Measuring Patients (Customers) Perceptions and Expectations of Service Quality in Public Healthcare Institutions: Servqual Model

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Published on International Journal of Economics & Business
Publication Date: July, 2019

Isaac Theophilus Ampah & Rabi Sidi Ali
Department of Marketing And Strategy, Faculty of Business Studies
Takoradi Technical University
P. O. Box 256, Takoradi, Ghana, West Africa

Journal Full Text PDF: Measuring Patients (Customers) Perceptions and Expectations of Service Quality in Public Healthcare Institutions: Servqual Model.

Aim: To find out the difference between patients expectations and perceptions of service quality delivery using SERVQUAL Model in public healthcare institutions in Ghana.
Methodology : Data was collected from public healthcare delivery respondents in health administration in Ghana. In all 252 respondents from public healthcare institutions (healthcare administrators, medical doctors, nursing officers and patients. Purposive sampling was utilized to select the participated healthcare players. With the use of self-completion structured questionnaires primary data were collected from respondents and analyzed using frequencies, mean and SERVQUAL service quality gap analysis. Furthermore, secondary sources such as health ministry’s books, quality standards manuals, internet and journals were used.
Result: 21 pubic healthcare administrators, 22 medical doctors, 125 nursing officers, 6 other public healthcare professionals and 78 patients (customers) were sampled from 24 million eligible Ghanaian patients ( Ministry of Health, Ghana). The structured questionnaire used consisted of multiple choice and Likert Scale questions. Summary of views of public healthcare participants 55% said service quality adoption in public healthcare institutions is medium followed by 45% of respondents who see it as high.
Conclusion: The study concluded that customers’ expectations exceeded the perceived levels of service quality. This resulted in a negative gap score (perception-expectation). Also, patients” perception of service quality offered by public healthcare institutions did not meet expectations as gap scores of all dimensions are all negative.

Keywords: Service Quality, Patients satisfaction, SERVQUAL Model and Public Healthcare Institutions.

Patients’ (customers”) satisfaction regarding quality healthcare delivery has become one of the critical issue governments all over the world are prioritizing in order to keep their citizens happy. Amin and Nasharuddin (2013) said that service quality from the lenses of patients demand that medical and other staff exhibit respect, empathy, concern and professional skills and service attitude. Patients’ ability to trust and depend on experiential service quality offered by public healthcare institutions would go a long way to guarantee quality healthcare and satisfaction.
As more and more patients (customers) become demanding regarding their healthcare needs/wants so should government worldwide have to double up their efforts in order to these changing healthcare needs. Constant improvements in healthcare infrastructure have to be pursued in order for this feat to be accomplished.
SERVQUAL Model on the other hand is popularly known for its ability to evaluate an organisation’s performance from customers” lenses in terms of relationship between perceived service quality and other major organizational outcomes (Parasuraman, et al,1985). In spite of SERVQUAL Model universal recognition and acceptance as service quality evaluator, its effectiveness in terms of evaluation of patients’ expectations and perception of public healthcare in developing countries is still under research. This implies that service quality should be assumed as a function of customers” expectation of the service as well as customer perception of the service actually offered. Zeithmal et al (1988) stressed that SERVQUAL Model is a proven tool for evaluating service quality and customer satisfaction and have been applied in different studies in different service delivery. In order to achieve patients’ satisfaction, SERVQUAL Model applicability in public healthcare setting in developing countries should be offered the same seriousness like those healthcare institutions in developed countries.
A total evaluation of service quality and customer satisfaction using SERVQUAL Model would help to ascertain the effectiveness of SERVQUAL as satisfaction evaluator in public healthcare institutions. Research has proven that SERVQUAL as customer satisfaction evaluator has been used in so many public healthcare industry (Anderson et al,2007). While it is undeniable fact that measurement of a good can be easily be assessed the same thing cannot be said of services because of their unique features such as lack of ownership, intangibility, perishability, inseparability and variability. Service measurement is normally done by comparing customer expectations with their actual experience of the service.
For public healthcare administration to fully measure patients’ satisfaction SERVQUAL Model plays a vital role. Even though other academic studies have measured patients’ satisfaction using SERVQUAL Model, its effectiveness in measuring patients’ expectations and perceptions of public healthcare delivery in Ghana is under research. The study seeks to capture essential knowledge and experiences of public healthcare practitioners in terms of customer expectations and perceptions using SERVQUAL Model in order to gauge the level of patients’ satisfaction of public healthcare delivery in Ghana.

2.1 Marketing in General
According to Scammell ( 1999) among the various definitions of marketing, the marketing mix concept (customer-oriented approach) and the notion of exchange is the centre of them. Marketing is about finding and meeting social needs while being profitable at the same time (Kotler and Keller, 2014). Also, American Marketing Association (2014) defined marketing as the activity, set of institutions and processes for establishing, communicating, delivering and exchanging offerings that have value for customers and larger societal needs in both short and long terms. Kotler and Keller (2014) said marketing is an art and science of selecting segment, getting, keeping and growing customers through creation, delivery and communication of superior customers’ value.

2.2 Service Quality
Service quality according to Gummesson (1994) implies management paradigm that deals with service management in the area of marketing which emphasise the importance of customer interaction with service provider in giving service and creating value for money. Also, Edvardsson (1988) said service quality should be seen from customers’ lenses because it is the total customers’ perception of the result which shape service delivery. According to Hoffman and Bateson (2011) service quality lies in the eyes of the customer and varies from person to person so is customer expectation and perception..
Customers usually compare their expectations with their perception of real service performance (Parasuraman, 1985). According to Parasuraman (1985) this comparism is known as disconfirmation.

2.3 SERVQUAL Model Development
Parasuraman et al (1985) found 97 attributes which tend to impact service quality. These 97 attributes were the basis that are vital in measuring customer’s expectations and perception on delivered service (Parasuraman et al, 1985). These 97 attributes were then grouped into ten dimensions which included tangibles, reliability, responsiveness, communication, credibility, security, competence, courtesy, understanding, knowing customers and access Parasuraman, et al, 1985). These ten dimensions were further grouped into five dimensions namely tangibility, reliability, responsiveness, assurance and empathy.

2.4 The Meaning Of Five Dimensions Of SERVQUAL Model
According to Parasuraman (1988) the five dimensions which included reliability, responsiveness, assurance, empathy and tangibility mean the following;
(i) Reliability-This is concerned with an organization’s ability to perform promised services dependably and accurately.
(ii) Assurance-This dimension deals with employees’ knowledge and courtesy as well as their ability to inspire and trust.
(iii) Responsiveness- This is concerned with employee’s ability, willingness to assist customers and offer quick service
(iv) Empathy-This dimension deals with the firm’s ability to offer individualised care and attention to its customers
(v) Tangibility-This is concerned with physical facilities, equipments and appearance of personnel.

2.5 Establishment Of Service Quality Gap Model
Parasuraman et al (1985) developed the GAP Service Quality Model through the results from exploratory research. The service quality GAP provided an avenue for organizations to assess systematically and enhance customer perception and expectations of service quality.
The following service GAPS were discovered by Parasuraman in 1985. These are;
(i) GAP 1 Customer Expectation-Management Perception Gap (Knowledge Gap)
This deals with management’s ability to identify and anticipate what customers are looking for. This means not comprehending customers’ requirements would result in management not able to offer quality service to customers (Parasuraman et al 1985 and Shariff,2012).
(ii) GAP 2 Management Perception-Service Quality Specification Gap (Policy Gap).
This is concerned with lack of suitable service design or yardsticks within an organization resulting in substandard service quality offerings.
(iii) GAP 3 Service Quality Specification-Service Delivery Gap (Delivery Gap).
This deals with weaknesses in employees service quality delivery performance. This situation normal occurs because of lack of team work.
(iv) GAP 4 Service Delivery Communication Gap (Communication Gap).
This happens because of difference between service quality delivery and what was communicated to employees about service quality delivery.
(v) GAP 5 Expected Service-Perceived Service Gap (Service Gap).
This is concerned with the difference between customers’ expectations and real service experienced. It is also measures customers’ anticipation of a service (Nyandoro, 2012 and Shariff,2012).

2.6 Patients’ Satisfaction
Kotler (2014) said satisfaction is the feeling of happiness because one has something or has achieved something of value. Kolter and Armstrong (2014) also added that satisfaction is state of happiness or disappointment that comes from the comparison of a perceived performance of a product relative to its expectations. They continue by saying that satisfaction is action which is meeting a genuine, desire, demand and expectation.
According to Gronnoos (1982) and Parasuraman et al (1985) customers’ perception of service quality is dependent on comparism of his/her expectation with their perceptions of the performance of the service provider. Parasuraman et al (1985) explained expectations differently in both satisfaction and service quality lenses. In satisfaction lenses, expectation is considered as prediction by consumers about what is likely to happen during a specific customer transaction while service quality angle refers to desires or wants of customers

Data was collected from public healthcare institutions respondents’ namely healthcare administrators, medical doctors, nursing officers, other healthcare practitioners and patients within the healthcare administration in Ghana. In total 252 respondents were selected from public healthcare institutions such as teaching hospital, regional hospital, district hospital, psychiatric hospital, poly clinic and others. 21 public healthcare administrators, 22 medical doctors, 125 nursing officers, 6 other public healthcare professionals and 78 patients. Data was collected through one set of self-completed questionnaires to public healthcare practitioners that permitted respondents to complete them at their own free time in order to lessen interruptions to those participating healthcare activities. The set of questionnaire dealt with the difference between patients’ expectations and perceptions of service quality delivery using SERVQUAL Model of Ghanaian public healthcare setting. The questionnaire was developed in such a way that the structure, focus and phrasing of questions was intelligible with respondents, reduced bias and provided data that could be statistically analysed (Gill and Johnson,2006). Both multiple choice and A five point Likert scale was utilised with responses ranging from ‘strongly disagree, disagree, neutral, agree and strongly agree’. Closed ended questions were also used to permit for collection of more depth data. Total of 265 questionnaires were sent out, out of which 252 questionnaires were returned representing 95%. Non probability purposive sampling method which consists of selection of respondents with knowledge and experience with service quality and patients satisfaction was utilised. Lastly, quantitative data was used to analyse using Statistical Packages for Social Science (SPSS) version 21 and Microsoft Excel 2013.

Basically, one set of data and information source was used to describe the study. This is a survey method that issued self-completion structured questionnaire to gather data from respondents. The researcher also used various service quality and customer satisfaction publications such as journals, books, reports, and manual and internet sources to gather more information to help answer the key objective. The descriptive approach used by the researcher implied that data and information were described with the help of Statistical Package for Social Science (SPSS) version 21 and Microsoft Excel. Descriptive tools such as frequency table, mean and SERVQUAL service quality gap analysis..

This section presents the analysis and discussion of the results based on designated objective of the study for Public healthcare institutions. The section is presented under the following headings
a. Reliability statistics
b. Respondents profile
c. Measuring differences between patients’ expectations and perceptions of service quality delivery using SERVQUAL Model of Ghanaian public healthcare institutions

4.1 Reliability/ Validity Test
A reliability test using Cronbach Alpha; resulting in a reliability coefficient of 0.992 which is above the recommended minimum of 0.7 (Santos & Reynolds, 1999) was conducted on all 113 items (variables) used in the study (see Table 1).

Table 1: Reliability/ Validity test

It can be inferred from Table 1 that variables assigned for the study were about 99% reliable to be used for inferential analysis. The study achieved a response rate of 98%.

4.2 Respondents Profile
This section of the study looks at the demographic characteristics of the respondents with respect to type of public health care institution, gender, age, educational level, current position within the institution and the number of years worked as shown in Figure 1 and Table 2 below.

Figure 1: Type of Public Health Care Institution

A critical look at Figure 1 show that 34% of the respondents were from regional hospitals, followed by district hospital (22%), teaching hospital and poly clinics accounted for 14% respectively, psychiatric hospital (12%) and the least of the respondents constituted others were 4%.

Table 2: Respondents Profile

Table 4.2 shows the respondents profile with respect to gender, age, educational level, current position and the number of years worked. With respect to gender, respondents were skewed towards female respondents. This accounted for 73% of the total respondents whilst their male counterpart was 27%. Respondents varied in relation to age, majority of the respondents (33%) were in the age range 26-35, followed by the age range 36-45 (29%) and the least 56 and above years accounted for 8%. In terms of educational level, more than half of the total respondents (55%) indicated they have had tertiary education, followed by postgraduate (32%) and the least JHS (3%). On current position, majority of the respondents posited nursing officer. This accounted for 49% of the total respondents, followed by patients (31%), health administrator (8%), medical doctors (9%) and the least others was 2.4%. Also 33% of the respondents had worked for their current health care institutions for 1-3 years, followed by more than 6 years (31%) and 12% indicated 12% as shown in Table 2 above.

Table 3: Crosstabulation on the Adoption and Extent of Quality Service Delivery

Table 3 above depicts a cross tabulation on the adoption and extent of quality service delivery. A look at the table shows that the extent to which quality service delivery has to be used saw majority of the respondents (55%) positing medium and the time to which quality service delivery has to be adopted was between 2-3 years. This was followed by high which also recorded 45% with time to which quality of service has to be adopted was between 4-5 years.

Table 4: Reliability Coefficients (Cronbach’s alphas)

The reliability coefficients (Cronbach alpha) presents the internal consistency of the modified SERQUAL items. These items were assessed by computing the total reliability scale for the study of 0.899, indicating an overall reliability factor slightly below to that of Parasuraman et al., (1988) study which was 0.92. This reliability value for this study is substantial considering the fact that the highest reliability that can be obtained is 1.0 and this is an indication that the items of the 5 dimensions of SERQUAL model is acceptable for the analysis of this study (see Table 4).
Table 4 above depicts the reliability scale for all 5 dimensions and also the reliability scale for each dimension calculated when each item is removed from the dimension in order to see if the removed item is unaffected. In case Cronbach’s alpha for a dimension increases when an item is removed, it depicts that that item is not genuine in that dimension. It can be observed from Table 4 above that quite a few items recorded a lower reliability value when item is deleted. However, all the five dimensions; reliability, responsiveness, assurance, empathy and tangibility produced a higher coefficient higher than 0.7, meaning these dimensions comparing of various items show a true measure of service quality.
Customers’ expectation and perceptions were both measured using the 5-point likert scale whereby the higher the numbers indicate higher level of expectations or perception. A critical look at Table 5 shows that generally, customers’ expectation exceeded the perceived level of services as presented in Table 5 below. This resulted in a negative gap score ( ). Results from the table (Table 5) shows that customers expectation exceeded the actual perceived service indicating the institutions need to do more to improve upon their service delivery to their clients. The items with the highest expectation scores were; employees should be respective to patients (4.825), hospital equipment and facility should be in a good working condition (4.723), staff should work hard while at work (4.6231) and staff should be helpful to patients find out what they are looking for (4.6235).

Table 5: Summary of Means of Customer’ Expectations and Gap Scores

The scores presented in Table 5 shows there is not much difference in the scores of other expectation items. The items with high perception score were, employees are respectful to patients (4.6534), staff are helpful to patients find out from patients what they are looking for (4.4352), hospital equipment and facilities are in good working condition (4.4324) and staff work hard while at work (4.4201). there is no much difference in the scores of perceptions but they are generally lower than that of expectations.
The gap scores are the difference between the perception and expectation scores with a range of values from . This gap score measure service quality (customer satisfaction). The more perception is closer to expectation, the higher the perceived quality and vice versa. The highest gap score were healthcare employees always put themselves in the shoes of patients (-0.5399), hospital staff readily give information to all patients (-0.4460), healthcare services are personalized to individual’s patient’s needs (-0.4180) and health workers respond to patients’ needs quickly (-0.4180).
The gap score analysis is to assist in finding out how patients (customers) perceive service quality in healthcare institutions and also to identify the dimension of service quality patients are satisfied with. Form the above, it can be observed that patient’s perception of service quality offered by healthcare institution did not meet expectations as gaps score of all the dimensions are all negative (See Table 5). The dimensions that reported larger mean gaps were empathy (-0.5399), reliability (-0.4460) and responsiveness (-0.4180). These values indicate that the perception of performances in healthcare delivery is less than expected of service quality.

The following conclusions were drawn from the analysis of the questionnaire:
a. Customers’ expectations exceeded the perceived levels of service as presented in Table 1. This resulted in a negative Gap Score (Perception-Expectation).
b. Since customers’ expectation exceeded the actual perceived service indicating the public healthcare institutions need to do more to improve upon their service quality to patients (customer).
c. From the analysis it can be observed that patients’ perceptions of service quality offered by public healthcare institutions did not meet expectations as Gap Scores of all dimensions are all negative.
The aforementioned mentioned result assessment indicated that both internal and external factors shape the measurement of service quality in terms of patients’ expectations and perceptions in public healthcare administration. The implication of such insights is that public healthcare practitioners and their affiliated stakeholders have to work together to measure accurately patients’ satisfaction in order to offer the right service quality infrastructure to public healthcare institutions. The key drawback of the study is that only 252 out of estimated population of 60,000 public healthcare practitioners in Ghana were considered for the study. This means that knowledge and experiences of the entire public healthcare institutional machinery might not have been captured.

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The Meaning of SERVQUAL Dimensions/Items
Reliability RLB
RLB1-Health employees should attend to work on time
RLB2-Staff should work hard while at work
RLB3-Employe should be able to act on their promise
RLB4-Hospitals equipment and facilities should bee in good working condition
RLB5-National Health Authority should pay health service providers promptly
RLB6-Healthcare services given to patients should be the same at all public healthcare centres.
RLB7-Hospital staff should readily give information to all patients.
RLB8-Healthcare policies of all governments should be consistent with the needs of patients.
RLB9-The service quality standards of all hospitals should be the same.

Responsiveness RSN
RSN1-Employees should be respectful to patients
RSN2-Staff should be helpful to patients to find out what they are looking for.
RSN3-Healthcare workers should respond to patients’ healthcare needs quickly
RSN4-Hospital management should pay attention to the needs of all healthcare stakeholders.
RSN5-Government should provide the right facilities, equipment and medicines to all healthcare centres.

Assurance ASS
ASS1-The attitude and behaviour of healthcare officials should be positive towards the needs of patients.
ASS2-Patients should have confidence in the professionalism of health officials
ASS3-Patients should have easy accessibility to healthcare.
ASS4-Quality healthcare practices should put to rest patients’ anxiety.
ASS5-Hospital management should let patients know that their concerns and problems are being addressed.
ASS6-Healthare patients charter should be made known to patients
ASS7-Healthcare should be offered to all types of socio economic groupings in society at the point of their needs.
ASS8-Healthcare officials should always offer patients motivation and professional advice.

Empathy EMP
EMP1-Healthcare service should be personalised to individual patient’s needs.
EMP2-Healthcare employees should always put themselves in the shoes of patients.
EMP3-Healthcare staff should not vacate post before closing time.
EMP4-There should not be favouritism in healthcare delivery.
EMP5-Staff of healthcare centres should not engage in other activities that distract them from attending to patients’ needs and concerns.

Tangibility TAN
TAN1-Healthcare equipment and facilities should be modern and fit for purpose.
TAN2-Broken down and out dated healthcare equipment and facilities should be replaced quickly.
TAN3-Healthcare centres facilities should be adapted in line with patients’ changing needs.
TAN4-All medicine should be available at all time.
TAN5-Healthcare employees should have neat and hygienic appearance.
TAN6-The atmosphere within healthcare centres should be cordial and friendly.
TAN7-Various healthcare processes and systems should be patients’ friendly.