MEASURING FUNCTIONAL SERVICE QUALITY AT JOSEPH N. FRANCE GENERAL HOSPITAL ST. KITTS AND NEVIS

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(1)Taipei Medical University School of Health Care Administration Master’s Thesis. MEASURING FUNCTIONAL SERVICE QUALITY AT JOSEPH N. FRANCE GENERAL HOSPITAL ST. KITTS AND NEVIS. Graduate Student: Kishma Tamica Cranstoun Advisor: Professor Nai-Wen Kuo. Date: June, 2011.

(2) Functional Service Quality in JNF Hospital. ―Measuring Functional Service Quality at Joseph N. France General Hospital St Kitts and Nevis”. ii.

(3) Functional Service Quality in JNF Hospital. iii.

(4) Functional Service Quality in JNF Hospital. iv.

(5) Functional Service Quality in JNF Hospital. Acknowledgements. I take this opportunity to express my sincere gratitude to persons, who have in some way supported me in completing this research. To my committee members, sincere appreciation, and special thanks to my advisor, Professor Nai-Wen Kuo for his guidance, and encouragement provided during the process of thesis writing.. Special Thanks to Mr. Elvis Newton and the Ministry of Health St Kitts and Nevis for granting permission and support given in conducting this study at the JNF General Hospital. I also express sincere appreciation to all my colleagues and friends who have provided assistance on various occasions.. To my family, I extend a heartfelt thank you for the support given to me during this process, special recognition to my parents; my mom, who has been my guiding light and my dad who unfortunately is not here to share in this moment, I dedicate this thesis in his honor.. Last but not least I take this opportunity to express my appreciation to the Almighty God for his grace and mercy; through which I have made it thus far.. v.

(6) Functional Service Quality in JNF Hospital. Abstract ―The Influence of Functional Service Quality on Patient Satisfaction: A Case Study at Joseph N. France Hospital St. Kitts and Nevis‖ Author: Kishma Tamica Cranstoun Thesis advised by: Professor Nai-Wen Kuo, PhD, MPH BACKGROUND: Throughout the health care industry issues of patient satisfaction with the quality of service received has gained much attention by management and researchers likewise. The study set in the largest referral Hospital in St Kitts and Nevis, seeks to measure the level of functional service quality utilizing the SERVQUAL, Parasuraman, Zeithaml, and Berry (1985) model to explore the gaps between expectation and perception among patients. The study also measures the association of the dimensions with overall patient satisfaction. The research hypothesis is based on the five dimensions: tangibles, reliability, responsiveness, assurance, empathy, and their ability to in influence the level of patient satisfaction.. It was expected that patient satisfaction would be. influenced by the five dimensions as well as other demographic factors.. METHODS: This study was conducted with use of questionnaire. A total of 253 respondents drawn from a systematic random sample of patients utilizing hospital services who were asked to complete a SERVQUAL questionnaires. The data was analyzed to measure existing gaps utilizing the students‘t-test paired differences, the Pearson correlation, and linear regression analysis was used to measure the association between the dimensions and overall satisfaction. .. RESULTS: The response rate was 90%. Internal reliability Cronbach's alpha was > 0.929 for the 30 item questionnaire. Throughout analyses differences were observed, as expectations exceeded perceptions. Overall, patients‘ mean perception score was 3.27 (SD=0.45) and mean expectation scores were 4.53 (SD=0.26) and the existing gap -1.25 (-1.35,-1.15) was significant (0.000), with t=-25.117. Among employees sub grouping, the existing gap -1.367 (-1.547,-1.187) was significant (0.000), with t=-15.262. While among the patients‘ sub group the existing gap, -1.32 (-1.45,-1.21) was also significant (0.000) with t=21.230. The five dimensions had a positive correlation with vi.

(7) Functional Service Quality in JNF Hospital. overall satisfaction. While utilizing a stepwise model of regression of the 5 dimensions and demographic variables to overall satisfaction only two predictors, assurance (0.000) and responsiveness (0.019) explained 25.6% of the variation in overall satisfaction at a 0.05 significance level.. CONCLUSION: The results of this research appear to show that the SERVQUAL instrument is a useful measurement tool in assessing and monitoring functional service quality in hospitals, and enabling management to identify where quality improvements initiatives are needed, from the patients' perspective. As such we can conclude, that should improvement in the overall level of satisfaction be the objective of management, quality improvement initiatives should be undertaken across all dimension however putting greater emphasis on the assurance and responsiveness dimensions.. vii.

(8) Functional Service Quality in JNF Hospital. Table of Contents. Contents. Page. Abstract ................................................................................................................................................vi Table of Contents ............................................................................................................................... viii List of Tables ......................................................................................................................................... x List of Figures ...................................................................................................................................... xi Chapter I Introduction ........................................................................................................................ 1-5 1.0 Background ..................................................................................................................................... 2 1.1 About St Kitts and Nevis ................................................................................................................. 2 1.2 Purpose of Study ............................................................................................................................. 4 1.3 Objectives of Research .................................................................................................................... 5 Chapter II Literature Review ............................................................................................................ 6-15 2.0 Introduction ..................................................................................................................................... 7 2.1 Service Quality Defined .................................................................................................................. 7 2.2 Health Care Service Quality ............................................................................................................ 8 2.3 Service Quality Dimensions .......................................................................................................... 10 2.4 Satisfaction in Health Care ............................................................................................................ 13 2.5 Summary ....................................................................................................................................... 15 Chapter III Methods ...................................................................................................................... 16-27 3.1 Introduction ................................................................................................................................... 17 3.2 Conceptual Framework ................................................................................................................. 17 3.3 Hypothesis ..................................................................................................................................... 21 3.4 Study Setting ................................................................................................................................. 22 3.5 Questionnaire................................................................................................................................. 23 3.6 Data Analysis ................................................................................................................................ 25 3.7 Ethical considerations.................................................................................................................... 27 Chapter IV Results and Discussion ............................................................................................. 28-51 4.1 Introduction ................................................................................................................................... 29 4.2 Data Profile.................................................................................................................................... 29 4.3 Service Quality Results ................................................................................................................. 32 viii.

(9) Functional Service Quality in JNF Hospital. 4.4 Overall Satisfaction ....................................................................................................................... 42 4.5 Discussion ..................................................................................................................................... 51 4.6 Summary ....................................................................................................................................... 53 Chapter V Conclusion and Recommendation ............................................................................... 54-60 5.1 Introduction ................................................................................................................................... 55 5.2 Conclusion to Objectives............................................................................................................... 55 5.2.1 Objective 1 ................................................................................................................................. 55 5.2.2 Objective 2 ................................................................................................................................. 55 5.2.3 Objective 3 ................................................................................................................................. 56 5.3 Research Methodology .................................................................................................................. 56 5.4 Management Implications ............................................................................................................. 58 5.5 Implications for Further Research ................................................................................................. 59 References ........................................................................................................................................... 61 Appendix 1: Questionnaire .................................................................................................................. 66 Appendix 2. Request Letter ................................................................................................................. 71 Appendix 3. Permission Response ..................................................................................................... 72. ix.

(10) Functional Service Quality in JNF Hospital. List of Tables. Table 1: Department visited by Patient Respondents ......................................................................... 29 Table 2: Staff Respondents and Non respondents by Category .......................................................... 30 Table 3: Respondents Demographic Backgrounds ............................................................................. 31 Table 4: Service Quality Mean, Standard Deviation, Minimum and Max scores of Patients Expectations and Perception ............................................................................................................... 33 Table 5: SERVQUAL Gap 5: Patients' Perception - Patients' Expectation, rank and paired difference t-statistics............................................................................................................................ 34 Table 6: Service Quality Mean, Standard Deviation, Minimum and Max Scores of Employee Expectations and Perception ............................................................................................................... 36 Table 7: Service Quality Gap: Employee Perception – Employee Expectation, Performance Rank and Paired Difference t-statistics ......................................................................................................... 39 Table 8: SERVQUAL Gap 6: Employees‘ Perception – Patients‘ Expectation, and Performance Rank..................................................................................................................................................... 41 Table 9: Respondent Overall Satisfaction with Services received at JNF Hospital ............................ 43 Table 10: Pearson‘s Correlation of Demographic variables to Overall Satisfaction .......................... 44 Table 11: Pearson‘s Correlation of Attributes to Overall Satisfaction ................................................ 45 Table 12: Pearson‘s Correlation of Service Quality Dimension to Overall Satisfaction ................... 47 Table 13: Stepwise Regression Results for model of Demographics Variables and Service Quality Dimensions to Overall Satisfaction ..................................................................................................... 50. x.

(11) Functional Service Quality in JNF Hospital. List of Figures Figure 1: Model of Service Quality Gaps ........................................................................................... 12 Figure 2: Conceptual Framework ........................................................................................................ 18 Figure 3: Variable Operation ............................................................................................................... 20. xi.

(12) Functional Service Quality in JNF Hospital. Chapter I Introduction. 1.

(13) Functional Service Quality in JNF Hospital. 1.0 Background. For years many health care institutions have highlighted their commitment to providing quality care, emphasized in their visions, missions, and core values and the application of quality management practices have become more pervasive. Empirical studies and theoretical models have cited patient expectation and perceived performance as major determinants of patients‘ satisfaction with their care. Hence in the patient centered approach to quality of care, patient satisfaction provides q valuable performance feedback mechanism.. Patient satisfaction within a hospital environment can be construed from a number of experiences; encounters with the facility, including: physically accessing facility, admissions process, hospital personnel, patient rooms as well as the billing and payment systems (Powell L., 2001). Environmental factors such as cleanliness, facility appearance as well as the waiting time for getting care, and the interaction and communication with providers, care outcomes, visit cost, quality of food and perceived efficiency can also affect the satisfaction level of the patients (Powell L., 2001). Health care literature suggests a dominant link with strategic decisions in the health service and patient satisfaction.. 1.1 About St Kitts and Nevis Considered the eight smallest nation in the world St Kitts and Nevis, is a twin island Federation in the western hemisphere. The most northern of the Leeward Islands, located in the Caribbean Sea, with a combined land mass of 101 square miles, St Kitts 65 square miles and Nevis 36 square miles. The Federation has a population of approximately 50,000 people with an estimated growth rate of 0.8%, and an average life expectancy of 74.4. The birth rate is 14.2/1000, and infant mortality rate of 9.9/1000.. St. Kitts and Nevis encapsulates a country rich with history culture and natural beauty which shaped the islands‘ economy. Both islands share a central government and the economy is based on 2.

(14) Functional Service Quality in JNF Hospital. services and agriculture, with tourism and offshore services playing an integral role. The health sector is characterized by a mainly publicly funded health system with health expenditure accounting for 5.6% of Gross Domestic Product (MoH, St Kitts and Nevis, 2009). The Ministry of Health St Kitts and Nevis in its vision endeavors to provide ―quality‖ service which will ―satisfy and exceed expectations of consumers‖ (MoH, St Kitts and Nevis, 2009 There are currently four hospitals all of which are publicly owned and operated. Three of these institutions are located on the island of St Kitts and the fourth on Nevis. The largest of these being the country‘s main referral center a 150 bed hospital, JNF General Hospital on St Kitts accounting for approximately 68% of the Federations inpatient beds. The other two hospitals on St Kitts, Pogson Health Facility and the Mary Charles Hospital, 24 hour urgent acute care centers with limited inpatient bed capacity, 12 and 8 beds respectively. The main hospital Alexandra Hospital, on Nevis has a 50 fifty inpatient bed capacity. There are also seventeen health centers all publicly owned which provide primary care to the general population.. The health system in St Kitts and Nevis, is overseen by the Ministry of Health, which is the authority responsible for safeguarding the health of the people of the Federation.. The Ministry‘s. organizational structure is characterized into three departments: The Office of Policy Development and Information Development, Institution Based Health Services, and Community Based Health Services each bearing different responsibility. The Office of Policy Development and Information Management bears the responsibility for the management and coordination of the Health Sector, as well as the management of health information.. The administering of Environmental Health. Services, Family Health Services, and Health Promotion are considered the responsibility of the Community Based Health Services, whose primary health services are administered from community health centers strategically located throughout the island.. The third department,. Institutions Based Health Services is responsible for administering the secondary health care services, or hospital administration.. In 2004, a patient satisfaction survey was conducted in St Kitts and Nevis for health centers. Results indicated by the study, saw that 90% of respondents had a favorable opinion of the quality of care in areas of interpersonal care, information and education, and provider attitudes, areas of dissatisfaction 3.

(15) Functional Service Quality in JNF Hospital. were found in the physical comfort and the regularity and issues of staff availability (PAHO, 2007). Following the study the initiative was taken to improve comfort of care settings as well as improving staff motivations (PAHO, 2007).. On average the health institutions or hospitals in St Kitts and Nevis utilize approximately 60% of the budgeted health recurrent expenditure (MoH, St Kitts and Nevis, 2009), representing the largest health spending area and carries a cost recovery factor of 9:1 for patients (PAHO, 2007). The Ministry is now in the process of developing a new financing mechanism to reduce the financial burden associated with provision of health services, which could possibly entail the shifting the government‘s share of health expenditure, possibly increasing service fees.. To date there has been no published research on patient satisfaction in the public hospitals of St Kitts and Nevis. There have however been internal mechanisms such as suggestion boxes and satisfaction surveys which have been used to provide a general overview of the patients‘ perspective of the quality of care being provided at the hospitals on island.. Given the significance of the institutions in the delivery of care and the amount of resources allocated annually, an assessment of the service quality in these institutions would provide valuable information to the institution and the Ministry of Health as it relate to the quality of care provided and areas of improvement, providing a base for future assessments and quality improvements. It would also be insightful to see which areas of service quality are most important to the level of satisfaction among patients.. 1.2 Purpose of Study. The research aims to measure the quality of services received by patients at JNF General Hospital, from patients‘ perspective. The study aims to assess the quality of service received by patients, and to assess the association between service quality and patients‘ overall satisfaction. Information of this nature could be useful to both the Ministry of Health and the Institutions Based Health Services in the strategic decision making process.. 4.

(16) Functional Service Quality in JNF Hospital. 1.3 Objectives of Research The objectives of the research are three fold. Firstly to analyze any existing gaps between patients‘ perception and expectations. Secondly, to analyze any existing gaps between employee perceptions and employees‘ expectations. Finally to measure relations between overall patient satisfaction and service quality dimensions.. 5.

(17) Functional Service Quality in JNF Hospital. Chapter II Literature Review. 6.

(18) Functional Service Quality in JNF Hospital. 2.0 Introduction. Patient satisfaction has received much research attention, as it is considered a key indicator of service and care, providing key feedback in managing quality initiatives in service provision.. This section provides a literature review of relevant research conducted in the area of service quality dimensions and patient satisfaction. It will attempt to provide a review of studies conducted on service quality, providing definitions of quality, the dimensions of quality as well as of quality in the context of health care. It will also provide relevant literature related to patient satisfaction as a measure of service quality.. 2.1 Service Quality Defined. 2.1.1 Service Quality. In many businesses service provision is the main operating function, while in other businesses service provision plays a supporting role in the operating function. Service as defined by Zeithaml & Bithner (2000) refers to the, deeds, processes and performances. Services possess intrinsic qualities; perishability (Zeithml & Bithner, 2000) intangibility, heterogeneity and inseparability which distinguish them from goods (Parasuraman, Zeithml, & Berry, 1988).. Service quality. according Parasuraman, Zeithml, & Berry, (1988) is related to the differences in personal qualities of service providers creating heterogeneity among providers. In a general context, Lehtinen & Lehtinen (1982) defined service quality in terms of physical quality, interactive quality and corporate (image) quality.. There has been much evidence linking quality with customer satisfaction and business performance, one of such research as cited by Buzzell R.D and Gale B.L, (1987), was the Profit Impact and Marketing Strategy research which endeavored to discover those business strategies which were most strongly related to performance. The research found that in the long run the quality of the business‘ products and services was the most important factor affecting the business performance.. 7.

(19) Functional Service Quality in JNF Hospital. The research went on further to provide evidence to linking customer satisfaction to economic performance.. 2.2 Health Care Service Quality. In the past many scholars have provided definitions of the quality concept. Quality as described by Lanning & O'Connor, (1990) is a concept which varies in different environments and according to who is defining it. In a health care context quality can be defined from various perspectives of the patients, practitioners, payers, and the society.. Donabedian, (1980), defined health care service quality as, ―that type of care which is expected to maximize an inclusive measure of patient welfare, after one has taken account of the balance of expected gains and losses that attend to the process of care in all its part‖ in an effort to provide a generalized and thorough meaning (Piligremienė & Bučiūnienė, 2008). Thus service quality in health would involve an analysis of the characteristics of the doctors, staff and hospitals referred to as the structure to achieve a given level of healthcare quality; of the interaction within that structure; and of the dimensions of service quality and satisfaction with healthcare result. Donabedian (1988) provided an additional definition, in ―the ability to reach desired objectives through legitimate means‖, where the achievable level of health is implied by the desired objective.. These two. definitions present the idea of desired and expected outcome as key in determinants of the quality of the service provided.. The 1984, definition by the American Medical Association as cited by Blumenthal, (1996) referred to that care which, ―consistently contributes to the improvement or maintenance of quality or duration of life‖ identifying specific attributes that should be examined in determining its quality. Emphasis was put on disease prevention, health promotion, informed participation of patients, timeliness, and efficient use of resources.. The European Committee for Standardization (1994), provided a more encompassing definition with a provider and patient perspective, as ―Quality is the totality of the characteristics of an entity that bears on its ability to satisfy stated or implied needs, (Helminen, 2000).‖ 8. On the other hand,.

(20) Functional Service Quality in JNF Hospital. Ovretveit (1992) defines quality as fully meeting the needs of those who needs the service most, ―at the lowest cost to the organization within limits and directives of higher authorities and purchasers‖.. Sofaer, & Firminger (2005), provided a review of qualitative studies, which directly reported patients‘ definition of quality. The review highlighted, that in most studies patients defined quality as ―patient-centered care‖ and that quality would include having physical and emotional needs met, having individualized care, as well as being involved in their care and decision making of care. Sofaer, & Firminger (2005), review also highlighted the importance of medical personnel who respect, listen to patients and anticipate their needs. Patients also viewed the protection of their privacy and confidentiality as important among others. The Institute of Medicine (IOM) has defined quality as ―the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (Shaneyfelt, 2001).‖ This definition suggests that a number of characteristics, the first being quality performance occurs on a scale, which range theoretically from unacceptable to excellent. Secondly, the attention is placed on services provided by the health care delivery system. Thirdly, that quality may be evaluated from the viewpoint of individuals or populations. Fourthly, research evidence should be used to identify the services that improve outcomes and in the absence of scientific evidence regarding effectiveness, professional consensus can be used to develop criteria (McGlynn, 1997).. The varying nature of these definitions highlights the importance of the perspective of who is defining quality.. From the practitioner‘s perspective service quality would be similar to that. proposed by the American Medical Association relating to improving the technical aspects of health and the individual health outcomes.. On the other hand patients and other consumers may define. quality as it relates to the functional aspects, the appearance of physical facilities and personnel as well as the appropriateness and efficiency of the services provided.. 9.

(21) Functional Service Quality in JNF Hospital. 2.3 Service Quality Dimensions. Health care service quality can be determined based on assessment criteria which can be technical or functional (Babakus & Mangold, 1992) or based on the technical and process-related of Zeithaml & Bitner, (2000). Stiles & Mick (1994) provided an alternative by including three types in technical, interpersonal and amenities. The technical quality has been the common dimension highlighted in most research.. There has however been a variation in the classification of the other quality. dimensions (Groönroos et al. (1984), Babakus & Mangold, (1992), Stiles & Mick (1994), Zeithaml & Bitner, (2000)). Weitzman (1995) also suggested that health care quality can be described in relationship to three areas: the technical aspects of care, the interpersonal relationship between practitioner and patient, and the amenities of care (Raposo et al., 2008).. Jun et al. (1998), highlighted eleven key attributes of quality derived from various research, these included; tangible, reliability, responsiveness, access, communication, (Parasuraman, et al.. understanding, competence, courtesy,. 1986), caring, patient outcome (Bowers, 1994), and. collaboration (Jun et al. 1998). These dimensions provide the necessary prerequisites of service quality.. The technical and functional aspects of service quality as identified by Groönroos (1982), are highlighted below:. 2.3.1 Technical Quality According to Groönroos (1982), the technical aspects are directly related to, ―what service is provided‖. Thus in the in health care context it may refer to those areas directly related to the actual care of the patients. In their review Kang & James, (2004) has highlighted that by tradition the technical aspect of quality was left to professionals. Further noting that in the healthcare context; the care providers‘ technical competence in addition to the immediate outcome of treatment may be difficult for patients to evaluate as they may lack the ability and understanding to do so. Patients. 10.

(22) Functional Service Quality in JNF Hospital. however may be able to rely on their ability to measure quality attributes associated with how the process of care is delivered (Kang & James, 2004).. In literature, as highlighted by Sofaer, & Firminger (2005), patients expressed a desire for providers who are; technically knowledgeable, experienced and competent; able to provide effective treatments, make accurate diagnoses and the need for diligent and efficient treatment to be provided and as well as providers who present themselves in a professional manner. As such patients would want their providers to ―strive for excellence‖ (Sofaer, & Firminger 2005). Thus in this regard, patients would refer to quality as having good health outcomes and improved quality of life.. 2.3.2 Functional Quality Groönroos (1984), went on to define functional quality as related to ―how‖ the service is provided. Parasuraman, Zeithamal and Berry, (1985) highlighted five key dimensions based on the functional aspect of quality; these purified dimensions were believed important to customers of service, patients included. These included: Intangibles, defined as the physical facilities, equipment, and appearance of personnel; Reliability, referred to ability to perform the promised service accurately and dependably; Responsiveness related to willingness to help customers and provide prompt service; Assurance looked at the knowledge and courtesy of employees and their ability to convey trust and confidence; While empathy referred to the caring, the individualized attention provided to customers (Lanning, & O'Connor, 1990).. Parasuraman et al. (1985), asserted that the dimensions could be measured utilizing the SERVQUAL analysis, or gap analysis, highlighting an initial 5 gaps, and revised to include up to 7 gaps (Curry 1999; Luk and Layton 2002) illustrated in Figure 1.. These gaps as highlighted below is an. expansion of Parasuraman et al, 1985 which Singh and Khanduja (2010) presented for analysis and the cited the most important of the gaps as the three gaps associated with the external customer, which are Gap 1, Gap 5 and Gap 6. The gaps as highlighted are: Gap 1: ―Customers’ expectations versus management perceptions‖, Gap 2: ―Management perceptions versus service specifications‖, Gap 3: ―Service specifications versus service delivery‖, Gap 4: ―Service delivery versus external communication‖, Gap 5: ―The discrepancy between customer expectations and their perceptions of 11.

(23) Functional Service Quality in JNF Hospital. the service delivered‖, Gap 6: ―The discrepancy between customer expectations and employees’ perceptions‖, Gap 7: ―The discrepancy between employee’s perceptions and management perceptions (Singh and Khanduja, 2010).. Figure 1: Model of Service Quality Gaps. Figure 1: Model of Service Quality Gaps (Parasuraman et al. 1986, Curry 1999, Luk and Layton 2002, Singh and Khanduja, 2010). 12.

(24) Functional Service Quality in JNF Hospital. 2.4 Satisfaction in Health Care. Satisfaction can be defined as fulfilling expectations, needs, or desires (Sitzia J, Wood N. 1997). In a review, Crow et al. (2002) contends that based on the above definition, satisfaction implies adequate or acceptable service, and not superior service, also that the satisfaction concept is relative, as what satisfies one person may dissatisfy another. Although the terms perception and satisfaction are often used interchangeably, Sofaer, & Firminger (2005), argue that conceptually satisfaction is a paradigm of perception.. Patient satisfaction instruments are useful in two major cases; First of these, in research studies in which considered patient satisfaction as an outcome, either to assess the value of a new intervention or to identify patient characteristics that appear to influence quality assessment. Secondly, used by hospitals, and other providers to assess the satisfaction of their patients or users with their services (Crow et al. 2002).. According to Crow et al. (2002), the conceptual development of patient satisfaction and its measures can be derived from three bases: the expectation theory, health services attribute evaluations, and economics as cases utility. The review further identified a holistic approach, which incorporated a wide range of predictors of satisfaction, emphasizing loops between expectation and experiences (Strasser et al. 1992).. Result and outcome are the two perspectives according to Oliver (1997) by which satisfaction can be analyzed. Satisfaction as a result is concerned with the nature of satisfaction (Oliver 1997) while as a process it is mainly concerned with its causes (Oliver 1997; Anderson 1993). John (1991), considered the patients‘ satisfaction to include both approaches. As such, from the result perspective patients‘ satisfaction can be ―viewed as an attitude resulting from the confirmation or disconfirmation of expectations‖ or as a process, ―resulting from the level of expectations the patient takes to the service experience‖ (John, 1991). This suggests the importance of knowing the result from the service experience, as well as the dimensions and causes giving rise to the satisfaction.. 13.

(25) Functional Service Quality in JNF Hospital. The review by Sofaer, & Firminger (2005), has also stated the inherent and instrumental value of patients perception of quality, by highlighting the two perspectives entwined; the normative in that the main focus in the healthcare system is the patient and their perception is meaningful. Also, that patients‘ perception can be considered a major driver of outcome to various stakeholders.. In research the use of patient perception of quality has shown that patient perception may not be stable over time creating difficulties in to develop services which the patients deem as high quality and provide meaningful comparison (Jackson et al., 2001). Research undertaken by Jackson et al. (2001), found that patients‘ rating of quality increased over time and that the ratings of various predictors shifted over time.. Boscarino, (1992), has noted evidence of the public‘s inclination to pay more for care from quality institutions which are better able to satisfy customer needs. This behavioral intention is supported by the model proposed by Zeithaml, Berry & Parasuraman, (1996), which contends that the customers‘ perception of the high service quality leads to favorable behavioral intentions while when patients perceive as low service quality the unfavorable behavioral intentions are derived. As highlighted in this model behavioral intentions can be captured in word of mouth, loyalty, complaint behavior, as well as price sensitivity (Zeithaml et al. 1996). Burton, Sheather, & Roberts, (2003), in research also concluded that behavioral intention is related to customer satisfaction, highlighting better customer experience improves the likelihood of favorable behavioral intention.. 14.

(26) Functional Service Quality in JNF Hospital. 2.5 Summary. Throughout literature on service quality is described in its varied nature, and varying definitions. Across perspectives, the definition of quality varies, while the health care industry is no exception. In hospitals the service quality can be defined from the patients‘ perspective, the practitioners‘ perspective, as well as other users providing the base for measuring quality from the various perspectives. However in measuring service quality from the patients‘ perspective, although the patients‘ definition of quality in health care services may entail, an all encompassing definition, it may be important to consider the ability of patients to accurately measure all aspects. For example the technical and functional dimensions, as defined by Groönroos (1982), when considered in the health care context, patients may be unable accurately measure the technical aspects of care (Donabedian, 1980, Kang & James, 2004).. However, irrespective the studies definitions used to measure the. patient satisfaction it may safe to assume that patients will be willing to portray favorable behavioral intentions when satisfaction is high. This has been evidenced by several studies which have noted that patient satisfaction is linked to favorable behavioral intention (Boscarino, (1992), Burton, Sheather, & Roberts, Zeithaml et al. 1996).. 15.

(27) Functional Service Quality in JNF Hospital. Chapter III Methods. 16.

(28) Functional Service Quality in JNF Hospital. 3.1 Introduction. This chapter presents the research methodology of the study; it provides information on the conceptual framework and operational definition; the study design, including the setting of the research, the research population, questionnaire design; data collection and data analysis.. 3.2 Conceptual Framework. The study is being conducted based on the Parasuraman et al, (1985) SERVQUAL model and is rooted in Donabedian (1980)‘s structure, process and outcome in health care organizations. In this framework the patient satisfaction is being used as the outcome of the patients‘ perception of how care is received, the structure refers to the physical facilities and personnel, and the process relates to the functional aspects of quality, as the research is based on the patients perspective. Because it is clearly outlined in the value statement of the hospital, ―We are committed to improving the quality of service we render to our Patients/Clients. We believe that Quality is meeting the needs of our Patients/Clients ….‖ The SERVQUAL method was deemed fit to measure the quality as it would measure the expectations of the patients as well as provide feedback as to their perception of the service received. Also, based on the notion that patients are often unable to accurately evaluate the technical quality of care; the research focuses on the functional quality ―how‖ the service is delivery, which is considered the primary determinant of the patient‘s quality (Donabedian 1980, Kovner and Smits 1978). Figure 2, illustrates the conceptual framework of study, in that the service quality is derived from the five dimensions as well as other demographic factors. In this study the existing gap between perceived and expected service quality is considered the patients‘ satisfaction or service quality. Utilizing the SERVQUAL five purified dimensions; tangibles, reliability, assurance, responsiveness, and empathy as the determinants of the level of satisfaction. In Parasuraman et al., (1985) concept, service quality = perception – expectation thus by identifying the existing gaps between perception and expectation the research intends to identify the strengths and weaknesses of the service quality and then make suggestions to improve areas 17.

(29) Functional Service Quality in JNF Hospital. which may require improvements from the patients‘ perspective.. Good service quality would. involve meeting and exceeding customer expectation. 3.2.1 Independent variables The independent variables of this research are as proposed by Parasuraman et al, (1985), Zeithaml et al, (1990); the five purified SERVQUAL dimensions; tangibles, reliability, assurance, responsiveness, and empathy. To account for other confounding variables demographics; age, sex, income, and education are also considered independent variables. 3.2.2 Dependent Variable The dependant variable refers to the outcome variable, the overall Satisfaction with the quality of service received at the hospital. Figure 2: Conceptual Framework. AGE SEX INCOME EDUCATION PERCEPTION. TANGIBLES RELIABILITY. G A P EXPECTATION. RESPONSIVENESS ASSURANCE EMPATHY. 18. OVERALL PATIENT SATISFACTION.

(30) Functional Service Quality in JNF Hospital. 3.2.1 Variable Definition As mentioned earlier the independent variables in this research are; tangibles, reliability, responsiveness, assurance and empathy, as well as the demographics, age, sex, income and education. As contended by Parasuraman et al, (1985), and Zeithaml et al, (1991), there is strong evidence to support that service quality is derived from the discrepancy between the expected service and the perceived service. Despite, these findings other research; Cronin and Taylor, (1994) and Teas, (1994) have suggested that the use of perceived service quality is as accurate as the perception less expectation score. This research follows the original authors and defines service quality dimensions as the gap between the perceived and expected service quality. The perceived quality of service would refer to the extent to which patients believe JNF Hospital has the features or dimensions under consideration. Expected quality would refer to the extent to which patients think hospitals in general offering medical services should possess the features or dimensions under consideration. Thus in this research the five SERVQUAL dimensions would be defined as the gap score of the perceived service quality – expected service quality. The following provides a description of the dimensions under consideration:. Tangibles refer to the service dimension that focuses on the elements that represent the service physically. Attributes measured by this dimension; are the hospital equipments, the physical facilities, and the employee appearances.. Reliability is defined as the ability to deliver the promised service dependably and accurately. It explores the ability to keep promises related to the delivery, pricing handling of complaints, etcetera. In this study the dimension covers the timeliness of services promised, the sympathetic and reassuring nature of hospital employees to patients as well as the accuracy of the billing system.. Responsiveness can be described as the willingness to help customers and provide prompt service. This dimension stresses service personnel‘s attitude to be attentive to customer requests, questions and complaints and covers employees telling patients exactly when services would be performed, the realistic nature of expecting prompt services from employees and the willingness of employees to help patients.. 19.

(31) Functional Service Quality in JNF Hospital. Assurance is the service quality dimension that focuses on the ability of staff to inspire trust and confidence. It explores the ability to feel safe in interaction with employees, employees‘ knowledge and politeness, as well as the adequate support of employees from employers.. Empathy is the service aspect that emphasizes the treatment of customers as individuals. It covers two areas personal attention for patients by employees as well as having the patients‘ best interest at heart. Figure 3: Variable Operation. Concept. Variable. Indicators. Measuring Scale. A. comparison. of Tangibles. Up to date equipment. Ordinal. variables based on the. Visually appealing. Likert 1-5. service expectations and. physical facilities. perceptions of services. Neat hospital. received.. employees. Analysis. utilizes the mean scores Reliability. Timely services as. Ordinal. Service. of. promised. Likert 1-5. Quality. indicators.. the. associated. Sympathetic and reassuring employees Accurate billing Responsiveness Tell patients when services will be. Ordinal Likert 1-5. performed Prompt services Willingness to help patients Assurance. Feel safe in interaction. Ordinal. with hospital. Likert 1-5. employees. 20.

(32) Functional Service Quality in JNF Hospital. Concept. Variable. Indicators. Measuring Scale. Knowledgeable employees Polite employees Adequate support from employers Empathy. Personal attention from. Ordinal. Service. employees. Likert 1-5. Quality. Patient's best interest at heart. Patient. Conceptualized. as. Patient. Satisfaction patients rating of the. overall Ordinal. satisfaction with care. Likert 1-5. overall satisfaction with care received. 3.3 Hypothesis Objective 1: Analyze any existing gaps between patients‘ perception and expectations. Hypothesis 1A: There is a difference between patients‘ perception and patients‘ expectation. Objective 2: Analyze any existing gaps between employees‘ perceptions and employees‘ expectations. Hypothesis 2A: There is a difference between the employees‘ perception and expectations. The research utilizes the assumption as suggested by many service quality researchers (Parasuraman et. al. 1985, 1991, Cronin and Taylor, 1994, Teas, 1994) that the level of satisfaction is influenced by the five domains as listed earlier as important in measuring service quality delivery.. 21.

(33) Functional Service Quality in JNF Hospital. Objective 3: Measure relations between overall patient satisfaction and service quality dimensions. Hypothesis 3A: There is a significant positive correlation between the demographics of age, sex, income and education and the level of satisfaction Hypothesis 3B: There is a significant positive correlation between the variable tangibles and the level of patient satisfaction. Hypothesis 3C: There is a significant positive correlation between the variable reliability and the level of patient satisfaction. Hypothesis 3D: There is a significant positive correlation between the variable responsiveness and the level of patient satisfaction Hypothesis 3E: There is a significant positive correlation between the variable assurance and the level of patient satisfaction Hypothesis 3F: There is a significant positive correlation between the variable empathy and the level of patient satisfaction. 3.4 Study Setting The research was conducted at an urban public hospital; the main referral hospital in St Kitts and Nevis and was chosen for convenience, and it being the most attended facility in the country. The hospital provides the most comprehensive range of services as compared to other facilities on the island and is the largest hospital in the Federation‘s health care system. It is also noteworthy to mention that the four (4) of hospitals are publicly owned and operated.. Services offered at J.N.F. General Hospital include the inpatient service wards, including; general surgery, internal medicine, pediatrics, obstetrics, gynecology, intensive care and psychiatry, and outpatient services including; laboratory, radiology, ophthalmology, physiotherapy, and pharmacy as well as the accident and emergency (E.R.). The hospital also operates as a teaching hospital, utilizing medical and nursing students as part of the patient care team.. 22.

(34) Functional Service Quality in JNF Hospital. The structure of the Institutions Based Health Services is organized with the administration of all public hospitals coordinated from the Joseph N. France General Hospital, which as highlighted earlier is the largest hospital in the country. As such similar management strategies and quality initiatives at conducted at all hospitals.. To aid the continuous quality improvement process at the institutional level i.e. hospitals there has been many quality improvement initiatives, including one which calls for the establishment a framework for continuous improvement throughout the health sector (MoH, St Kitts and Nevis, 2009). As well as the establishment of its hospital accreditation system, this is overseen by a multistakeholder committee.. 3.5 Questionnaire. Questionnaire was developed based on the SERVQUAL measure for evaluating services. SERVQUAL was developed to measure service quality in organizations and the scale was and tested across four service environments: banking, credit card services, repair and maintenance long distance telephone services and was adapted to hospital services by Babakus & Mangold, (1992).. The data was collected using generic SERVQUAL questionnaire modified by Babakus & Mangold (1992), to suit the hospital context (see questionnaire in appendix 1). The questionnaire included 15 paired questions, an overall rating scale as well as questions as it relates to the patients willingness to pay more of better quality service. Each item was rated on a five –point likert scale anchored at the numeral 1 with the verbal statement ‗‗Strongly Disagree‘‘ and at the numeral 5 with the verbal statement ‗‗Strongly Agree.‘‘. 3.5.1 Validity. This instrument as adapted by Babakus and Mangold, (1992), is deemed a valid tool for measuring the patients‘ expectations of hospital services and patients‘ perceptions of the hospital services. 23.

(35) Functional Service Quality in JNF Hospital. received. The tool offered ―excellent internal consistency reliabilities‖ for measuring service quality in the hospital setting (Babakus and Mangold, 1992). Considering the validated questionnaire was taken from the Babakus and Mangold, 1992 study, which had been scaled to suit the hospital setting, a pretest test was not conducted as the generic 22 item questionnaire had already been, scaled to remove irrelevant questions in the hospital setting, thus removing the confusion and frustration of too many items in the questionnaire (Babakus and Mangold, 1992). Thus the current questionnaire was deemed to have a ―high content validity‖ (Babakus and Mangold, 1992).. 3.5.2 Reliability The questionnaire was considered to have good internal consistency based findings presented by Babakus and Mangold, (1992), however for analysis purpose the two groups of questionnaires conducted were utilized to confirm the reliability of the questionnaire, combined the Cronbach‘s alpha was > 0.929, for the employees alpha was>.896 and for the patients alpha was>.936 for the 30 item questionnaire. While among the dimensions overall alpha ranged between 0.82 and 0.85, all alpha > 0.80 indicating acceptable internal reliability according to rule of thumb, alpha > 0.70 (Nunnally, 1978). These results supported by Babakus and Mangold, (1992), initial findings indicating that the scale is sufficiently adequate to measure both perceptions and expectations indicating the questionnaires ability to measure successfully the magnitude of the gap between expectations and perceptions. 3.5.1. Sample (size and technique). The sample size was selected using G Power statistical software version 3.1 using an effect size 0.07, alpha 0.05, power 0.80 and predictors 7. Results indicated a sample size of at least 213 would be needed.. A total of 215 questionnaires were distributed to patients who received services at the JNF hospital between the periods August 2010 to September 2010. They were distributed through systematic random sampling on 15 days during the period; approximately 15 patients on each day. These questionnaires would be representative of the ratio of the patient flow of the outpatient, emergency department, and the inpatient wards, which will be 7:5:3 respectively on each day. A total of 66 24.

(36) Functional Service Quality in JNF Hospital. questionnaires were also distributed to employees of the hospital, in an effort to make comparison between employees and patients. The sample was drawn from employees of the hospital who themselves had been patients at the hospital.. 3.5.2 Data Collection The patients‘ questionnaire was collected August 16 to September 1, 2010, at the JNF General Hospital. It involved the distribution of 215 self administered survey questions, distributed at various key points of service delivery at the hospital, emergency department, outpatient department and the inpatient services of the hospitals, a total of 200 questionnaires were returned.. 66 Employee questionnaires were distributed from December 2010 to February 2011, by the hospital. A total of 53 questionnaires were returned. An overall response rate of 90% response rate was achieved.. Although both samples were collected at different time frame the data is considered consistent enough for comparison purposes as there was no significant changes in management policy within the three month time difference.. 3.6 Data Analysis. The descriptive statistics was used to summarize the sample data, providing information related to the sample characteristics and means. Analysis utilized include the frequencies, means to measure the central tendency of the data and standard deviation to measure the variation of the distribution. Based on the three objectives outlined the data analysis was performed as follows. Objective 1: To analyze any existing gaps between patients‘ perception and expectations.. In assessing the level of satisfaction the expected and perceived service quality of the services at JNF, the patient data sets of n=200 was utilized to perform analysis.. Patient demographic. characteristics were utilized to provide frequencies. The patients‘ expectations and perceptions were 25.

(37) Functional Service Quality in JNF Hospital. then utilized to present summary of the data, the means and standard deviations were explored as well as the minimum and maximum scores for each of the 15 items and 5 domains under consideration. The Student t-test was utilized to establish the existence of a significant difference between patients‘ expectations and perceptions. A comparison table was utilized to compare means for the patients‘ expectations and perceptions, as well as the gap score.. The gap score was. calculated, perception – expectation.. Objective 2:. To analyze any existing gaps between employee perceptions and patients‘. expectations.. In assessing the level of satisfaction the expected and perceived service quality of the services at JNF, the employee data sets of n=53 was utilized to perform analysis. Employee demographic characteristics were utilized to provide frequencies. The patients‘ expectations and perceptions were then utilized to present summary of the data, the means and standard deviations were explored as well as the minimum and maximum scores for each of the 15 items and 5 domains under consideration. The Student t-test was utilized to establish the existence of a significant difference between employees‘ expectations and employees‘ perceptions. From the employee data set a comparison table was utilized to compare means for the patients‘ expectations and perceptions, as well as the gap score.. The gap score was calculated, perception – expectation.. A second. comparison table was utilized to compare mean differences in the employees‘ expectation and perception.. Objective 3: To measure relations between patient satisfaction and service quality dimensions.. The two data sets were merged to establish the association between the service quality and the level overall satisfaction. To establish the internal validity of the questionnaire the Cronbach‘s alpha was > 0.929 for the 30 item questionnaire. While among the dimensions alpha ranged between 0.82 and 0.85, all alpha > 0.80 indicating acceptable internal reliability according to rule of thumb, alpha > 0.70 (Nunnally, 1978).. 26.

(38) Functional Service Quality in JNF Hospital. To rank hierarchically in terms of importance the Pearson‘s correlation coefficient was performed on the 5 dimensions and 15 attributes. While in assessing the association between overall satisfaction and service quality the Pearsons‘ correlation coefficient was used and regression analysis was performed to measure the fitness of the model. The sample was adjusted for missing data, and the analysis utilized a data set of n=195 for patients and n=49 for employees for a total of 244 to be analyzed. Service quality was calculated using the mean service quality score for each dimension.. Throughout analyses, the statistical level of significance will be P < 0.05 and statistical analyses was be used performed using Microsoft Excel 2007 and SPSS 16.0.. 3.7 Ethical considerations. In absence of a research committee, permission was sought and received from the Ministry of Health to utilize patients‘ views in this study (Appendix 2. Permission Request Letter). Only patients willing to answer the questions were required to participate.. 27.

(39) Functional Service Quality in JNF Hospital. Chapter IV Results and Discussion. 28.

(40) Functional Service Quality in JNF Hospital. 4.1 Introduction. This chapter presents the results of the research findings, highlighting the patterns of results in relations to the research objectives. Firstly, providing summary statistics and analysis of the two samples demographics, as well as the expectations and perception of the services provided at the hospital.. 4.2 Data Profile. In this research, questionnaires were distributed to two groups, patients and staff of the hospital. The analysis would consist of data collected from 200 patient results, and 53 staff members.. Table 1: Department visited by Patient Respondents n=200. Department. Frequency Percentage. Emergency. 59. 30%. Outpatient. 97. 49%. Inpatient services. 44. 22%. As illustrated in Table 1. 49% of 97 of the respondents were drawn from patient who visited the outpatient department, 30 % or 59 respondents from the Emergency department and 22% or 44 respondents drawn from the patients who were admitted to the hospital.. 29.

(41) Functional Service Quality in JNF Hospital. Table 2: Staff Respondents and Non respondents by Category n=53. Staff Category. Respondents. Percentage. Non-. Percentage. Respondents Physician. 6. 11%. 1. 8%. Nurse. 17. 32%. 2. 15%. Administrative. 11. 21%. 3. 23%. Laboratory. 4. 8%. 0. 0%. Pharmacist. 3. 6%. 0. 0%. Auxiliary. 12. 23%. 7. 54%. Respondents from the staff was drawn from six categories, with the largest representation from nurses which had a total of 17 or 32% of staff respondents, followed by auxiliary workers who comprised 23% or a total of 12 respondents, administrative with 21% or 11 respondents, physicians with 11% or a total of 6 respondents, and 8% or 4 and 6% or 3 for laboratory and pharmacist, see table 2. More than half of the non-respondents represented the auxiliary staff category, other categories with non respondents in include administrative with 23% and nurses with 15% and physicians with 8%. Both pharmacists and laboratory staff had 100% response rates.. Table 3, the background demographic data for respondents, it presents the sex of respondents, as highlighted 73% or 146 of the patient respondents were female and 26.5% or 53 being male only 1 respondent did not indicate sex. Of the 53 staff respondents 81% or 42 were female while males accounted for 19% or a total of 10. The results indicate an almost 3:1 female to male ratio of patient respondents while the staff respondents carried an almost 4:1 female to male ratio. Results indicating a higher presence of females among both groups of respondents.. Also highlighted in Table 3, 31% or a total of 62 of patient respondents were between the ages of 18-30, 45% or 90 respondents within the age range of 31-50, 20% or 40 respondents within the age range 51-60, and 4% or 8 respondents above the age of 60. While there was 21% or a total of 11 of staff respondents were within the age group 18-30, 62% or 33 respondents were within the age range 31-50, and the 15% or 8 staff respondents within the 51-60 age range. Only one staff respondent was. 30.

(42) Functional Service Quality in JNF Hospital. above 60 years. Both groups displayed a similar attributes with the modal class for each falling within the age range of 31-50, recording 45% and 62% for patients and staff respectively.. Table 3: Respondents Demographic Backgrounds Patients N. Staff. %. N. %. 53. 27%. 10. 19%. 146. 73%. 42. 81%. 18-30. 62. 31%. 11. 21%. 31-50. 90. 45%. 33. 62%. 51-60. 40. 20%. 8. 15%. 8. 4%. 1. 2%. <$1000. 27. 14%. 0. 0%. $1001-$2500. 59. 30%. 15. 29%. $2501-$4000. 83. 42%. 18. 35%. >$4000. 29. 14%. 19. 36%. 8. 4%. 0. 0%. 138. 70%. 20. 39%. Undergraduate. 33. 17%. 12. 24%. Graduate. 18. 9%. 19. 37%. Sex Male Female Age. 60+ Monthly Income (EC$). Education Primary Secondary. The level if income was measured in local currency, Eastern Caribbean Dollars (EC$), as shown in Table 3, the level of income among the patient respondents were as follows, 27 or 14% below EC $1,000 range, 59 or 30% between EC $1001-$2500, 83 or 42% between EC $2501-$4000 and 29 or 15% of patient respondents above EC $4,000. Among the staff, 15 or 28% responded to having an 31.

(43) Functional Service Quality in JNF Hospital. income between the range EC $1,001-$2,500, 18 or 34% within the range EC $2,501-$4,000, and 19 or 36% of staff above EC $4,000.. Also illustrated in Table 3, when asked about the highest level of education attained, 8 or 4% of patient respondents stated that they had received education only to primary school level, 138 or 70% received up to a secondary school level, while 33 or 17% of respondents had received undergraduate education, 18 respondents or 9% had received graduate level education, 3 or 2% respondents did not indicate their level of education.. Among the staff respondent, 20 or 39% responded having. completed up to a secondary education, 12 or 24% had completed an undergraduate education, while 19 or 37% of respondents had completed a graduate education.. 4.3 Service Quality Results This section provides an analysis of the SERVQUAL questionnaire.. Table four presents the. summary statistics for patients‘ expectations and perceptions. As illustrated expectation scores among the dimensions ranged from 1 to 5, with assurance and responsiveness gaining minimum scores of 1, while in all dimensions the maximum expectation score was gained was 5. The highest mean expectation score among the dimension was received by assurance with 4.62, while the lowest was received by tangibles with 4.47. Standard deviations ranged from as low as 0.551 assurance to a high of 0.621 empathy; tangibles, reliability and responsiveness with standard deviations of 0.926, 0.937, 0.969 respectively. When the patients‘ perception of the service quality dimensions was considered the scores ranged from 1 to 5 in all dimension, mean perception scores ranged from 3.21 responsiveness to 3.39 assurance while empathy, tangibles and reliability had a mean perception scores of 3.31 and 3.32 respectively.. 32.

(44) Functional Service Quality in JNF Hospital. Table 4: Service Quality Mean, Standard Deviation, Minimum and Max scores of Patients Expectations and Perception Mean 4.47. Expectation S.D. Min 0.589 3. Mean 3.31. Perception S.D. Min 0.926 1. M 5ax. Max 5. Up to date equipment. 4.37. 0.622. 3. 5. 3.03. 0.943. 1. 5. Visually appealing physical. 4.50. 0.585. 3. 5. 3.45. 0.855. 1. 5. 4.55. 0.547. 3. 5. 3.45. 0.917. 1. 5. 4.56. 0.560. 3. 5. 3.32. 0.937. 1. 5. Timely services as promised. 4.50. 0.610. 3. 5. 3.16. 0.978. 1. 5. Sympathetic and reassuring. 4.62. 0.537. 3. 5. 3.41. 0.881. 1. 5. 4.57. 0.526. 3. 5. 3.39. 0.900. 1. 5. 4.53. 0.643. 1. 5. 3.22. 0.969. 1. 5. 4.45. 0.678. 2. 5. 3.22. 0.957. 1. 5. Prompt services. 4.46. 0.716. 1. 5. 3.17. 1.013. 1. 5. Willingness to help patients. 4.68. 0.487. 3. 5. 3.28. 0.936. 1. 5. 4.62. 0.551. 1. 5. 3.39. 0.897. 1. 5. 4.65. 0.520. 3. 5. 3.33. 0.874. 1. 5. 4.66. 0.535. 2. 5. 3.54. 0.850. 1. 5. Polite employees. 4.62. 0.554. 2. 5. 3.37. 0.931. 1. 5. Adequate support from. 4.56. 0.590. 1. 5. 3.31. 0.921. 1. 5. 4.52. 0.621. 2. 5. 3.39. 0.894. 1. 5. 4.45. 0.632. 2. 5. 3.32. 0.923. 1. 5. 4.60. 0.602. 2. 5. 3.45. 0.861. 1. 5. Tangibles. facilities Neat hospital employees Reliability. employees Accurate billing Responsiveness Tell patients when services will be performed. Assurance Feel safe in interaction with hospital employees Knowledgeable employees. employers Empathy Personal attention from employees Patient's best interest at heart. 33.

(45) Functional Service Quality in JNF Hospital. When individual attributes were considered the minimum expectation score was 1 while the maximum score was 5. Among the attributes mean expectation scores ranged from a high of 4.68 related to willingness to help patients to a low of 4.37 for the attribute related to up to date equipment. Standard deviations ranged from 0.487 to 0.716. The patients‘ perception scores for attributes were lower than the expectation scores, with the minimum perception score being 1 and the highest being 5. Mean perception scores among the attributes ranged from 3.03 for the attribute related to up to date equipment to 3.54 related to knowledgeable employees. Standard deviations ranged from 0.850 to 1.013.. Table 5, below presents the findings of the 15 attribute questions, providing a summary of the mean expectation and perception scores, as well as the mean differences, (perception- expectation) for patients receiving services.. Table 5: SERVQUAL Gap 5: Patients' Perception - Patients' Expectation,. rank and paired. difference t-statistics Service Quality Attribute:. Mean. Mean. SERVQUAL. Perception. Expectation. Score. 3.31. 4.47. -1.17. II. Up to date equipment. 3.03. 4.37. -1.34. 14. Visually appealing. 3.45. 4.50. -1.06. 1. 3.45. 4.55. -1.10. 2. 3.32. 4.56. -1.25. IV. 3.16. 4.50. -1.34. 13. 3.41. 4.62. -1.21. 7. 3.39. 4.57. -1.19. 6. 3.22. 4.53. -1.31. V. 3.22. 4.45. -1.23. 8. Tangibles. Rank. t. Sig.. -17.832. 0.000. -19.737. 0.000. -19.498. 0.000. physical facilities Neat hospital employees Reliability Timely services as promised Sympathetic and reassuring employees Accurate billing Responsiveness Tell patients when. 34.

(46) Functional Service Quality in JNF Hospital. Service Quality Attribute:. Mean. Mean. SERVQUAL. Rank. Perception. Expectation. Score. Prompt services. 3.17. 4.46. -1.29. 11. Willingness to help. 3.28. 4.68. -1.40. 15. 3.39. 4.62. -1.24. III. 3.33. 4.65. -1.32. 12. 3.54. 4.66. -1.12. 3. Polite employees. 3.37. 4.62. -1.26. 10. Adequate support from. 3.31. 4.56. -1.25. 9. 3.39. 4.52. -1.14. I. 3.32. 4.45. -1.13. 4. 3.45. 4.60. -1.15. 5. t. Sig.. -19.929. 0.000. -17.107. 0.000. services will be performed. patients Assurance Feel safe in interaction with hospital employees Knowledgeable employees. employers Empathy Personal attention from employees Patient's best interest at heart Overall Score = -1.32 t = -21.23 sig. 0.000. Table 5 present the SERVQUAL score for the gap between patients‘ perception and expectation. The findings indicate all 15 attributes bear a negative SERVQUAL score, thus in none of the attributes under consideration is the hospital able to meet its patients; expectation. The most favorable score -1.06, achieved by the attribute related to visually appealing physical facilities, while the most unfavorable score -1.40 was achieved in the area of willingness to help patients. The dimensions had similar findings with all scores being negative; scores ranged from -1.14 for empathy, to -1.31 for responsiveness, empathy being the most favorable score with responsiveness being least favorable. The SERVQUAL scores for the other dimensions were; -1.17 tangibles, -1.24 assurance and -1.25 for reliability. 35.

(47) Functional Service Quality in JNF Hospital. All dimensions having a significant difference between patient perception and expectations, when the paired t-test was performed, the null hypothesis was rejected as significance level were small <0.05, thus indicating the existence of a gap between mean perception and expectation scores.. Although all scores are negative patients expectations are being closer met in the empathy dimension, indicating that patients feel that the hospital is empathetic towards its patients. Empathy is closely followed by tangibles. The performance in the tangibles dimension could be attributed to the recent upgrade of hospital facilities, in which the government invested substantially into the refurbishment of the hospital. The responsiveness dimension, as highlighted in table 5, is furthest from patient expectations, this indicates that patients observed the largest gap between their expectations and perceptions as it relates to the employees willingness to assist patients and prompt delivery of service.. With regards to the level of service quality among the employees, table 6, present the summary statistics for the employees.. Table 6: Service Quality Mean, Standard Deviation, Minimum and Max Scores of Employee Expectations and Perception Expectation. Perception. Mean. S.D.. Min. Max. Mean. 4.52. 0.594. 3. 5. 3.28. Up to date equipment. 4.62. 0.527. 3. 5. Visually appealing. 4.45. 0.637. 3. 4.47. 0.608. 4.47 4.40. Tangibles. S.D.. Min. Max. 0.722. 1. 5. 3.30. 0.696. 2. 4. 5. 3.32. 0.701. 2. 4. 3. 5. 3.23. 0.776. 1. 5. 0.583. 3. 5. 3.08. 0.784. 1. 5. 0.599. 3. 5. 2.98. 0.772. 1. 5. physical facilities Neat hospital employees Reliability Timely services as promised 36.

(48) Functional Service Quality in JNF Hospital. Expectation. Perception. Mean. S.D.. Min. Max. Mean. Min. Max. 4.51. 0.576. 3. 5. 3.19. 0.786. 2. 5. 4.51. 0.576. 3. 5. 3.06. 0.795. 1. 4. 4.45. 0.681. 2. 5. 3.04. 0.787. 1. 5. 4.32. 0.754. 2. 5. 2.92. 0.805. 1. 4. Prompt services. 4.36. 0.710. 2. 5. 2.94. 0.818. 1. 4. Willingness to help. 4.66. 0.517. 3. 5. 3.25. 0.705. 2. 5. 4.72. 0.449. 4. 5. 3.22. 0.797. 1. 5. 4.70. 0.463. 4. 5. 3.28. 0.717. 2. 5. 4.75. 0.434. 4. 5. 3.45. 0.722. 2. 5. Polite employees. 4.66. 0.478. 4. 5. 3.25. 0.757. 2. 5. Adequate support from. 4.77. 0.423. 4. 5. 2.89. 0.891. 1. 5. 4.46. 0.706. 2. 5. 3.27. 0.834. 1. 5. 4.25. 0.806. 2. 5. 3.04. 0.808. 1. 4. 4.68. 0.510. 3. 5. 3.51. 0.800. 2. 5. Sympathetic and. S.D.. reassuring employees Accurate billing Responsiveness Tell patients when services will be performed. patients Assurance Feel safe in interaction with hospital employees Knowledgeable employees. employers Empathy Personal attention from employees Patient's best interest at heart. As shown in table 6, expectation scores among the dimensions ranged from 2 to 5, with empathy and responsiveness gaining minimum scores of 2, while in all dimensions the maximum expectation score was gained was 5. The highest mean expectation score among the dimension was received by assurance with 4.72, while the lowest was received by responsiveness with 4.45.. 37. Standard.

(49) Functional Service Quality in JNF Hospital. deviations ranged from as low as 0.449 assurance, to a high of 0.706 empathy; tangibles, reliability and responsiveness with standard deviations of 0.594, 0.583, 0.681 respectively. When the employees‘ perception of the service quality dimensions was considered the scores ranged from 1 to 5 in all dimension, mean perception scores ranged from 3.04 responsiveness, to 3.28 by tangibles; and empathy, assurance and reliability had a mean perception scores of 3.27, 3.22, and 3.08 respectively.. When individual attributes were considered the minimum expectation score was 1while the maximum score was 5. Among the attributes mean expectation scores ranged from a high of 3.51 related to having the patients‘ best interest at heart to a low of 2.89 for the attribute related to adequate support from employees. Standard deviations ranged from 0.487 to 0.716. The patients‘ perception scores for attributes were lower than the expectation scores, with the minimum perception score being 1 and the highest being 5. Mean perception scores among the attributes ranged from 3.03 for the attribute related to up to date equipment to 3.54 related to knowledgeable employees. Standard deviations ranged from 0.696 to 0.891.. The results for the service quality gap for employees found all scores to be negative, in both the dimensions and attributes. Table 7 shows the gap scores for the employees; among the five dimensions the least favorable score being -1.50 for assurance while the most favorable score -1.19 was achieved by empathy. Tangibles, reliability and responsiveness had gaps scores of -1.23, 1.40, and 1.41 respectively. The overall service quality score was -1.346 among the employees‘. Similar to the patients sample, all dimensions had a significant difference between perception and expectations, when the paired t-test was performed, the null hypothesis was rejected as significance level were small <0.05, thus indicating the existence of a gap between mean perception and expectation scores.. 38.

(50) Functional Service Quality in JNF Hospital. Table 7: Service Quality Gap: Employee Perception – Employee Expectation, Performance Rank and Paired Difference t-statistics Service Quality. Mean. Mean. SERVQUAL. Perception. Expectation. Score. 3.28. 4.52. -1.23. II. Up to date equipment. 3.30. 4.62. -1.32. 6. Visually appealing. 3.32. 4.45. -1.13. 1. 3.23. 4.47. -1.25. 4. 3.08. 4.47. -1.40. III. 2.98. 4.40. -1.42. 9. 3.19. 4.51. -1.32. 7. 3.06. 4.51. -1.45. 14. 3.04. 4.45. -1.41. IV. 2.92. 4.32. -1.40. 8. Prompt services. 2.94. 4.36. -1.42. 11. Willingness to help. 3.25. 4.66. -1.41. 10. 3.22. 4.72. -1.50. V. 3.28. 4.70. -1.42. 13. 3.45. 4.75. -1.30. 5. Polite employees. 3.25. 4.66. -1.41. 12. Adequate support from. 2.89. 4.77. -1.89. 15. Tangibles. Rank. t. Sig.. -12.554. 0.000. -11.854. 0.000. -11.975. 0.000. -14.498. 0.000. physical facilities Neat hospital employees Reliability Timely services as promised Sympathetic and reassuring employees Accurate billing Responsiveness Tell patients when services will be performed. patients Assurance Feel safe in interaction with hospital employees Knowledgeable employees. 39.