Service Quality Case

8/13/2019 Service Quality Case

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Journal of Services Research,Volume 6, Number 1 (April 2006 - September 2006)

2006 by Institute for International Management and Technology. All Rights Reserved.

In todays highly competitive environment, hospitals are increasingly realizing the

need to focus on service quality as a measure to improve their competitive position.

Customer based determinants and perceptions of service quality, therefore, play an

important role when choosing a hospital. In this paper, we present a service qualityperception study-undertaken in five hospitals in Bangalore city. The well-documented

Service Quality Model was used as a conceptual framework for understanding

service quality delivery in health care services. The measuring instrument used

in this study was the SERVQUAL questionnaire for the measurement of Gap 5

and Gap 1. An analysis covering a sample of 500 patients revealed that there

exists an overall service quality gap between patients perceptions and their

expectations. An analysis covering a sample of 40 management personnel revealed

that a gap between managements perception about patients expectations and

pat ien ts expectations of service qualit y also exists . The study sugges ts

improvements across all the five dimensions of service quality - tangibles,

reliability, responsiveness, assurance and empathy.

R. Rohini B. Mahadevappa

INTRODUCTION

Research evidence in both the manufacturing and services

industries indicates that delivering high service quality produces

measurable benefits in profit, cost savings and market share

(Ziethaml, Berry and Parasuraman, 1988). In India, the past few years

have witnessed an increasing concern regarding the quality of

healthcare services. The globalisation and liberalisation policies have

significantly changed the health care scenario in India. With increasing

awareness, the patients, as consumers expect quality in healthcare

services. Quality has been shown to be an important element in the

consumers choice of hospitals (Lynch and Schuler, 1990). In the light

of these changes, there is an emerging need to improve the quality of

healthcare services.

Researchers commonly divide service quality into two components:

technical quality and functional quality (Gronroos, 1984: Parasuraman

et al., 1985: Lewis and Mitchel, 1990: Lewis, 1991). Technical quality

SERVICE QUALITY IN BANGALORE HOSPITALS

AN EMPIRICAL STUDY


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Journal of Services Research, Volume 6, Number 1 (April 2006 - September 2006)

60 Service Quality in Bangalore Hospitals

is defined primarily on the basis of technical accuracy and procedures.

Functional quality refers to the manner in which service is delivered to

the customer. In the health care setting, patients understandably tend

to rely on functional attributes (eg., facilities, cleanliness, quality of

hospital food, hospital personnels attitudes etc.,) rather than technical

attributes when evaluating the service quality because they are unable

to evaluate the technical quality due to lack of expertise (Babakus and

Boller, 1991: Lanning and OConnor, 1990).

This paper presents the results of a service quality perception study

designed to measure the patients perceptions and expectations of service

quality in five Bangalore based hospitals, using the multidimensional,generic, internationally used market research instrument called

SERVQUAL (Parasuraman et al., 1988). The same instrument has been

used to measure the managements perceptions about patients

expectations and actual patients expectations across all the five

hospitals. The SERVQUAL instrument has been widely used in many

service industries, including hotels, dentistry, travel, higher education,

real estate, hospitals and architecture. The advantages of SERVQUAL

include the following (Buttle, 1994):

l It is accepted as a standard for assessing different dimensions of

service quality.

l It has been shown to be valid for a number of service situations.l It has been known to be reliable.

l The instrument is parsimonious in that it has a limited number of

items. This means that customers and employers can fill it out

quickly.

l It has a standardized analysis procedure to aid interpretation and

results.

The present study covers a sample of five hospitals- a Super

Specialty hospital (A), a Missionary hospital (B), a Government hospital

(C), a Teaching hospital (D) and a Multi- Specialty hospital (E) based

in Bangalore city, Karnataka, India.

LITERATURE REVIEW

The research literature on service quality has thrown numerous models

by different researchers across the world. Health care service quality is


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61 Rohini, Mahadevappa

multi dimensional. The multi - dimensionality of healthcare quality was

supported by Griffith and Alexander (2002). Given the consumers

propensity to switch service providers rather than complain, it is of

paramount importance for hospitals to be acutely aware of what the

general public looks for while evaluating the professional service of a

particular hospital.

Perception of hospital care is derived from a set of criteria based

on perceptual cues that patients use. Lehtinen and Laitamaki (1985)

present a holistic view on how to measure, monitor, and operationalise

customer perceptions of service quality in health care organisations.

John (1989) argues that there are four dimensions of health care servicequality: the curing dimension, the caring dimension, the access

dimension, and the physical environment dimension. However, most

of the studies of health care quality are based on SERVQUAL, a generic,

internationally used market research instrument.

Reidenbach and Sandifer-Smallwood (1990) developed an

instrument based on the original ten-dimension questionnaire developed

by Parasuraman et al. (1985). They analysed patient service needs by

examining the differing perceptions of service held by patients in three

basic hospital settings: emergency room services; inpatient services;

and outpatient services. Differential impacts were found in all the three

hospital settings.

Babakus and Mangold (1992) empirically evaluated SERVQUAL

for its potential usefulness in a hospital service environment. The

completed perceptions and expectations scales met various criteria for

reliability and validity. Suggestions were provided for the managerial

use of the scale and a number of future research issues were identified.

An empirical study in a Belgian hospital by Vandamme and Leunis

(1993) has been reported on the development of an appropriate multiple-

item scale to measure hospital service quality. Discrepancies between

SERVQUAL and the dimensions obtained from their study were discussed

in some detail, along with the reliability and validity properties of the

scale.

Bowers et al. (1994) studied the five attributes of quality fromSERVQUAL model. Their results from a quantitative analysis lend

support to qualitative conclusions. Caring and communication were

found to be significant. Three of the generic SERVQUAL dimensions


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were found to be related significantly to patient satisfaction: empathy,

responsiveness and reliability.

Anderson (1995) measured the quality of services provided by a

public university health clinic, using a 15-item instrument representing

the five dimensions of SERVQUAL. According to her findings, all the

five dimensions measured negatively, assurance being most negatively

measured. Based on these results, Anderson made some

recommendations for budgeting future quality improvement projects.

Youssef et al.(1995) measured service quality in West Midlands

NHS hospital and in all the five dimensions of SERVQUAL that were

measured found that patients perceptions failed to meet their

expectations. Another study by Youssef (1996) revealed reliability as

the most serious problem facing the NHS hospital providers involved

in their study.

A study by Sewell (1997) in the NHS hospitals showed reliability

as the most important dimension, followed by assurance. Empathy and

responsiveness were found to be of equal importance, while tangibles

was found to be the least important dimension.

Lim and Tang (2000) attempted to determine the expectations and

perceptions of patients in Singapore hospitals through the use of

modified SERVQUAL that included 25 items representing six

dimensions; namely, tangibles, reliability, assurance, responsiveness,

empathy, and accessibility and affordability. Their study revealed theexistence of an overall service quality gap between patients perceptions

and expectations.

Jobnoun and Chaker (2003) compared the service quality rendered by

private and public hospitals in the UAE. They used the ten-dimensions

instruments developed by Parasuraman et al. (1985) namely, tangibles

(7 items); accessibility (5 items); understanding (3 items); courtesy (3 items);

reliability (2 items), security (2 items); credibility (2 items); responsiveness

(7 items); communication (3 items) and competence (5 items). Their study

revealed that there is a significant difference between private and public

hospitals in overall service quality.

The literature survey suggests a study for the existence of research gap

in service quality of health care sector in India. To fill this research gap, aservice quality perception study was undertaken in five Bangalore based

hospitals.


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RESEARCH OBJECTIVES

The specific objectives of the study were to determine:

l how well the hospitals in Bangalore city were meeting the patientsexpectations on the service quality dimensions.

l service quality scores by dimensions and overall service quality index.

l the relative importance of the five dimensions to the customers.l managements perceptions of patients expectations.

HYPOTHESES

Two hypotheses were formulated for testing this study. They were:

a) Patient Perceptions of Service QualityH

0: There is no difference in patients perception of service quality

among the five hospitals.

H1: There is a difference in patients perception of service quality among

the five hospitals.b) Managements Perceptions about Patients Expectations.

H0: There is no difference in managements perception of patients

expectations of service quality among the five hospitals.

H1: There is a difference in managements perception of patients

expectations of service quality among the five hospitals.

METHODOLOGY

A Conceptual Model of Service QualityThe well-documented Service Quality model of Parasuraman et.al. (1985)

was used as a conceptual framework for measuring service quality deliveryin Health Care Services.

The service quality model indicates that consumers quality perceptionsare influenced by a series of four distinct gaps occurring in organisations.

These gaps on the service providers side, which can impede delivery ofservices that consumers perceive to be of high quality, are:

Gap 1: Differences between patient expectations and managementperceptions of patient expectations.

Gap 2: Difference between management perceptions of patient expectations

and service quality specifications.Gap 3: Difference between service quality specifications and service actually

delivered.

Gap 4: Difference between service delivery and what is communicated about

the service to patients.


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Perceived service quality (Gap 5) is defined in the model (fig. 1) as the

difference between consumer expectations and perceptions, which in turn

depends on the size and direction of the four gaps associated with the

delivery of service quality on the marketers side.

Word of mouth

communications

Personal

needs

Past

Experience

Expected Service

Perceived Service

Servicedelivery(includingpre and post-

contacts)

Translation ofperceptions into

service quality specs

Managementperceptions ofConsumer

expectations

Externalcommunications

to others

GAP 5

GAP 4

GAP 2

GAP 3GAP 1

Consumer

Marketer

Figure 1: Conceptual Model of Service Quality

[Source: Parasuraman et al (1985)]

In the Service Quality Gaps Model, an underlying assumption is that

service quality is critically determined by measuring the gap between


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customers expectations of a service and their perceptions of the service as

actually experienced.

Sample

The present study was designed with the co-operation of five Bangalore

based Hospitals.The management teams were up-to-date with the current

literature and emphasised the pragmatic aspects of the research. Their active

involvement helped in the assessment of reliability and ensured that the

research instrument would be of practical significance. Hospitals were

stratified on the basis of Specialty-Non Specialty, Government-Private and

Missionary, ISO-9000 certified and ISO-9000 Non- certified. The samplehospitals consisted of A-a single specialty, ISO-certified, private hospital; B

- a Missionary, ISO-9000 certified, general hospital; C- a Government, ISO-

9000 Non- certified hospital; D- a Medical college attached, ISO-9000 Non-

certified, private hospital; E-a multi specialty, ISO9000 Non- certified,

private hospital. In these five hospitals, a sample of 500 patients were

randomly selected to measure Gap 5 and a sample of 40 hospital executives

were randomly selected to measure Gap 1. The sample of hospitals, patients

and hospital executives are presented in Table 1.

Table 1: Sample of Hospitals, Patients and Hospital Executives

Hospital Type Patients Hospital Executives

Bed size SpecialityOwnershipIso-9000

Samplesize

Sex Age /Education

Samplesize

Sex Age/Education

A100

SinglePrivatecertified

100 M:72

F: 28

35-80yrs/S.S.L.C-

PG

7 M:5

F: 2

40-50yrs/Graduation-PG

B160

GeneralMissionary

certified

100 M:35

F:65

15-80yrs/S.S.L.C-

PG

11 M:3

F:8


C

450

GeneralGovernmentNon-certified

100 M:49

F: 51

15-80yrs/Primary-

Graduation

6 M:3

F: 3


D750

GeneralPrivate

Non-certified

100 M:42

F: 58

10-80 yrsPrimary-

Graduation

7 M:3

F: 4


E

350

Multi-specialtyPrivate

Non-certified

100 M:56

F: 44

10-80 yrsPrimary-PG

9 M:6

F :3



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The Research Instrument

The questionnaire used in this study followed the basic five dimensions of

the SERVQUAL instrument developed by Parasuraman et al (1988). The

instrument includes 22 items: four items belong to tangibles dimension;

five items belong to reliability dimension; four items belong to

responsiveness dimension; assurance dimension has four items and empathy

dimension has five items. Respondents were asked to mark their extent of

perception and expectation on a seven-point scale. The first section of the

questionnaire contained the SERVQUAL scale, with 22 statements relating

to patients expectations on the quality of service that the hospital should

offer and 22 corresponding items relating to their perceptions of the qualityof service actually delivered in a specified hospital. This simultaneous

administration of expectations and perceptions statements is consistent

with the methodology employed by the developers of SERVQUAL.

Data collection and Analysis

The primary data on 500 patients expectations and perceptions were

collected in five hospitals using SERVQUAL research instrument to

measure Gap 5. Personal interviews with the patients were also

conducted. Out of the 75 distributed questionnaires among hospital

executives, 40 responses were received to measure managements

perceptions about patients expectations of hospital service (Gap 1).

The response rate for patients sample was hundred percent, where as

for hospital executives sample, it was 53.33 percent.

Reliability was tested using the Cronbach alpha coefficient. Simple

one-way ANOVA was used to test whether any significant difference

exists in the perceptions of patients service quality among the hospitals

(Hypothesis 1) and managements perceptions about patients

expectations among the hospitals (Hypothesis 2). Averages were used

to measure expectation and perception scores. Statistical Package for

Social Sciences (SPSS) was used for data analyses.

Reliability and Validity

The internal consistency method (Nunnally, 1978) was chosen to assess

the reliability of the research instrument used in this study. The internal

consistency of a set of measurement items refers to the degree to which

items in the set are homogeneous. Internal consistency can be estimated

using a reliability coefficient such as Cronbachs alpha (Cronbach, 1951).


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Cronbachs alpha is computed for a scale based on a given set of items.

Using the reliability programme, (Hull and Nic, 1981), an internal

consistency analysis was performed separately for the items of each of the

five dimensions of SERVQUAL. Table 2 presents the reliability co-efficient

associated with the five dimensions of service quality. The reliability co-

efficient ranged from 0.887 to 0.934 for expectation scores and from 0.905

to 0.928 for perception scores. Typically, reliability co-efficient of 0.7 or

more are considered adequate (Cronbach, 1951, Nunnally, 1978).

Accordingly the scale used here was judged to be reliable.

Table 2: Results of Reliability Analysis

Cronbachs Alpha

SERVQUAL

DimensionsNo. ofItems

Expectation

Score

Perception

Score

TangiblesReliability

Responsiveness

AssuranceEmpathy

454

4

5

0.9340.9340.887

0.8840.893

0.9230.9280.915

0.9050.912

Overall Score 22 0.950 0.906

The SERVQUAL questionnaire also fulfils the more practical requirements

of validity as found in a number of studies (Vandamme, R. and Leunis,J

1993; Parasuraman et al, 1988).

RESULTS AND DISCUSSION

The results of the study include analyses of Gap 5 and gap 1.


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Gap - 5: Patient Perceptions of Service Quality

In Table 3, the average expectation and perception scores are presented for

each statement in the SERVQUAL questionnaire. The aggregated dimensional

scores and overall service quality among the five hospitals are reported in

Table 4. The comparative hospitals means of the five servqual dimensions

and their overall service quality scores are presented in Table 5.

Table 3: Average Scores on Expectations,

Perceptions and Difference between Expectation

and Perception: Gap-5 (n=500)

SERVQUAL Dimensions and their Items P

score

E

score

(P-E)

Score

Tangibles

Excellent hospitals will have modern looking equipment. (eg., C.T. Scan, X-Ray, M.R.I.Scan, Tread mill etc.).

The physical facilities at excellent hospitals are visually appealing. (eg., well maintained

reception area, computerized billing and registration facilities, neat and clean pathology,biochemistry labs, hospital rooms, canteen etc.).

Personnel at excellent hospitals will be neat in appearance (eg., staff with uniform andappropriate name badges, professional appearance of staff etc.).

Materials associated with the services will be visually appealing in an excellent hospital.(eg., clean and comfortable environment with good directional signs, informative

brochures about services, stretcher, wheel chairs, well maintained records etc.).

Reliability

When excellent hospitals promise to do something by a certain date, they do so. (eg.,

tests, follow up checks, surgeries etc.).

When a patient has a problem, excellent hospitals will show a sincere interest in solvingit. (eg., registration ,calling the concerned doctor to attend the case etc.).

Excellent hospitals will be dependable (eg., services provided at appointed time, error-free and fast retrieval of documents, good communication, good treatment etc.).

Excellent hospitals will provide their services at the time they promise to do so.(eg.,emergency care, casualty services etc.).

Excellent hospitals will get the things right the first time.(eg., correct diagnosis, prompttreatment etc.).

5.33

5.32

5.66

5.46

5.44

5.42

5.59

5.46

5.59

5.68

5.73

5.97

5.86

5.78

5.89

5.98

5.94

5.93

-0.35

-0.41

-0.31

-0.40

-0.34

-0.47

-0.39

-0.48

-0.34


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Responsiveness

Personnel in excellent hospitals will tell patients exactly when

services are provided. (eg., admissions, ward facilities, visitinghours etc.).

Personnel in excellent hospitals will give prompt services to

patients. (eg., good reception ,house keeping, nursing ,speedand ease of admission, speed and ease of discharge etc.).

Personnel in excellent hospitals will always be willing to help

patients. (eg., ever smiling, kind hearted staff).

Personnel in excellent hospitals will never be too busy to

respond to patients requests (eg., attending immediately

whenever called).

Assurance

The behavi our of personnel in excellent hospitals will instill

confidence in patients. (eg., convincing briefings byspecialists, doctors, nurses etc.).

Patients of excellent hospitals will feel safe in their dealingswith the hospital. (eg., cost of treatment, medicines, trust withthe personnel etc.).

Personnel at excellent hospitals will be consistently courteous

with their patients. (eg., patients treated with dignity and

respect, impartial treatment, sympathetic approach etc.).

Personnel of excellent hospitals will have the knowledge toanswer patients questions. (eg., thoroughness of explanation

of medical condition, proper advice in their respective areasetc.).

Empathy

Excellent hospitals will give patients individual attention. (eg.,

bed side care, proper diet requirements , politeness ofphysicians, nurses and other staff etc.)

Excellent hospitals will have operating hours convenient to alltheir patients. (eg., 24- hour service facility, fixing the

operation timings according to the requirement etc.).

Excellent hospitals will have the patients best interest at heart.(eg., good, sympathetic care, consistency of charges etc.).

The personnel at excellent hospitals will understand the

specific needs of their patients. (eg., receiving, investigating &

sending them to specific departments for treatment).

Excellent hospitals will keep their patients informed and listen

to them. (eg., operation details, explaining nutritional needs,pre-op & pos t-op care etc.).

5.40

5.58

5.74

5.80

6.16

6.30

6.40

6.18

5.67

5.06

5.45

5.47

5.68

5.67

5.82

6.06

6.03

6.20

6.34

6.47

6.37

5.88

5.38

5.77

5.87

6.01

-0.27

-0.24

-0.32

-0.21

-0.04

-0.04

-0.08

-0.19

-0.21

-0.32

-0.32

-0.40

-0.33


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Table 4: Aggregated dimensional scores, and overall Service Quality

Index (SQI): Gap 5 (n= 500)

SERVQUAL Dimensions P score E score Difference

(P-E)

Tangibles 5.44 5.81 - 0.37

Reliability 5.50 5.91 - 0.41

Responsiveness 5.63 5.90 - 0.27Assurance 6.26 6.35 - 0.09

Empathy 5.47 5.78 - 0.31

Overall Service Quality

Index

5.66 5.95 - 0.29

-100% -50% 0% 50% 100%

P score

E score

Difference

(P-E)

Tangibles

Reliability

Responsiveness

Assurance

Empathy

Overall ServiceQuality Index

In all the 22 items of the five dimensions of service quality (Table 3

and Table 4), patients expectations exceeded their perceptions. The

most serious shortfalls (gaps on dimensions exceeding 0.25) are on

dimensions-Tangibles (-0.37), Reliability (-0.41), Responsiveness (-0.27)

and Empathy (-0.31). Obviously, these are the dimensions that will require

most attention by hospital management if gap 5 is to be closed.


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The detailed findings of the study by SERVQUAL dimensions and by

hospitals are presented in Table 5.

Table 5: SERVQUAL Scores by Dimensions and by Hospitals

SERVQUAL SCORES

DIMENSIONS HOSPITAL MEANS

A B C D E

n=100 n=100 n=100 n=100 n=100

1.Tangibles -0.10 -0.48 -0.79 -0.34 -0.14

2.Reliability -0.14 -0.43 -0.70 -0.36 -0.42

3.Responsiveness -0.07 -0.36 -0.55 -0.16 -0.18

4.Assurance 0.05 -0.33 -0.26 0.24 -0.15

5.Empathy 0.03 -0.57 -0.55 -0.12 -0.38

Overall service

Quality score

-0.046 -0.44 -0.57 -0.15 -0.25

-100% -50% 0% 50%

Dimensions

Hospitals

1.Tangibles

2.Reliability

3.Responsiveness

4.Assurance

5.Empathy

Overall serviceQuality score *


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Table 6: ANOVA for Gap 5 of the five Hospitals

Dimensions Groups Sum of

Squaresdf Mean square F Sig.

TangiblesBetween GroupsWithin GroupsTotal

1.591.415

2.006

41519

.3982.770E-02 14.361* .000

ReliabilityBetween GroupsWithin GroupsTotal

.800

.3421.142

42024

.2001.711E-02 11.696* .000

ResponsivenessBetween GroupsWithin GroupsTotal

.504

.181

.685

41519

.1261.206E-02 10.450* .000

AssuranceBetween GroupsWithin GroupsTotal

.905

.2091.114

41519

.2261.391E-02 16.272* .000

EmpathyBetween GroupsWithin GroupsTotal

1.392.180

1.572

42024

.3489.000E-03 38.656* .000

Overall ServiceQuality Index

Between GroupsWithin GroupsTotal

.904

.5401.444

42024

.2262.701E-02 8.362* .000

Significant at .001 level

SURVEY FINDINGS

The survey findings are summarised below:

Tangibles

In the personal interviews with the patients, it was brought to the notice of

the researchers that most of the in-patients were extremely happy about the

neat and clean house keeping facility, computerised billing and registration,

modern looking equipments etc., (Hospitals A and E). However, some of

the patients felt that even though the inside environment of the hospitals

are conducive enough, there is disturbance due to the noise from the adjacent

buildings which are under construction. Since most of the patients (generally

in the age group 50-70 yrs) were admitted due to heart problems, they felt

the toilet facility should have been inside the rooms rather than outside

(Hospital A). Most of the patients felt that the hospital personnel (including


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physicians) should be provided with name and designation badges so that

their identification could be made easier (Hospitals C, D and E). They also

felt the need for a spacious visitor lounge, which would add to the hospitals

reputation. Some patients felt the need for a professional counselor who

would psychologically boost their morale (All five hospitals). Some of the

male patients felt the need for a television set as an entertainment facility

and a rest room for their attendants (Hospital B). Most of the new mothers

were very much unhappy about the neonatal ICU being shifted to a farther

place where in they find it difficult to walk often to feed their babies (Hospital

B). With respect to Hospital C, in the personal interviews with the patients,

it was brought to the notice of the researchers that most of the in-patientswere extremely happy about the neat and clean rooms (both private and

general wards) and registration, cost of service etc. However, majority of

the patients felt that even though the inside environment of the hospital is

conducive enough, there is disturbance due to the noise from the vehicles

that are being parked just outside the VIP ward. Almost all the patients

(generally in the age group 40-70 yrs) felt the need for western type of

toilet facility (at least one in each general ward). Thus, an overall large

negative score for Hospital C and least negative scores for hospitals A

and E has been observed for tangibles (Table 5).

Reliability

Even though the patients expressed their satisfaction regarding the

correct diagnosis and prompt treatment, error-free retrieval of records,

good communication etc., (Hospital A), it seemed to the researchers

that some of them were not very happy about the fast retrieval of

documents, communication with the security personnel, follow up

checks etc., (Hospitals D and E). The patients were also unhappy about

the long waiting hours in the OPD and scanning, booking dates for

surgeries and registration delays (hospital D). All these factors accounted

for larger negative gaps for Hospital C and least negative gap for hospital

A. However hospitals B and D showed equal negative gaps (Table 5).

ResponsivenessThere were some patients who expressed their dissatisfaction as to not

getting information on the type of service facilities that are provided

for the costs incurred at the time of admission (Hospitals A, B, D and


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E). Most of the patients were unhappy with the delayed discharge procedure

(Hospital E). Some of them felt the need for briefing regarding health

insurance facilities and expected booking of rooms at the time of admission

itself (Hospital B). However all the patients were happy about the quick

response to the emergency attending of the hospital personnel (Hospital A,

B, D and E). Thus an overall small negative gap with hospital A and large

negative gap with hospital C and an in between negative scores for B has

been observed. Hospitals D and E scored equal with respect to

responsiveness dimension (Table 5).

Assurance

In the personal interviews with the patients, it was brought to the notice of

the researchers that most of the in-patients were extremely happy about the

excellent nursing care, assistance in the reception, neat and clean house

keeping facility, very cordial and empathetic staff, ever smiling - ever

ready helpers and the attitude of the physicians who would listen to their

queries sympathetically (All Hospitals). Very few of the patients felt the

hospital charges as high (Hospitals A and E), but some of them expressed

that cost cannot be considered for the excellent quality of services offered

by the hospitals. The patients were also convinced about the technical

knowledge of the paramedical staff. All the patients were happy with respect

to doctors treatments and briefings (All Hospitals). Still an overall small

negative score has been observed (Hospitals A and E) which may be due

to the patients expectations regarding the quality of nursing care, cleanliness

and housekeeping being much higher than their experience in the hospital.

Many patients from the economically poor background felt that even though

the hospital charges are less, the cost of medicines, blood donation cost

etc., as high and expected further reduction in these aspects (Hospital C),

but some of them expressed that cost can not be considered for the

sufficiently satisfactory quality of services offered by the hospitals

(Hospitals A, D and E), thus accounting for a comparatively lower negative

score for assurance dimension for hospital A and a higher negative score

for hospital B.

Empathy

Even though the patients felt that there is excellent pre and post- operative

care rendered by both doctors, nurses and dieticians, round the clock service


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facilities and good sympathetic care (All Hospitals), very few of them

seemed to be confused about the individual attention given by the staff and

the type of investigations carried out by the doctors (Hospitals B, D and E).

Thus an overall small positive score has been observed for empathy for

hospital A. During our personal interactions, it was brought to our notice

that the patients were satisfied with the bedside care and concern shown by

the hospital personnel. But, they expressed their dissatisfaction regarding

discrimination in treatment by ward boys and some nursing staff between

the general and private ward patients (Hospitals C and D), accounting for

larger negative scores for hospitals B, C and D for empathy.

Thus, Gap 5 is hypothesised to be related to positive patient evaluationbecause it measures the difference between patient perceptions and

expectations, a standard approach to determining satisfaction and assessing

an encounter.

One way ANOVA results show that there are significant differences

in all the five dimensions of service quality-Tangibles, Reliability,

Responsiveness, Assurance and Empathy among the five hospitals in

Bangalore city. There is also a significant difference in the Overall

service quality among the five hospitals. The result of the ANOVA

rejects H0and accepts H

1- there is a difference in the patients perception

of service quality in the five hospitals and also in the Overall Service

Quality Index.

Gap 1: Management Perceptions about Patient Expectations

Gap 1 is hypothesised to be related to positive patient evaluation because

it reflects the difference between the managements perceptions about

patients expectations of service quality provided and patients

expectations of service quality. From a marketing perspective, the

provider would design, develop and deliver the service offering on the

basis of his or her perceptions of patient expectations. Likewise,

modifications to the service offering would be affected by the service

providers perceptions about patient expectations. Whether these

perceptions of patient expectations exceed, match or measure below

patient expectations can have a profound effect on future patient-hospital relationship. Therefore, it can be argued that gaps in these

areas can directly influence positive patient evaluation.


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Gap 1 scores by dimensions and by 22-Servqual items are shown in

Table 7.

Items for each subscale were subjected to reliability assessment. The

Cronbachs alpha values for the managements perceptions about patients

expectations were 0.941, 0.650, 0.958, 0.959 and 0.818 for tangibles,

reliability, responsiveness, assurance and empathy respectively.

Table 7: Average Scores of Management perceptions about patient

expectations, patient expectations and their difference

(M E): Gap 1 (n=40)

Se rv ic e Q ua l i ty D ime ns ions M

score

E

sc ore

( M - E )

Sc ore

Ta ngib le s

Exc e l l e n t hosp it a l s w i l l ha ve mode rn lookin g

e quipme n t . ( eg . , C .T . Sc a n , X -Ra y, M .R . I . Sc a n , Tre a dm il l e tc . ) .

The physica l fac i l i t ies a t exce l lent hospita ls a rev i sua l ly a ppe a l ing . ( e g ., w e l l ma in ta ine d r e c e pt ionarea , computer ized bi l l ing and regis tra t ion fac i l i t ies ,

ne a t a nd c le a n pa thology , b ioc he mis t ry l a bs , hosp i t al

rooms e tc . ) .

Personnel a t exce l lent hospita ls wil l be nea t ina ppe a ra nc e ( e g . , s t a f f w i th un i form a nd a ppropr ia te

name badges , profess ional appearance of s ta ff e tc . ) .

M ater ia ls assoc ia ted with the services wil l be visua l ly

appealing in an excel lent hospita l . (eg. , c lean andc omfor ta b le e nvi ronme n t w i th good d i r e c t ional s igns ,informative brochures about services , s t re tcher , wheel

chairs , well mainta ined records e tc . )

Reliabi l i ty

W he n e xc e l l e n t hosp i t a l s p romise to do some th ing by

a cer ta in da te , they do so. (eg. , tes ts , fol low up c heck s ,

surger ies e tc . ) .

W he n a pa t i e n t ha s a proble m, e xc e l l e n t hosp it a l s w i l l

show a s incere interes t in solvin g i t . (eg. , regis tra t ion,

ca l l ing the concerned doctor to a t tend the case e tc . )

Excellent hospita ls wil l be dependable (eg. , se rvices

provided a t appointed t ime, e rror-free and fas t re tr ieva lof doc um e nts , good c ommun ic a t ion , good t r ea tme nt

etc.).

Excel lent hospita ls wil l provide the ir services a t thet ime the y promise to do so . ( eg . , e me rge nc y c a re ,casual ty services e tc . ) .

Excel lent hosp ita ls wil l ge t the things r igh t the f i rs tt ime. (eg. , correc t diagnosis , prompt t rea tment e tc . ) .

5 . 25

5 .85

6 .18

5 .83

6 .01

6 .53

6 .15

6 .27

5 .20

5 .68

5 .73

5 .97

5 .86

5 .78

5 .89

5 .98

5 .94

5 .93

-0 .43

0 .12

0 .21

-0 .03

0 .31

0 .63

0 .17

0 .33

-0 .73


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Responsiveness

Personnel in excellent hospitals will tell patients exactly whenservices are provided. (eg., admissions, ward facilities, visitinghours etc.).

Personnel in excellent hospitals will give prompt services to

patients. (eg., good reception ,house keeping, nursing ,speed andease of admission, speed and ease of discharge etc.).

Personnel in excellent hospitals will always be willing to helppatients. (eg., ever smiling, kind hearted staff).

Personnel in excellent hospitals will never be too busy to respond to

patients requests (eg., attending immediately whenever called).

Assurance

The behaviour of personnel in excellent hospitals will instill

confidence in patients. (eg., convincing briefings by specialists,doctors, nurses etc.).

Patients of excellent hospitals will feel safe in their dealings with

the hospital. (eg., cost of treatment, medicines, trust with the

personnel etc.).

Personnel at excellent hospitals will be consistently courteous withtheir patients. (eg., patients treated with dignity and respect,

impartial treatment, sympathetic approach etc.).

Personnel of excellent hospitals will have the knowledge to answerpatients questions. (eg., thoroughness of explanation of medical

condition, proper advice in their respective areas etc.).

Empathy

Excellent hospitals will give patients individual attention. (eg., bed

side care, proper diet requirements , politeness of physicians, nursesand other staff etc.).

Excellent hospitals will have operating hours convenient to all their

patients. (eg., 24- hour service facility, fixing the operation timingsaccording to the requirement etc.).

Excellent hospitals will have the patients best interest at heart. (eg.,good, sympathetic care, consistency of charges etc.).

The personnel at excellent hospitals will understand the specificneeds of their patients. (eg., receiving, investigating & sending them

to specific departments for treatment).

Excellent hospitals will keep their patients informed and listen tothem. (eg., operation details, explaining nutritional needs, pre-op &

post-op care etc.).

6.03

6.23

6.40

5.88

6.43

6.48

6.28

6.30

6.05

5.25

6.20

6.20

6.43

5.67

5.82

6.06

6.03

6.20

6.34

6.47

6.37

5.88

5.38

5.77

5.87

6.01

0.36

0.41

0.34

-0.15

0.23

0.14

-0.19

-0.07

0.17

0.87

0.43

0.33

0.42


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The Gap 1 scores for the study are reported in Table 7. It consists

of managements average perceptions scores, customers average

expectation scores and the difference between the two. As can be

seen in Table 7, only six items on which managements underestimate

customers expectations are- Q1(Excellent hospitals will have modern

looking equipment), Q4 (Materials associated with the services will

be visually appealing in an excellent hospital), Q9 (Excellent

hospitals will get the things right the first time), Q13 (Personnel in

excellent hospitals will never be too busy to respond to patients

requests), Q16 (Personnel at excellent hospitals will be consistently

courteous with their patients) and Q17 (Personnel of excellent

hospitals will have the knowledge to answer patients questions).

The more negative the score, the more serious the Gap. A negative

score denotes managements lack of understanding of customers

expectations. A positive score means that managements overestimate

and are thus still out of touch with customers expectations (on all

the remaining 16 items). The closer the scores are to zero, the more

ideal they are.

Table 8: Aggregated Dimensional Scores and

Overall Score: Gap 1(n=40)

SERVQUAL

Dimensions

M score E score Difference

(M-E)

Tangibles 5.78 5.81 - 0.03

Reliability 6.04 5.91 0.13

Responsiveness 6.14 5.90 0.24

Assurance 6.37 6.35 0.02

Empathy 6.03 5.78 0.25

Overall Gap 1 Score 6.08 5.95 0.13


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-50% 0% 50% 100%

Dimensions

M score

E score

Difference

(M-E)

Tangibles

Reliability

Responsiveness

Assurance

Empathy

Overall Service

Quality Index

The aggregated dimensional scores and overall Gap 1 score are reported

in Table 8. It can be seen that only one dimensional score is negative and

the rest are positive with the Overall Gap 1 score positive. This means that

the managements enjoy reasonably a good understanding of customers

expectations eventhough these tend to be overestimated in general.

The Gap 1 score by dimensions among the hospitals-A,B,C,D and E

and their overall Gap 1 score scores are presented in Table 9. Analysis of

variance is shown in Table 10.

Table 9: Overall Scores by Dimensions and by Hospitals

SERVQUAL SCORES

HOSPITAL MEANS

A B C D EHospitals

Dimensions n = 7 n = 11 n= 6 n=7 n=9

1.Tangibles -1.01 -0.37 0.23 0.61 0.51

2.Reliability -0.07 0.27 0.41 0.22 -0.22

3.Responsiveness -0.22 0.25 0.32 0.37 0.41

4.Assurance -0.28 -0.11 -0.26 0.22 0.21

5.Empathy -0.35 -0.20 0.75 0.68 0.42

Overall score -0.39 -0.03 0.29 0.42 0.30


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-100% -50% 0% 50% 100%

Dimensions

Hospitals

1.Tangibles

2.Reliability

3.Responsiveness

4.Assurance

5.Empathy

Overall score *

Table 10: ANOVA for Gap 1 of the five Hospitals.

ANOVA

Dimensions Groups Sum of

Squaresdf Mean square F Sig.

Tangibles

Between Groups

Within GroupsTotal

7.350

3.86211.212

4

1519

1.837

.257 7.136* .002

ReliabilityBetween GroupsWithin GroupsTotal

1.1158.1209.235

42024

.279

.406 0.687 .609

ResponsivenessBetween GroupsWithin GroupsTotal

1.0691.6902.759

41519

.267

.113 2.372 .099

Assurance

Between Groups

Within GroupsTotal

.749

1.1251.874

4

1519

.187

7.500E-02 2.495 .087

EmpathyBetween GroupsWithin Groups

Total

5.3373.170

8.508

420

24

1.334.159 8.417* .000

Overall Gap-1Score

Between GroupsWithin GroupsTotal

2.0951.9114.006

42024

.5249.556E-02 5.481* .004

* significant at .001 level


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It can be seen that overall Gap 1 scores for hospitals A and B are

negative and for hospitals C, D and E are positive (Table 9). The overall

gap 1 score in hospital B is nearer to zero, though it is slightly negative.

In this hospital, the management enjoys a good understanding of

patients expectations. The overall Gap 1 score in hospital A is negative.

It shows the lack of managements understanding of patients

expectations. The overall Gap 1 scores for hospital C, D and E are

positive. These scores show that management overestimates patients

expectations in providing services.

One-way ANOVA results (Table 10) show that there is a significant

difference in the Overall Gap 1 Score among the five hospitals. The ANOVAresult rejects H

0and accepts H

1- there is a difference in managements

perceptions about patients expectations of service quality among the five

hospitals.

An overall small negative SERVQUAL score in Gap 5 (-0.29) and

a small positive score in Gap 1 (0.13) is a fairly typical result, because

whatever be the quality of service provided by the management, the

expectations of patients on the service quality of the hospital will be

higher than that of the managements perceptions, because patients

always compare quality to the cost incurred to get the services, which

is very difficult to assess.

CONCLUSION

The importance and the human touch involved in the health care

encourage patients to seek the highest possible quality. As patients are

unable to assess the technical quality of health care, the quality attributes

associated with the delivery of health care has been utilised by the

patients.

Results from this study suggest that patients define health care

quality in terms of tangibles, reliability, responsiveness, assurance and

empathy. In the present study based on the data from the five hospitals

in Bangalore, SERVQUAL appears to be a consistent and reliable

instrument to measure health care service quality. The results pinpoint

areas for attention to improve upon health care service quality.The negative SERVQUAL score (Gap 5) across all the dimensions

clearly shows that there is room for service quality improvement in

Bangalore hospitals especially in Reliability (Hospital A), Empathy


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(Hospital B), Tangibles and Reliability (Hospitals C and D), Reliability

and Empathy (Hospital E). Assurance dimension scored least negative

in all the five hospitals. This indicates that the hospitals are performing

satisfactorily on the assurance aspect of health care services that are

most critical to patients.

Timely, professional and competent service is what the patients

expect from health care providers, and although hospitals in Bangalore

are generally providing good services in these areas, improvements

are still needed to meet patients expectations. Health care managers

should focus more on training the paramedical staff in order to build

confidence in the patients mind regarding the service delivery.Physicians should be involved in continuous learning programmes to

further improve their knowledge in professional subject matters.

Our study shows that gap analysis is a straightforward and

appropriate way to identify inconsistencies between management and

patient expectations of service performance. Addressing these gaps

seems to be a logical basis for formulating strategies and tactics to

ensure consistent expectations and experiences, thus increasing the

likelihood of satisfaction and a positive quality evaluation. More

consistent expectations and perceptions can be achieved in one or both

of the following ways-(1). Altering the professional behaviors and

expectations; (2). Altering patients expectations and perceptions.

Examination of the perceptions of both the management and the

patients in an exchange is a way to identify gaps in expectations and

experiences. Once inconsistencies have been identified, strategies and

tactics for achieving more congruent expectations and experiences can

be initiated. Greater consistency, in turn, leads to a more positive service

encounter and enhances the likelihood that the experience will evolve

into a longer-term patient-hospital relationship.

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Dr. B. Mahadevappa, M.Com, Ph.D, Lecturer (Senior Scale) in the

Department of Studies in Commerce, University of Mysore, PostGraduate Centre, Hemagangotri, Hassan, Karnataka, India.


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Service Quality Case