Comparing Public and Private

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Comparing public and privatehospital care service quality

in Turkey

Tolga TanerInstitute of Biomedical Engineering, Bogazici University, Istanbul, Turkey, and

Jiju AntonyCaledonian Business School, Glasgow Caledonian University, Glasgow, UK

Abstract

Purpose The aim of this article is to examine the differences in service quality between public andprivate hospitals in Turkey.

Design/methodology/approach This study applies the principles behind the SERVQUAL modeland compares Turkeys public and private hospital care service quality. The study sample contains atotal of 200 outpatients. Through the identification of 40 service quality indicators and the use of aLikert-type scale, two questionnaires containing 80-items was developed. The former measuredpatients expectations prior to admission to public and private hospital service quality. The lattermeasured patient perceptions of provided service quality.

Findings The results indicate that inpatients in the private hospitals were more satisfied withservice quality than those in the public hospitals. The results also suggest that inpatients in the privatehospitals were more satisfied with doctors, nurses and supportive services than their counterparts inthe public hospitals. Finally, the results show that satisfaction with doctors and reasonable costs is thebiggest determinants of service quality in the public hospitals.

Originality/value Consequently, SERVQUAL, as a standard instrument for measuring functionalservice quality, is reliable and valid in a hospital environment.

KeywordsHospitals, Turkey, Perception, SERVQUAL

Paper typeResearch paper

IntroductionService quality is an abstract and elusive construct. Its intangible, variable andinseparable characteristic is unique to services (Zeithmal et al. 1990). Service qualityhas been increasingly identified as a key factor in differentiating services and buildingcompetitive advantage. Therefore, understanding, measuring and improving quality isa formidable challenge for all organizations since they compete to some degree on thebasis of service. More and more executives in manufacturing and service businesses

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Care servicequality in

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Leadership in Health Services

Vol. 19 No. 2, 2006

pp. i-x

q Emerald Group Publishing Limited

1366-0756

DOI 10.1108/13660750610664991


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are interested in service quality and believe that high quality pays off, creates truecustomers and leads to efficiencies.

Services have been categorized as being either consumer services (e.g. departmentstores) or professional services (e.g. health care). On a product-service continuum,

professional services come close to being pure services. They are offered, byprofessionals, frequently no tangible output is exchanged, the service is produced andconsumed simultaneously, the service is non-storable and the consumer is animportant part of what actually is delivered. As a result, service quality is moredifficult for customers to evaluate than goods quality. Customers evaluate servicequality both on the outcome of the service and the process of service delivery.

Health care services have a distinct position among other services due to the highlyinvolving and risky nature of services and the general lack of expertise possessed byconsumers. This makes conceptualizing and measuring customer satisfaction andservice quality in health care settings more important and at the same time morecomplex. To maintain and improve the quality of health care services, besides relyingon clinical and economic criteria, administrators should utilize the feedback throughpatient perceptions of care surveys. Adopting the marketing concept to health care,requires that the providers be consumer-oriented, and concern themselves with thesatisfaction of their patients. As hospitals and other health care providers begin toimplement better and sophisticated patient surveys, they will understand the strengthsand weaknesses of their organization from the patients point of view.

A better understanding of how consumers evaluate the quality of health care willhelp administrators and service providers, in determining and improving weakeraspects of their health care delivery system. With continuous monitoring of patientperceptions and improvements based on patient feedback, quality of care and patientsatisfaction will improve.

MethodsThe main purpose of this study is to provide health care administrators and marketerswith a conceptual and operational framework integrating patients expectations andperceptions of services with their quality of assessments and satisfaction judgments.To serve this purpose, a customized service quality measurement scale, namelySERVQUAL, is used in order to work on the dimensions by which patients evaluateservice quality in hospitals. This scale is distributed evenly to 200 patients in twodifferent types of hospitals in Istanbul to find out whether service quality expectations,perceptions and evaluations of patients change in different hospitals. This will alsoenable us to make a comparison of the expected and perceived public and privatehospital care service quality in Turkey.

Yet, a number of researches on patient satisfaction have been carried out in public,university and private hospitals in Turkey (Alakavuk, 1996; Tengilimoglu et al., 1999).

In order to be able to develop service-marketing models, a clear picture of whatcustomers in the marketplace really looking for and what they are evaluating isnecessary. Service quality is a function of range of resources and activities. A model ofservice quality will be useful if it can be defined to guide management decisions. Todevelop such a model, the first step is to define how service quality, is perceived by theconsumers and in what way service quality is influenced (Gronroos, 1984).

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Quality is a judgmental concept. The real operational definition of quality is basedon values and perceptions, or attitudes (Taylor and Cronin, 1994). The key implicationof this observation for the development of quality measures is that these measures aremost useful if based on the judgments of experts, specifically customers and

practitioners in health care.Satisfaction is a customers post-purchase evaluation of a product/service offering

(Bolton and Drew, 1991). A customer is satisfied when an offering performs better thanexpected and is dissatisfied when expectations exceed performance. More specifically,an individuals expectations are confirmed when a product performs as expected;negatively disconfirmed when the product performs more poorly than expected;positively disconfirmed when the product performs better than expected (Churchill andSurprenant, 1982).

The consumers experience of a service can be expected to influence hispost-consumption evaluation of the service quality, which he has experienced(Gronroos, 1984). Perceived quality of a service will be the outcome of an evaluationprocess, where the consumer compares his expectations with the service he perceiveshe has received. Perceived quality is the consumers judgment about an entitys overallexcellence or superiority (Zeithaml, 1988). It results from a comparison of expectationswith perceptions of performance (Parasuraman et al., 1985). Perceived service quality isan overall judgment or attitude relating to the superiority of the service, whereassatisfaction is related to a specific transaction. Quality and satisfaction are related butdistinct constructs, in that, incidents of satisfaction over time result in perceptions ofservice quality (Parasuraman et al., 1985). The SERVQUAL approach developed byParasuman et al., for measuring service quality assesses both the consumers serviceexpectations and perceptions of the providers performance.

Positioned as a generic method applicable to a wide range of service industries,SERVQUAL have been widely applied and frequently reported in the literature. The

SERVQUAL scale has been used in a wide variety of studies in health care to assesscustomer perceptions of service quality in a number of service categories such as acutecare hospital (Carman, 1990); independent dental offices (McAlexanderet al., 1994); atAIDS service agencies (Fusilier and Simpson, 1995); with physicians (Brown andSwartz, 1989; Walbridge and Delene, 1993) and nurses (Uzun, 2001); hospitals(Camilleri and OCallaghan, 1998; Lim and Tang, 2000; Alakavuk, 1996).

In this study, a six-point Likert-type scale ranging from strongly agree (6) tostrongly disagree (1) was used. Our questionnaire contained the SERVQUAL scale,with a total of 80 statements relating to patients expectations on the quality of servicethat hospitals should offer and their perceptions of the quality of service actuallydelivered. Answers to the questionnaire were taken from the patients on the phone whohad been discharged from the hospital with the previous six months. Age, education

level and the influence factor on the choice of the hospital were also asked to thepatient. For this purpose, the original 22-item SERVQUAL scale of Parasuman et al.,were supplemented by items specific to the health care setting. Those items werederived from the service quality studies in health care settings (Taylor and Cronin,1994; Reidenbach and Sandifer-Smallwood, 1990; Woodside et al., 1989) and theinformation gathered from hospital stays of experienced patients. The items in theexpectations and perceptions sections fall under the ten dimensions revealed by theexploratory research of Parasuraman et al. (1985).


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The distribution of items under the dimensions, are as follows: tangibles (eightitems), reliability (four items), responsiveness (seven items), competence (five items),courtesy (three items), credibility (one item), security (two items), access (two items),communications (six items), understanding (two items) and cost (one item). Cost was

added as a dimension due to the fact that it came out as a dimension in the dental clinicstudies of Carman, 1990 and price is added to the transaction specific and globalquality framework of Parasuraman et al., 1985.

The original ten dimensions of SERVQUAL were reduced to five for analysis.Tangibles, reliability and responsiveness are the same as the original dimensions butthe last two dimensions, namely assurance and empathy contain items representingseven original dimensions.

In this study, the indices of mean expectation (E), perception (P) and gap scores(P-E) are calculated for each quality dimension of tangibles, reliability, responsiveness,empathy and assurance. The gap score is calculated by subtracting the expectationsfrom perceptions and numbers are mean values ranging from (2)5 to ()5 on whichzero implies that patient perceptions and expectations coincide, negative values implyperceptions fall short of expectations and positive values imply that perceptions exceedexpectations. Mean values for perceptions (P) and expectations (E) range from 1 to 6,where (1) is strongly disagree and (6) is strongly agree meaning higher scoresindicate higher expectations and better patient evaluations for that item.

DiscussionExpectationsThe means for all 40-items in the expectation section for private hospitals are above5.30 ranging from the highest 5.97 for up-to-date equipment and technology to thelowest 5.30 or taste of food. Among the five dimensions, expectations for privatehospitals are highest for Assurance (5.745) a dimension that covers the issues ofcompetence, courtesy, credibility and security. Assurance is followed by reliability(5.752), which includes issues like the right and the prompt service performances, i.e.the ability to perform the promised service dependably and accurately. Expectationsfor private hospitals are lowest for responsiveness (5.526).

On the other hand, the means for all 40-items in the expectation section for publichospitals are above 5.00 ranging from the highest 5.92 for up-to-date equipment andtechnology to the lowest 5.04 for ease of admission and performance of servicesprompt every time. Among the five dimensions, expectations for private hospitals arehighest for assurance (5.54) and lowest for reliability (5.248).

Overall the mean expectation score is 5.537. These high values were anticipatedtaking into consideration the unique characteristics of hospital services. These

findings are in accordance with Parasuramanet al.(1991) where they found a mean of6.22 on a seven-point scale. They also argued that those high mean values were nottotally unanticipated because the items were intended to measure customersnormative expectations.

Expectations of patients are very high for hospital services, which may be due totwo reasons:

(1) The should terminology used in the expectation statements.

(2) Distinctive characteristics of health care services.

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The important thing at this point is to define the two levels of expectations, i.e.adequate and desired. The difference between those two levels will give the zone oftolerance of the consumers of that service (Zeithamlet al., 1993). Due to the complexityof the need served by health care and the immeasurable value of good health and life as

an asset, the zone of tolerance is rather small when compared to other services.Therefore, the use of should terminology is adequate especially for hospital servicesthat make up the core product benefit or related to the medical outcome.

Realistic expectation scales are very useful for hospital administrators andmarketers in designing improvement and marketing plans to differentiate theirservices from competitors and to serve the needs of patients better.

PerceptionsThe means for all 40-items in the perceptions for private hospitals are above 4.60 ranging from the highest 5.94 for politeness of hospital personnel to the lowest 4.69for reasonable costs. Among the five dimensions, perceptions for private hospitals

are highest for Assurance (5,625) and within that dimension, highest perception meansare for politeness of hospital personnel. Private hospitals get the best evaluation fromthe patients on sense of security/trust doctors and nurses provide andknowledgeable doctors and nurses as well. The evaluation of patients fall to 5 orbelow for taste of food, availability of parking, performance of only necessarytests/treatments and reasonable costs. These are the areas where private hospitalsneed to work on to improve patients evaluation of services on service quality.

The means for all 40-items in the perceptions for public hospitals are above 4.00 ranging from the highest 5.86 for knowledgeable doctors to the lowest 4.06 forwaiting time for tests. Among the five dimensions, perceptions for public hospitalsare highest for Assurance (5,157) and within that dimension, high perception means arefor knowledgeable and experienced doctors. This is an important indication that

patients trust the knowledge and experience of doctors. However, the perceived senseof security patients get from doctors is lower that the above mentioned means whichindicate that lowered patient confidence in a successful medical outcome is not due toknowledge and experience of doctors but to some other factors like lack ofcommunication between patients and doctors. This is also reflected in the lowerperception scores and highest gap scores of patients on attributes making up theempathy dimension of hospital services like information flow and communication.

Perceptions for public hospitals are lowest for reliability (4,548). Tangibles are thesecond lowest for public hospitals with a perception of 4.811. The evaluation ofpatients fall to 4.50 or below for cleanliness and hygienic of the toilets, taste of food,waiting time for tests, performance of services prompt every time, convenientservice delivery sites for patients, politeness of hospital personnel and favorable

attitude towards visitors. These are the areas where public hospitals need to work onto improve patients evaluation of services on service quality.

The overall mean perception score is 5.152. In a similar study, John (1991) hadperception means ranging from 3.67 to 4.54 on a five-point scale (see Table I).

The mean differences across two hospital types are significant for all fivedimensions at 95 percent confidence interval. The overall service quality mean is alsosignificant across hospital types. Service quality is higher in private hospitals (5.458)than in public hospitals (4.866).


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Gap scoresIn examining the mean gap scores, one can observe that some values are positivemeaning that expectations fall short of perceptions on nine items in private hospitalsand one item in public hospitals. Among five dimensions: assurance, empathy and

responsiveness have positive gap scores. This can be due to the increasing importancegiven in private hospitals to hospitality and hotel services. The gap in private hospitalsis the largest for availability of parking and the lowest for respect for patientsprivacy (see Table II).

On the other hand, the gap in public hospitals is the largest for waiting time fortests and the lowest for knowledgeable doctors.

If the mathematical difference between the two gap scores is examined for eachitem, one can determine for which items there is a crucial difference in terms of servicequality in two types of hospitals. This difference is high, i.e. above 0.75, for thefollowing seven-items: personal attention of nurses to the patient, favorable attitudetowards visitors, politeness of hospital personnel, favorable attitude towardsvisitors, cleanliness and hygienic of the toilets, cleanliness and hygienic of theroom and waiting time for tests.

The gap is largest for reliability in private hospitals and tangibles in publichospitals. The overall gap mean score is 20.38.

ConclusionSERVQUAL, as a standard instrument for measuring functional service quality, isreliable and valid in a hospital environment. Therefore, it can be used as a tool by

Dimension/item Mean values

E P Gap scoreTangibles Private Public Private Public Private Public

Up-to-date equipment and technology 5.97 5.92 5.88 5.41 20.09 20.51Visually appealing hospital/room 5.74 5.40 5.48 4.85 20.26 20.55Peaceful/quiet hospital environment 5.69 5.51 5.47 4.81 20.22 20.7Cleanliness and hygiene of the room 5.93 5.58 5.74 4.64 20.19 20.94Cleanliness and hygiene of the toilets 5.89 5.52 5.68 4.40 20.21 21.12Taste of food 5.30 5.12 4.68 4.34 20.62 20.78Appearance of hospital personnel 5.72 5.61 5.66 5.06 20.06 20.55Availability of parking 5.44 5.62 4.71 4.98 20.73 20.64

Table I.Mean perception,expectation and gap scoreof tangibles

Dimension/item Mean valuesE P Gap score

Reliability Private Public Private Public Private Public

Waiting time for tests 5.75 5.22 5.34 4.06 20.41 21.16Performance of services right every time 5.78 5.17 5.40 4.61 20.38 20.56Accuracy of medical/expense reports 5.70 5.56 5.27 5.38 20.43 20.18Performance of services prompt every time 5.78 5.04 5.46 4.14 20.22 20.90

Table II.Mean perception,expectation and gap scoreof reliability

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hospital administrators for the measurement of functional quality in theirorganizations. Measuring the opinion of patients can help facilitate hospital serviceprovision and management as well as increase the marketability and desirability of theservice provided.

The SERVQUAL scale used in this study, demonstrates that consumers behavedifferently in the health care setting and evaluate service quality by unique dimensionssuch as: tangibles, competence, understanding, admission and communication with thephysician. With a better understanding of how patients evaluate the quality of healthcare services, health care providers and administrators can improve the health caredelivery system. Continuous monitoring of patient expectations and perceptions willimprove the quality of health care and patient satisfaction (see Table III).

Gap scores give valuable insights on the scope of improvement necessary to getbetter overall quality evaluations from patients on the hospital services. Large gapscores indicate that there is more space for improvement in that service area. Sincebetter service quality can be attained by trying to close the gap between perceived

service quality and expected service quality, hospital administrators and managerscan make use of the gap scores to improve service quality in their hospitals in thedirection of patient expectations.

Private hospitals in Turkey excel on the dimension of Assurance. This is anindication that private hospitals are better at hospital hotel services. In recent years,with the changing of consumer needs and wants and the increase in third party payerssuch as insurance companies and government, the health care environment changedand the private hospitals have been more receptive to those changes for turning theminto a competitive advantage. They especially gave importance to both medical andnon-medical physical environment, which refers to any physical evidence of the servicesuch as appearance and attitude of the personnel, design and layout of the facility,up-to-date equipment and technology and visiting hours. This conclusion is also

supported by positive gap scores of private hospitals in items responsiveness to theneeds of the patients family and favorable attitude toward visitors.


Responsiveness Private Public Private Public Private Public

Ease of admission 5.86 5.04 5.67 4.53 20.19 20.49Readiness of nurses/personnel toprovide service

5.72 5.29 5.84 5.06 0.12 20.23

Readiness of doctors to provideservice

5.46 5.42 5.51 5.11 0.05 20.31

Responsiveness to the needsof family 5.44 5.38 5.80 4.79 0.36 2

0.59

Convenient timing of servicesfor patients

5.52 5.14 5.40 4.66 20.12 20.48

Convenient service delivery sitesfor patients

5.32 5.05 5.02 4.26 20.30 20.79

Availability of skillful/experiencedpersonnel on weekends

5.31 5.09 5.07 4.56 20.24 20.53

Ease of discharge 5.68 5.74 5.62 5.6 20.06 20.14

Table III.Mean perception,

expectation and gap scoreof responsiveness


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Health care personnel at all levels and positions in hospitals are at critical points. Thefindings of this study can help all health care personnel including doctors, nurses, andall personnel employed at any level and position in hospitals. This study suggests thatpatients also pay attention to the ease of communication and availability of

information. It also shows that there is a lack of communication between the patientsand the hospital personnel in Turkish public hospitals. Communication between thepatient and the service provider is a two-way process involving listening to thepatients concerns and informing patients about their medical experiences. Doctors andnursing personnel should be encouraged to share information about the patientsmedical condition with the patient. The importance of communication between thepatient and the service provider should be emphasized. If needed, hospital personnelshould be educated to plan their time more effectively and efficiently, emphasizingthose activities that have direct influence on quality evaluations (see Table IV).

Time factor is very important for the doctor taking into consideration the heavypatient load of doctors in Turkey. Ease of reaching and communicating with the doctor

stands out as a very important dimension in service quality. Therefore, doctors shouldwork on to improve their communication with the patient to make it efficient time-wise.The medical personnel also play an important role in the decision making of

patients for their future choice of hospitals. They should find out about individualneeds of patients and adjust their bedside manner accordingly. The most influentialfactors on Turkish patients on the choice of hospital are the recommendations offriends and relatives and the presence of a physician the patient can trust at thehospital. When patients perceive high health care quality, they are more likely toreturn to the same hospital in the future and recommend their services to relatives andfriends. In Turkey, service quality evaluations of patients in private hospitals arehigher than the evaluations of patients in public hospitals. In addition, younger peoplewith higher education and income levels perceive lower levels of service quality in

hospitals (see Table V).Further, qualitative information (i.e. direct customer comment) can facilitate the

information given to specific questions and should be utilized to further understandand interpret trends that appear to be occurring in certain hospitals. This appears to be


Assurance Private Public Private Public Private Public

Knowledgeable doctors 5.88 5.91 5.73 5.86 20.15 20.05

Knowledgeable nurses 5.79 5.59 5.70 5.46 2

0.09 2

0.13Experienced doctors 5.94 5.91 5.60 5.81 20.34 20.10Experienced nurses 5.78 5.86 5.52 5.49 20.26 20.37Respect for patients privacy 5.69 5.20 5.66 4.48 20.03 20.68Politeness of hospital personnel 5.80 5.11 5.94 4.24 0.14 20.87Favorable attitude towards visitors 5.77 5.29 5.86 4.31 0.09 20.98Performance of only necessary tests/treatments 5.44 5.57 4.66 5.02 20.78 20.55Sense of security/trust nurses provide 5.60 5.52 5.80 5.29 0.2 20.23Sense of security/trust doctors provide 5.76 5.44 5.78 5.61 0.02 0.17

Table IV.Mean perception,expectation and gap scoreof assurance

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Further reading

Coleman, V., Xiao, Y.D., Bair, L. and Chollett, B. (1997), Toward a TQM Paradigm: UsingSERVQUAL to Measure Library Service Quality, College and Research Libraries,pp. 237-51.

Parasuraman, A., Zeithaml, V.A. and Berry, L.L. (1988), SERVQUAL: a multiple-item scale formeasuring consumer perceptions of service quality, Journal of Retailing, Vol. 64 No. 1,pp. 12-40.

Parasuraman, A., Zeithaml, V.A. and Berry, L.L. (1994), Reassessment of expectations as a

comparison standard in measuring service quality: implications for further research,Journal of Marketing, Vol. 58, January, pp. 111-24.

Corresponding authorTolga Taner can be contacted at: [email protected]

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Comparing Public and Private