners (Zeithaml and Bitner, 2000).
Its applicability, however, is debated. Several authors identify potential difficulties with the
scale’s conceptual foundation and operationalization (Arasli et al., 2008; Asubonteng et al.,
1996; Badri et al., 2005; Brown et al., 1993; Buttle, 1996; Carman, 1990; Cronin and Taylor,
1992; Jabnoun and Khalifa, 2005; Ladhari, 2009; Lam, 1997; Van Dyke et al., 1997).
Ladhari’s (2009) 20 year SERVQUAL research review (1988 to 2008) points out the
problems related to scores, reliability, validity (convergent, discriminant and predictive),
emphasis on process (rather than outcome), applicability as a generic scale and to different
cultural contexts.
Several studies, conducted in healthcare settings based on Parasuraman et al. (1988),
include: Arasli et al. (2008); Amira (2008); Babakus and Mangold (1992); Bakar et al.
(2008); Fuentes (1999); Headley and Miller (1993); Jabnoun and Chakar (2003); Kara et al.
(2005); Karassavidou et al. (2009); Kilbourne et al. (2004); Lam (1997); Lee (2005); Lim and
Tang (2000); Mostafa (2005); Ramsaran-Fowdar (2008); Rohini and Mahadevappa (2006);
Taner and Antony (2006); Taylor and Cronin (1994); Wisniewski and Wisniewski (2005);
Youssef et al., (1995). Among the studies conducted in healthcare, Pai and Chary (2013)
reiterate that excepting Sohail (2003); Jabnoun and Chakar (2003); and Rohini and
Mahadevappa (2006); discovered SERVQUAL items did not load onto their respective
 dimensions (Lee, 2005); and the five component scale structure was not supported (Amira,
2008; Fuentes, 1999; Mostafa, 2005). Studies resulted in one or more dimensions: one
(Babakus and Mangold, 1992), two (Lam, 1997), three (Fuentes, 1999; Mostafa, 2005;
Karassavidou et al., 2009), four (Kilbourne et al., 2004), six (Headley and Miller, 1993). The
SERVQUAL authors failed to replicate the five factor structure when tangibles were spilt
into two factors: physical facilities/equipment and employee/communication materials and
when two SERVQUAL dimensions: responsiveness and assurance loaded onto one
dimension (Parasuraman et al., 1991). The five factor model has a poor fit (using
confirmatory factor analysis) (Badri et al., 2005; Chi Cui et al., 2003). Additionally,
Zeithaml, a SERVQUAL (Parasuraman et al., 1988) contributor with Boulding et al. (1993,
p.24) admits that ‘our results are incompatible with both this one-dimensional view of
expectations and the gap formation for service quality. Instead we find that perceived quality
is directly influenced only by perceptions (of performance)’. These arguments raise other
important research questions: ‘Are there universal factors that are relevant across service
industries?’ and ‘Is the instrument SERVQUAL appropriate in all settings?’.
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Developing an alternative framework for measuring hospital service quality

It is evident from the literature that SERVQUAL does not appear to be universally applicable
without modification (Schneider and White, 2004). Babakus and Boller (1992), Cronin and
Taylor (1992) suggest that there are no universal factors that are relevant across service
industries. Service quality constructs developed in one culture may not be applicable in
another (Murti et al., 2013a), as scales that work in western culture may not perform in others
(Malhotra et al., 1996; Smith and Reynolds, 2001; Ueltschy and Krampf, 2001). The effort to
replicate the SERVQUAL factor structure has not always been successful in Asian countries
(Kettinger et al., 1995; Jabnoun and Khalifa, 2005). Additionally, studies failed to discover
the original five factor structure, with none, other than the original SERVQUAL contributors,
failing to achieve the results, which hints that SERVQUAL is not an appropriate
measurement. This means that we may need to develop an alternative scale (Pai and Chary,
2013). Additionally, it is acknowledged that most studies have been conducted in developed
countries and researchers in developing countries are exploring applicability in context
(Padma et al., 2009). Berry and Seltman’s (2008) found that differences among healthcare
and other services only reiterate the argument that ‘healthcare services have so few elements
in common with other services … that relying on previously developed scales like
SERVQUAL may not lead to reliable results’ (Vandamme and Leunis, 1993 p.43). Therefore,
our purpose is to: (i) develop a conceptual framework for measuring hospital service quality;
(ii) expand existing healthcare service models; (iii) enhance our understanding of patient
perceived hospital service quality and (iv) address the gaps in the literature.

Patient perceived service quality dimensions in hospitals

Framework for measuring hospital service quality
A healthcare quality literature review was undertaken from the patient’s perspective using
nine patient perceived hospital service quality (HSQ) dimensions (termed indicators).

Healthscape
Kotler (1973) introduced the physical environment as an important service experience. Later,
Bitner (1992) took atmospherics a step further by developing a framework that addresses the
physical environment’s effects on consumers in service settings (servicescapes). Hutton and
Richardson (1995) narrowed the topic to healthcare facilities and modified Bitner’s
servicescape framework by combining it with Kotler’s atmospherics (1973), calling it
healthscape. Brady and Cronin (2001) and Raajpoot (2002) found that in different service
 industries, customers listed the service environment as a consideration in their service quality
evaluations. Healthcare is a need service, that serves patients who arrive with illness, pain,
anxiety, fear and under stress (Bendapudi et al., 2006). With patients arriving at healthcare
facilities distressed, concerned and anxious in an unfamiliar environment, only worsens their
negative emotions (Lee, 2011). Pai and Chary (2014) highlight healthscape’s influence on
service quality. Therefore, healthcare providers need to understand which healthscape
features affect service quality, to create a healthscape that can satisfy customer need for
comfort, convenience, safety, security, privacy and support. In our conceptual model, this
dimension includes tangible service facilities such as equipment, machinery, signage,
employee appearance or other man-made physical environment.

Personnel
Service delivery occurs during the interaction between employee and customer. During the
service encounter, customer perception is based upon the encounter’s emotional and
intangible elements (Lemmink and Mattsson, 2002; Stauss and Mang, 1999). Thus employee
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attitudes and behaviours can influence customer perceptions (Schneider and Bowen, 1985).
In high contact services, for customers to be happy, employees must be happy (Bitran and
Hoech, 1990). Service-profit chains (S-PC) highlight employee attributes needed to deliver
high service quality (Heskett et al., 1994). Hays and Hill (2006) explain that service
organizations with highly motivated employees enhance service quality. Service
organisations are classified on customer contact and high-contact service industries typically
involve activities in which employees and customers have close and direct interaction for a
prolonged period (Chase, 1981). High contact services must fulfil higher order human needs
to a much larger extent than low contact services (Chase and Tansik, 1983). Hospital services
are high contact services, where personnel play an important role in service evaluation among
patients (Bowen and Schneider, 1985). As the interaction involves interpersonal elements,
patients develop positive emotional responses that lead to positive evaluations (Gabbott and
Hogg, 2000). Service quality is directly related to customer satisfaction and service quality
perceptions (Jayawardhena et al., 2007). Hence, this dimension evaluates courtesy,
competency, friendliness, caring attitude, politeness, mannerisms and staff appearance.

Hospital image
Image is defined as perceptions reflected in the associations held in a consumer’s memory
(Keller, 1993) and is a short-term perception that stakeholders have (Carrillo et al., 2011).
According to the Nordic model, image is emphasized as a filter that influences the perception
of the organisation’s operation (Gronoos, 1984) that externally validates the perceptions
(Zeithaml, 1988). Moreover, corporate image has been identified as an important factor in the
overall service evaluation (Bitner, 1991; Grönroos, 1984). However, intrinsic service
qualities prior to their purchase are relatively difficult to identify (Darby and Karni, 1973;
Zeithaml, 1988); therefore, service provider performance gets harder to evaluate and image
assessment rises in importance (Hansen et al., 2008). A company with a good image is more
likely to stand out in the market place because it draws both repeat customers and trial users
(Connor and Davidson, 1997) and positive image might serve as a proxy for service quality
(Kirmani and Rao, 2000). Consumer’s perceptions are ignored in the literature (Kristensen,
1998). In healthcare services, the hospital’s reputation has to be considered as a service
quality element and accordingly, this dimension includes good doctors, honesty and ethics.

Trustworthiness
Parasuraman et al. (1985) introduced trust, suggesting that customer should be able to trust
service providers, feel safe and be assured that their dealings are confidential. Zeithaml et al.
 (2000), in their e-service quality study, categorized security/privacy as the degree to which
customers believe the service is safe from intrusion and that personal information is
protected. Trustworthiness has the greatest impact on overall perceived service quality among
retail grocery businesses (Siu and Chow, 2003). Healthcare is dissimilar to other services in
the manner that ‘patients submit confidentiality and relinquish their privacy (and modesty) to
clinicians’ (Berry and Seltman, 2008 p.11). In healthcare, knowledge control is an important
part of privacy and control includes the decisions about what information is and isn’t given
and what information is shared (Muyeskens, 1982; Ziporyn, 1984). Silvestro (2005)
recognized that health service privacy is important and that maintaining privacy and
confidentiality is important from the patient perspective. Consequently, this dimension deals
with providing medical treatment and maintaining privacy and confidentiality.

Clinical care process

Healthcare has similar characteristics to other services such as car repairs, where customers
are disadvantaged when it comes to knowledge about the service (Berry and Bendapudi,
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2007). Patients cannot judge an employee’s technical competence; i.e., patients have few
skills to evaluate a service’s technical reliability (Vinagre and Neves, 2008), consistent with
Donabedian’s (1988) statement that patients often are in no position to assess technical
quality and they are sensitive to interpersonal relationships. Hence, hospital service quality
judgements are made by the patient based on interpersonal aspects and the manner in which
medical care is delivered. Interpersonal aspects are directly experienced and their evaluation
requires no technical expertise. What service features are offered is as important as how they
are delivered (Rust and Oliver, 1994). Accordingly, this dimension deals with assessing
patient condition, instruction and advice received, and time spent examining the patient.

Communication
Service delivery shapes, to a great extent, customer service perceptions (Bitran and Lojo,
1993). Lehtinen and Lehtinen (1991) recognised the quality arising from an interaction
between provider and customer as one factor affecting service quality. Communication
embraces information transmission between provider and customer; i.e., two-way
communication. Flow is an important characteristic in a relationship (Morgan and Hunt,
1994) and timely communication fosters trust by resolving disputes and aligning perceptions
and expectations (Moorman et al., 1993). Patients’ need for information and a patient-centred
approach often remain unfulfilled (Schattner et al., 2006). Research shows that many medical
service providers tend to communicate in such a manner that reveals their power, authority,
professional detachment and status (Hall et al., 1981; Street and Weimann, 1987). Likewise,
customers do not appreciate rudeness (Gutek et al., 2002). Provider communication style is a
key factor in determining customer satisfaction and in most service situations, a non-
dominating communication style will lead to greater customer satisfaction (Webster and
Sundaram, 2009). In healthcare, patients want to know that communication is occurring
between different parties involved, so this dimension includes information provision,
providing adequate information about ailments and treatments, obtaining information,
updating patient to family members and feelings about interaction with staff.

Relationship
Deciding to deliver a service in relationships or encounters is a strategic choice. The
difference between interaction among customer and service employee who know each other
personally and an interaction between two strangers who never expect to see each other again
represents a fundamental dichotomy in the service industry (Gutek et al., 2002). One
distinguishing characteristics is collaboration (Pai and Chary, 2013); i.e. patient cooperation
 during the encounter (answering questions honestly) and afterwards (taking the prescribed
medication) is important for successful treatment (Berry and Bendapudi, 2007). Patients
share the responsibility for their own healthcare with physicians. Human relationships are
complex and the relationship between patient and physician is no exception (Beach and
Roter, 2000). Relationships refer to closeness and strength developed between provider and
customer (Beatty et al., 1996), which includes interpersonally close interactions in which
trust or mutual liking exists (Koerner, 2000). Trust is necessary for a successful patient-
provider relationship and exceeds the level found in most other relationships, as both
participants know relatively little about each other (Davis and Roberts, 2009). A patient-
provider relationship is based on faith, paternalism, family input and mutual understanding
(Balint and Shelton, 1996). Patient-physician relationship was found to be the patient's first
priority (Schattner et al., 2006), highlighting the relationship’s significance. Therefore, this
dimension examines the relationship between patient and staff.

Personalization
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Personalization is defined as customizing services to an individual through service

representatives adapting their behaviour (Shen and Ball, 2009). Service personalization has
two dimensions: interpersonal adaptive behaviour and service-offering adaptive behaviour
(Gwinner et al., 2005; Shen and Ball, 2009; Surprenant and Solomon, 1987). The former is
also referred as programmed personalization where the employees may adjust their verbal
and nonverbal behaviour to interpersonal service interaction, such as addressing customers by
their first name, engaging in small talk; while the latter, also stated as customized
personalization, where employees tailor service to an individual customer by offering options
(Shen and Ball, 2009; Surprenant and Solomon, 1987) or exercising discretion to
accommodate customer needs (Kelley, 1993). Personalization is an important service quality
determinant (Mittal and Lassar, 1996) and customers evaluate employees on their ability to
recognize the customers’ place in society and their importance to business (Raajpoot, 2004).
Service products are custom-made and healthcare is a service class that involves
customization and customer-contact personnel to exercise judgement that is often prescriptive
(Lovelock, 1983). Personalized care was among eight important themes emerging among
family planning clinic service users (Becker et al., 2009). Hence this dimension includes
addressing the patient by name, treating patients as individuals and the personalized attention.

Administrative procedures
Hospital administrative procedures include admission, stay and discharge, which comprise a
nonstop interaction. Similarly, administrative procedures include registration, billing, etc.
Facilitation is essential to core service delivery and consumption, while supporting elements
augment the service but are not necessary to its core (Grönroos, 1990; Lovelock et al., 2001).
One important administrative process is the delay at different stages (Duggirala et al., 2008).
During the whole hospitalisation experience, employees should demonstrate that they care
about their patients and ensure that patients feel safe (Boshoff and Gray, 2004). Therefore,
this dimension includes the appointment, waiting time, error-free records and documentation.

Method adopted for designing the framework

Qualitative research methods can be used to study facts, observations and experiences -
empirical indicators when developing an instrument (Knapp, 1998). Churchill’s (1979)
suggestion: using focus groups to develop items is normally used in research that improves
itemization and thus minimizes measurement error – an approach we adopted. Researchers
believe that one or more small focus groups from the study population yield important
observable sentiments and behaviours pertaining to study constructs. Focus groups reduce the
 guesswork when identifying valid items for a new or a revised measure (Ping, 2004). One
focus group - family, relatives and friends, who had visited the hospital known to the
researcher, was also considered. Participants’ familiarity with the researcher, who moderated
the focus group, helped them express their views freely. Although only one focus group
discussion was conducted, it brought out meaningful indicators that supported some well-
established empirical indicators.
Principally for determining the service quality items, we recognised past
recommendations; i.e., that the scale be unique to the specific service situation under
consideration (Babakus and Boller, 1992; Caro and Garcia, 2007; Dabholkar et al., 1996).
Further, Easterby-Smith et al. (2002) advocated borrowing items from other questionnaires,
when much prior questionnaire-based research exists. Pai and Chary (2013) found healthcare
service quality is based on survey research; therefore, items were borrowed from previous
studies for the present framework using nine dimensions; e.g., the healthscape dimension in
our study is similar to tangibles (Choi et al., 2005); infrastructure (Duggirala et al., 2008);
surroundings (Angelopoulou et al., 1998); physical environment and infrastructure
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(Karassavidou et al., 2009) (Table I). Hence, items under each dimension were grouped.
There were items that had similar meaning under each dimension; e.g., ‘Excellent companies
will have modern looking equipment’ an item under the tangibles dimension (Raajpoot,
2004), which is similar to the item ‘Hospital has up-to-date equipment’ under tangibles
(Babakus and Mangold, 1992). These two items are similar to ‘Availability of adequate and
up-to-date technological capability in the hospital (e.g., diagnostic facilities like CT scan,
MRI scans, X-Ray) to serve patients more effectively’, an item under infrastructure
(Duggirala et al. 2008). In such cases only one item is considered from the pool. Thus, our
instrument was designed to measure nine dimensions (Appendix 1). Our instrument is based
on a method adopted by Badri et al., (2005) who designed a patient satisfaction instrument.
The procedure includes generating items for assessing outpatient/inpatient service quality
through an extensive literature review and grouping similar items. We had initially classified
them into ten dimensions that included support (three items), which measured contribution to
society. Each dimension defined an important service quality aspect resulting in a final
instrument for measuring hospital service quality (Pai and Chary, 2012).
To establish content validity, we adopted the Badri et al. (2008) method; i.e., items
were critically and extensively reviewed by academics and students, who found two items
under support: ‘The hospital runs various programs for patients to support different societal
sections’ and ‘The hospital provides medical services with nominal cost to needy patients’ be
grouped under ‘hospital image’ while ‘The hospital provides patients with services beyond
medical treatment’ should be grouped under ‘trustworthiness’. Hence, after reclassifying
certain items, they were subjected to pre-test involving experts. Following the pre-test, the
questionnaire was distributed to patients who were asked to rate all questionnaire items by
assigning a score on a ten-point scale (1, not relevant at all and 10, very relevant) and that
items were quite relevant or very relevant to the scale to which they were assigned, thus
establishing content validity (Badri et al., 2008). Additionally, face validity was tested by
sending the refined questionnaire to several medical consultants asking for their views on the
instrument (Badri et al., 2008). Later, face validity was assessed by asking other medical
professionals for views on the instrument. The questionnaire was deemed a useful service
quality measure and covered important aspects.

Questionnaire design and administration

We use a Likert summated rating scale (Likert, 1932), for measuring opinions, beliefs and
attitudes. Churchill (1979) proposed a negative (reverse-polarity) and positively worded
statements in the questionnaire and found no effect on reliability. Subsequent studies
 suggested that mixing positively- and negatively-worded items affects
consistency/unidimensionality adversely (Herche and Engelland, 1996). Babakus and Boller
(1992) found that all negatively-worded items loaded heavily on one factor while all
positively-worded items loaded on another. They also found that mixing statements created
confusion and frustration for respondents. Other studies reported the same and adopted only
positively-worded statement items and administered the questionnaire with jumbled scale
items (Lam, 1997; Tomes and Ng, 1995; Vandamme and Leunis, 1993). Easterby-Smith et al.
(2012) advocate five good design principles; one, avoiding negatives. Therefore, our
questionnaire did not use negatives. Other good design principles include: (i) each item
expressed only one idea; (ii) jargon was avoided; (iii) simple expressions were used; and (iv)
leading questions were avoided. The questionnaire’s reading level is important; i.e., Streiner
and Norman (1995) suggested that unless the reading level is known, a scale should not
require reading skills beyond sixth grade (a 12 year-old). In Microsoft Word, the document’s
readability statistics can be checked using Flesch-Kincaid Grade Level. According to Pett et
al., (2003), 6.0 on this scale means that a sixth grader can understand the document.
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However, a score 7.0 to 8.0 is recommended for most standard documents. Our Flesch-
Kincaid Grade Level was 7.0, which is acceptable.

Scores
In the healthcare quality measurement literature, scales range from four- to ten-point (Pai and
Chary, 2013). The scaling issues need to be addressed in cross-cultural research, as different
cultures react differently to scaling. A five-point or a seven-point scale may make no
difference in the United States, but could make a significant difference in other countries
(Sekaran and Bougie, 2010). Likewise, cultural practices may condition participants to a
standard metric; e.g., a 10-point scale in Italy (Cooper et al., 2012). A five-point format
reduces respondents’ frustrations and also increases the response rate and response quality
(Lam, 1997). A five-point scale is the easiest to complete and item omission is less frequent
(Nagata et al., 1996). Hence, a balanced rating scale with equal categories above and below
the midpoint was used; each anchored with verbal statements: ‘strongly disagree’, ‘disagree’,
‘neither agree or disagree’, ‘agree’, ‘strongly agree’.

Discussion
Appraising the proposed framework
The nine dimensions that we propose have been used in previous studies but were called
differently; e.g., healthscape as tangibles, surroundings, physical environment, while
personnel has been referred to as staff professionalism, health personnel practices and
conduct. The dimensions we propose and their typology in previous studies is shown in Table
I.

Table I here.

Although there has been continuous debate about SERVQUAL, which is criticized for
various reasons, it has support; Reynoso and Moore (1995) suggest that the instrument is
somewhat applicable and researchers should keep the more generic SERVQUAL dimensions
before adding others that are particular to a specific situation. Carman (1990) suggests
measuring each function separately within a multifaceted service environment with items that
are similar to SERVQUAL. Hence, associating our hospital service quality dimensions with
Parasuraman et al. (1985, 1988), we find that, other than relationship, dimensions can be
equated to Parasuraman et al. (1985,1988) (Table II). Schneider and White (2004, p.40) opine
 that ‘it is important to capture the service quality issues for a particular organisation or
industry than it is to slavishly rely on the published version of SERVQUAL …’.

Table II here.

SERVQUAL (Parasuraman et al., 1988), the generic scale for measuring service quality, with
five dimensions, evolved from Parasuraman et al. (1985), which originally had ten
dimensions. Thus, our nine dimensions are universal to healthcare service quality and fine-
tuning may be done based on the hospital settings. The hospitals can be any type: private,
teaching and public. Two new instruments, PRIVHEALTHQUAL (Ramsaran-Fowdar, 2008)
for private settings and PubHosQual (Aagja and Garg, 2010) for public settings have been
developed for measuring these service quality contexts. Hence, comparing our hospital
service quality dimensions with those instruments, we discover that the relationship
dimension has neither been assessed among PubHosQual (Aagja and Garg, 2010) nor
PRIVHEALTHQUAL (Ramsaran-Fowdar, 2008) (Table III).
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Table III and Figure 1 here.

Service quality, satisfaction and behavioural intentions

Figure 1 shows our framework for measuring hospital service quality captured through nine
dimensions. There seems to be consensus in the literature that satisfaction and service quality
are unique constructs, such that service quality evaluations formed prior to satisfaction
(Brady and Robertson, 2001; Dabholkar et al., 2000; Gotlieb et al., 1994). There is evidence
supporting this causal linkage between healthcare quality and patient satisfaction (Bowers et
al., 1994; Dagger et al., 2007; Reidenbach and Sandifer-Smallwood, 1990; Woodside et al.,
1989). The studies show an indirect relationship between service quality and intentions
through satisfaction (Cronin and Taylor, 1992; Dabholkar et al., 2000; Gotlieb et al., 1994).
A direct relationship between these constructs (Cronin et al., 2000) and service quality was
found to have a greater total effect on behavioural intention than satisfaction (Dagger et al.,
2007). Thus, the model framework’s causal sequence - service quality leads to customer
satisfaction, which leads to behavioral intention have also been suggested by researchers such
as Dagger et al. (2007), Murti et al. (2013b) and Padma et al. (2009).

Conclusion
Quality perceptions have a strong influence on patients desire to use health services (Bellou
and Thanopoulos, 2006). If the system cannot be trusted to guarantee threshold quality then it
will remain underutilized, bypassed, used only for minor ailments or a last resort (Andaleeb,
2001). Moreover, developing country patients are now willing to go to private hospitals and
even travel abroad to a developed country’s hospital when they feel unsafe about healthcare
quality in their public hospitals (Bellou and Thanopoulos, 2006). Therefore, healthcare
quality management practices are important (Van and Koch, 2009), owing to the sector’s
overall influence on the economy (Burns et al., 2008) and the phenomenal change in
hospitals operating globally (Hensher et al., 1999) amounting to rising competition.
Henceforth, healthcare manager knowledge about service quality factors is an important
element in continuous quality improvement. Moreover, rising customer knowledge and
technology improvement mean that quality aspects and factors have changed over time.
Healthcare service quality is difficult to evaluate as credence values are high. Although, there
is a debate about how healthcare should be assessed, authors feel patient perceptions are
valuable healthcare quality indicators. Patient assessment becomes relevant with the patient
centric approach in healthcare. Thus, the proposed model provides insights so that managers
 and academics can evaluate healthcare service quality. Our framework needs an empirical
assessment and calls for studies using these dimensions to affirm the conceptual framework
we propose.

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 Table I: Dimensions and typologies among previous studies

Dimensions Typologies in previous studies

Healthscape Tangibles (Anderson, 1995; Bakar et al., 2008; Choi et al., 2005; Dagger et al.,
2007; Fuentes, 1999; Headley and Miller, 1993; Kara et al., 2005; Kilbourne et
al., 2004; Lim and Tang, 2000; McAlexander et al., 1994; Raajpoot, 2004;
Rohini and Mahadevappa, 2006; Sohail, 2003; Taner and Antony, 2006;
Vandamme and Leunis, 1993; Wisniewski and Wisniewski, 2005; Youssef et
al., 1995); Surroundings (Angelopoulou et al., 1998); Physical Environment
(Arasli et al., 2008); Physical surroundings (Reidenbach and Smallwood,
1990); Pleasantness of surroundings (Otani and Kurz, 2004); Hospital
environment (Camilleri and Callaghan, 1998); Infrastructure (Duggirala et al.,
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2008; Padma et al., 2009; Rao et al., 2006); Physical environment and
infrastructure (Karassavidou et al., 2009); Facility Quality (Mostafa, 2005);
Facilities (Raposo et al., 2009); Amenities/Environment (Rose et al., 2004);
Tangibility/Image (Ramsaran – Fowdar, 2008);
Personnel Professional competence and interpersonal skills for both physicians and
nurses (Angelopoulou et al., 1998); Professionalism of staff (Arasli et al.,
2008); Health personnel practices and conduct (Baltussen et al., 2002);
Professional and technical quality (Camilleri and Callaghan, 1998); Physician
concern and staff concern (Choi et al., 2005); Personal Quality (Duggirala et
al., 2008; Padma et al., 2009); Human aspect (Karassavidou et al., 2009);
Human performance quality (Mostafa, 2005); Human personnel practices and
conduct (Narang, 2010); Interpersonal (Rose et al., 2004)
Hospital Image First Impression (Sower et al., 2001); Image (Zifko-Baliga et al., 1997);
Hospital Image (Padma et al., 2009)
Trustworthiness Dependability (Headley and Miller, 1993); Credibility and security (Taner and
Antony, 2006); Dignity (Tomes and Ng, 1995); Social Support (Rose et al.,
2004); Privacy during visit (Hansen et al., 2008); Social responsibility
(Duggirala et al., 2008; Sureshchandar et al., 2002); Trustworthiness of the
Hospital (Padma et al., 2009)
Clinical Care Process Characteristics (Amira, 2008); Healthcare delivery (Narang, 2010);
Process Medical Care (Raposo et al., 2009); Understanding of illness (Tomes and Ng,
1995); Convenience of care process (Choi et al., 2005); Core service
(Sureshchandar et al., 2002); Process of Clinical Care (Padma et al., 2009)
Communication Information (Sower et al., 2001); Interactive communication (Zifko-Baliga et
al., 1997); Communication (Akter et al., 2008; Taner and Antony, 2006)
Relationship Relationship of mutual respect (Tomes and Ng, 1995); Relationships (Arasli et
al., 2008)
Personalization Service personalization (Camilleri and Callaghan, 1998)
Administrative Administrative services offered (Angelopoulou et al., 1998); Administrative
Procedures responsiveness (Jabnoun and Chakar, 2003); Adminstrative process (Duggirala
et al., 2008); Administrative Procedures (Padma et al., 2009); Administrative
quality (Dagger et al., 2007); Accessibility (Gross and Nirel, 1998);
Access/Waiting time (Rose et al., 2004); Operational care quality (D’Souza
and Sequeira, 2012)
 Table II: Hospital service quality dimensions: a comparison with established scale

Our Dimensions Parasuraman et al., (1985) Parasuraman et al., (1988)

Healthscape Tangibles Tangibles
Personnel Courtesy and competency Assurance
Hospital Image Credibility Assurance
Trustworthiness Security Assurance
Clinical Care Process Reliability and Reliability and
Responsiveness Responsiveness
Communication Communication Assurance
Relationship ---- ----
Personalization Understanding/Knowing the Empathy
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customer
Administrative Procedures Access Empathy and Reliability
 Table III: Hospital service quality dimensions: comparing public and private hospital
instruments

Our Dimensions PubHosQual (Aagja and Garg, 2010) PRIVHEALTHQUAL

(Ramsaran-Fowdar, 2008)
Healthscape Overall Service (factor 3) Tangibility/Image
Personnel Medical services (factor 2) Assurance/empathy
Hospital Image Social Responsibility (factor 5) Assurance/empathy
Trustworthiness Social Responsibility (factor 5) Assurance/empathy
Clinical Care Overall Service (factor 3) Reliability/fair and
equitable
Process
Treatment
Communication Communication not explicitly Information dissemination
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mentioned. However, the dimensions

discharge and overall service
incorporates communication indirectly.
Relationship ----- ----
Personalization ----- Assurance/empathy
Administrative Admission (factor 1) and discharge Core medical services/
Procedures (factor 4) professionalism/skill/
competence

Figure 1: Conceptual framework

Healthscape

Personnel

Hospital Image

Trustworthiness

Clinical Care Process Service Quality Customer Satisfaction Behavioural Intentions

Communication

Relationship

Personalisation

Administrative Procedure
 Appendix 1: Dimensions
Healthscape
1. Modern and up-to-date equipment (e.g., CT and MRI, patient information and billing) to
serve patients more effectively.
2. Physical facilities are visually appealing.
3. Adequacy of different facilities (e.g., wards, beds, OT, ICU).
4. Cleanliness (Clean toilets, clean rooms and wards).
5. Infection-free environment/treatment provided by the hospital.
6. Hospital staff follow adequate hygienic care and procedures (e.g. wearing gloves).
7. The employees of hospital are dressed neatly.
8. Drugs availability.
9. Comfortable ambient conditions with proper lighting.
10. The hospital has an appealing atmosphere.
11. The hospital has clean rooms without foul smell.
12. There are sufficient waiting areas for the patients and patient party.
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13. It is easy to find my way in the hospital.

14. It is easy to find care facilities (lab, Doctor’s office).
15. It is easy to use the amenities (public telephone, cafeteria, etc.,) in the hospital.
Personnel
1. Courtesy shown by hospital administrative staff towards patient and patient party.
2. Doctor and nurse availability.
3. Doctors are competent and skilful.
4. Knowledgeable nurses.
5. Paramedical and support staff competency and skill.
6. The doctors are friendly and caring and understands patient’s feelings and needs.
7. Doctors talked to me frankly and politely.
8. Nursing staff give prompt and timely attention.
9. Nursing staff are polite and well-mannered.
10. Staff at the hospital are polite.
11. Doctors are professional.
Hospital Image
1. Good doctors are available in the hospital.
2. Hospital has a positive reputation.
3. Sincerity, honesty and ethics when providing medical services.
4. The hospital runs various programs for patients to support different societal sections.
5. The hospital provides medical services with nominal cost to the needy patients.
Trustworthiness
1. Patient privacy and confidentiality are maintained by the hospital.
2. Hospital provided services as promised and on time.
3. Equal treatment to all.
4. Confidence in the doctor who treated me in hospital.
5. The hospital provides patients with services beyond medical treatment.
Clinical Care Process
1. Faultless assessment of health conditions by doctors.
2. Explanation provided by doctor about health status, medical tests.
3. Description offered by the doctor about treatment procedures and outcomes.
4. Medical advice and instructions provided by doctor.
5. Diagnosis is only made after careful examination.
6. Doctors spent enough time examining the patient.
Communication
 1. Doctor provide information quickly by to patient.
2. My family was told what they needed to know.
3. Hospital provided adequate information about my illness/treatment(s).
4. Information can be easily obtained.
5. Obtaining information from hospital administrative personnel (e.g., admission, treatment,
discharge) is easy.
6. Extent to which doctors answer patient’s questions and explain treatment that you could
understand.
7. I feel good about the interaction I have with the doctor at the hospital.
8. I feel good about the interaction I have with the nurses at the hospital.
9. I feel good about the interaction I have with other staff at the hospital.
Relationship
1. I have built a close relationship with some staff at the hospital.
2. I have built a close relationship with the doctor at the hospital.
3. I have built a close relationship with the nurses at the hospital.
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Personalization
1. I always get personalized attention from the staff at the hospital.
2. Hospital staff treat me as a human being and not just a patient.
3. The doctor calls me by my name while addressing me.
Administrative Procedures
1. Waiting time to consult the doctors is minimal.
2. Provides right patient services the first time, every time.
3. Reasonable waiting time spent for diagnostic test and treatments.
4. Time between successive processes is minimum.
5. The process for setting up the appointment was simple and easy.
6. Appointment at the hospital runs on time.
7. Hospital records and documentation are error free.
8. The interaction among the departments within the hospital is well managed.
9. I believe the hospital is well-managed.