Service Quality At Hospitals

ABSTRACT - This study examines the determinants of consumer satisfaction (CS) with hospitals and clinics using SERVPERF and whether there are differences across institutions. Several interesting results are found. First, the major determinants of customer satisfaction at clinics are aspects related with 'tangibles’ and 'empathy’ dimensions of services. Secondly, the factor related with 'reliability’ is important determinant of CS at hospitals. Finally, CS has a significant effect on word of mouth (WOM) and patronage for clinics, whereas CS has a significant effect on WOM but not on patronage for hospitals.


Sungjin Yoo (2005) ,"Service Quality At Hospitals", in AP - Asia Pacific Advances in Consumer Research Volume 6, eds. Yong-Uon Ha and Youjae Yi, Duluth, MN : Association for Consumer Research, Pages: 188-193.

Asia Pacific Advances in Consumer Research Volume 6, 2005      Pages 188-193


Sungjin Yoo, Inje University, Korea


This study examines the determinants of consumer satisfaction (CS) with hospitals and clinics using SERVPERF and whether there are differences across institutions. Several interesting results are found. First, the major determinants of customer satisfaction at clinics are aspects related with 'tangibles’ and 'empathy’ dimensions of services. Secondly, the factor related with 'reliability’ is important determinant of CS at hospitals. Finally, CS has a significant effect on word of mouth (WOM) and patronage for clinics, whereas CS has a significant effect on WOM but not on patronage for hospitals.


Nationwide, income increased significantly during the 1980s and 1990s. This phenomenon has led to the boom for more concern for well-being, health. The value and lifestyles of Korean is changing dramatically from perspective of survival to enjoying life. So no quality of life (QOL), healthy food, Yoga, diet and health training are trends in Korea and the key word for these symptoms is well-being. Significant portion of TV programs and books are assigned to well-being or health-related stuff. High expectation toward health and well-being has led to demand for high quality medical services

Furthermore, competition in medical services is increasing among domestic hospital and clinics. The number of doctors is increasing rapidly nowadays. In the next 15 years, the number of doctors will be almost doubled, so the managers of hospitals and clinics are concerned with intense competition due to the oversupply of doctors. So they are now more interested in improving service quality and customer satisfaction to make a long-term relationship with customers and attract new customers. Researchers have to provide them with insightful solutions with theoretical and strategic implications. So, there is more need for industry-based researches in service quality studies. There are some researches in service quality of medical services. However, there are few researches on the comparison between hospitals & clinics in terms of service quality.


Service Quality

The definition of quality has different meanings without accordance among scholars and managers. Parasurman, Zeithaml & Berry (1988) proposed SERVQUAL model. In SERVQUAL model, PZB made conceptualization and measurement of service quality. PZB (1994) states that their focus group interview has captured not only the attributes of service quality but also the underlying psychological process by which consumers form service quality judgments. Essentially, on the basis of their focus group findings, PZB (1988) concludes that service quality judgments comprise of five underlying attributes that consumers evaluate on the basis of the expectancy-disconfirmation paradigm (Oliver 1980). The five dimensions or factors of service quality are tangibles, reliability, responsiveness, assurance, and empathy. The definitions of five dimensions are as follows:

* Tangibles: Appearance of physical facilities, equipment, personnel, and communication materials

* Reliability: Ability to perform the promised service dependably and accurately

* Responsiveness: Willingness to help customers and provide prompt service

* Assurance: Knowledge and courtesy of employees and their ability to convey trust

* Empathy: Caring, individualized attention the firm provides its customers

The five SERVQUAL dimensions, by virtue of being derived from systematic analysis of customers’ rating from hundreds of interviews in several service sectors, are a concise representation of the core criteria that customers employ in evaluating service quality. As such, it is reasonable to speculate that customers would consider all five criteria to be quite important. In fact, PZB (1988) asked users of credit-card, repair-and-maintenance, long-distance telephone, and retail banking service to rate the importance of each SERVQUAL dimension and they found that all five dimensions were considered critical.

Cronin & Taylor (1992) proposed SERVPEF model. They insist on that service quality is determined by performance only. The authors investigated the conceptualization and measurement of service quality and the relationship among service quality, consumer satisfaction, and purchase intentions. They suggested the current operationalization of service quality confounds satisfaction and attitude. Hence, they tested an alternative method of operationalizing perceived service quality and the significance of the relationships among service quality, consumer satisfaction, and purchase intentions. They suggested that the performance-based measure of service quality may be an improved means of measuring the service quality construct, and service quality is an antecedent of consumer satisfaction. Consumer satisfaction has a significant effect on purchase intentions, and service quality has less effect on purchase intentions than does consumer satisfaction.

Service Quality in Medical Services

Cronin and Taylor (1994) revealed that patient satisfaction and healthcare service quality are two empirically different constructs, contrary to the existing healthcare marketing literature. A model for distinguishing between the two is provided. Study results suggest that healthcare managers can dispense with the SERVQUAL service quality measurement scale and concentrate on the SERVPERF scale instead.

Four models for measuring healthcare service quality were examined to determine their efficacy when applied to dental practices (McAlexander, Kaldenberg, and Koenig 1994). The four models were the SERVQUAL method that measures consumer service expectations and perceptions of the performance of the healthcare provider, a weighted SERVQUAL model, a SERVPERF model measuring performance only, and a weighted SERVPERF model. Research results indicate that the SERVPERF model is superior to the SERVQUAL model for measuring the provision of dental healthcare services. Dental healthcare consumers’ perceptions of quality were heavily influenced by provider performance assessments.

Customer Satisfaction (CS)

I defined customer satisfaction in this study as the emotional state that occurs as a result of a customer’s interaction with the firm over time (Anderson, Fornell, and Lehman 1994; Crosby, Evans, and Cowles 1990)

There are two types of definitions that differ in term of emphasizing either as an outcome or as a process. Some definitions construe CS as an outcome resulting from the consumption experience. These definitions include: "the buyer’s cognitive state of being adequately or inadequately rewarded for the sacrifices he has undergone" (Howard and Sheth 1969); "an emotional response to the experience provided by, associated with particular products or services purchased, retail outlets, or even molar patterns of behavior such as shopping and buyer behavior, as well as the overall marketplace" (Westbrook and Reilly 1983); and "the summary psychological state resulting when the emotion surrounding disconfirmed expectations is coupled with the consumer’s prior feelings about the consumption experience" (Oliver 1981).

Consumer satisfaction has also been defined as "an evaluation rendered that the consumption experience was at least as good as it was supposed to be" (Hunt 1977), as "an evaluation that the chosen alternative is consistent with prior beliefs with respect to that alternative" (Engel and Blackwell 1982) and as "the consumer’s response to the evaluation of the perceived discrepancy between prior expectations and the actual performance of the product after its consumption" (Tse and Wilton 1988). These definitions suggest that an evaluation process is an important element underlying CS. This process-oriented approach, as compared to the outcome-oriented approach, seems useful in that it spans the entire consumption experience and points t an important process which may lead to CS with unique measures capturing unique components of each stage. This approach seems to draw more attention to the perceptual, evaluative, and psychological process that combine to generate CS. The process approach has been adopted by many researchers.

Relationship between Service Quality & CS

Service quality has been described as a form of attitude, related but not equivalent to satisfaction, that result from the comparison of expectations with performance (Bolton and Drew 1991; Parasuraman, Zeithaml, and Berry 1988). Bolton and Drew (1991) suggest that service quality and satisfaction are distinct construct. The best explanation of the difference between the two is that perceived service quality is a form of attitude, a long-run overall evaluation, whereas satisfaction is a transaction-specific measure (Bitner 1990; Bolton and Drew 1991; Parasuraman, Zeithaml, and Berry 1988). PZB (1998) further suggest that the difference lies in the way disconfirmation is operationalized. They state that in measuring perceived service quality the level of comparison is what a consumer should expect, whereas in measures of satisfaction the appropriate comparison is what a consumer would expect.

This distinction is important to mangers and researchers alike because providers need to know whether their objective should be to have consumers who are satisfied with their performance or to deliver the maximum level of perceived service quality. PZB (1988) proposed that higher levels of perceived service quality result in increased consumer satisfaction.

Consequences of CS


Word-of-mouth seems to have an important impact on consumer responses for several reasons. First, since it involves face-to-face communication, it might have a communication. Word-of-mouth communication may contain concrete information based on vivid experience incidents. Second, it is originated by non-firm, non-marketing sources, and it is likely to be perceived as more credible than other communications from marketers. Third, word-of-mouth can be more damaging since it is communicated to many others. An important determinant of word-of-mouth seems to be consumer satisfaction or dissatisfaction. Thus, researchers have examined word-of-mouth as one of the consequences of CS with a consumption experience.

Richins (1983) examined negative word-of-mouth by dissatisfied consumers (telling others about their unsatisfactory experience) and identified variables that distinguish this response from others, such as switching brands, stopping patronage of the store, or making a complaint. The results indicated that negative word-of-mouth occurred when the problem was severe, and when the retailer’s responsiveness to complaints was negatively perceived. It was also affected by attributions of the dissatisfaction; more negative word-of-mouth was made when blame for the dissatisfaction was attributed to the retailers.

A review by Weinberger, Allen, and Dillon (1981) regarding research investigating the impact of negative information on consumers lists few studies that investigate negative word-of-mouth. Consumers seem to give more weight to negative information and non-marketing sources of information in evaluations than to positive information and marketing information. Further, word-of-mouth communication literature has focused on opinion leaders and diffusion of innovation.


Newman and Werbel (1973) noted that dissatisfied consumers are less likely to repurchase the brand than satisfied consumers. One study reported that from 30% to more than 90% of dissatisfied consumers did not intend to repurchase the brand. Oliver (1980) hypothesized that CS influences attitude, which in turn affects repurchase intention. Results supported this view in that CS had a positive effect on attitudes. These positive attitudes were found to increase patronage or purchase intention, which is consistent with the Fishbein model. Many studies have found that CS influences patronage as well as post-purchase intention. This implies that CS is likely to increase repeat purchase behavior and brand loyalty and to reduce brand switching.

It was also found that those dissatisfied consumers who made a complaint about their dissatisfaction reported higher repurchase intentions than those who did not complain, even if their complaints were not satisfactorily handled. This finding implies that firms should encourage dissatisfied consumers to voice their complaints rather than switching to other brands. The act of giving consumers opportunities to complain seems to be important for a firm’s positive image and sales.


Research Model

The research model of this study can be summarized just like Figure 1. Factors such as tangibles, reliability, responsiveness, assurance, empathy that are five factors of SERVQUAL, influence CS. Consequences of CS are word of mouth (WOM) and patronage.

The Sample

I obtained data from inhabitants who have the experience of clinics and hospitals. I used interviewed survey and gathered data using convenience sampling in the periods from Oct. 1, to Oct.14, 2003 in Seoul and Busan area. I obtained responses from 200 people (clinics 100; hospitals 100).


I used SERVQUAL 22 items for the measurement of tangibles, reliability, responsiveness, assurance, empathy. I used for this study 10-point Likert-type scale.






Study 1 (Clinics)

TABLE 1 shows that tangibles and empathy among 5 SERVQUAL factors have significant effects on customer satisfaction in clinics.

TABLE 2 shows that customer satisfaction (CS) in clinics has a significant effect on word of mouth (WOM).

TABLE 3 shows that customer satisfaction (CS) in clinics has a significant effect on patronage.

Figure 2 is summary of study1 (clinics). Among 5 SERVQUAL dimensions, tangibles and empathy has a significant effect on CS, and CS has significant effects on WOM and patronage.

Study 2 (Hospitals)

TABLE 4 shows that only reliability among 5 SERVQUAL factors have significant effects on customer satisfaction in hospitals.

TABLE 5 shows that customer satisfaction (CS) in hospitals has a significant effect on word of mouth (WOM).

TABLE 6 shows that customer satisfaction (CS) in hospitals does not have a significant effect on patronage.

Figure 3 is summary of study 2 (hospitals). Among 5 SERVQUAL dimensions, only reliability has a significant effect on CS, and CS has significant effects on WOM, but not on patronage.

This study examined the determinants and consequences of customer satisfaction with clinics and hospitals and there are some differences according to different medical institutions. Specifically, we extended the target of the research to medical services applying SERVQUAL to the clinics and hospitals. In clinics, the determinants of CS are aspects related with the tangibles, empathy. In hospitals, the determinants of CS are aspects related with the reliability. In clinics, WOM and patronage are positively influenced by CS. In hospitals, WOM is positively influenced by CS but patronage is not. So, determinants and consequences of customer satisfaction are different according to different medical services type.

Strategic Implications (Clinics)

The appearance of physical facilities, equipment and parking space are important factors. The quality of building and interior of clinics are very important especially to the new customers. Parking space or convenience of the parking might determine success or failure of the clinics. Convenient location is also important to improve profits. Usually customers of clinics are inclined to visit clinics that are located close to their houses or offices. Convenience of location can improve the accessibility of patients and ease of contact.

Doctors have the tendency to use medical terms to patients, but we hardly understand the meaning. To improve customer satisfaction, they should keep customers informed in language they can understand and they should listen to customers. The doctors have to clearly and kindly explain the causes and process of the illness. The doctors in clinics have to be expert not only in medical knowledge but also in communication. And, the clinics continuously have to devote themselves to know customers and their needs.















Strategic Implications (Hospitals)

In hospitals, reliability only has the critical impact on customer satisfaction among 5 SERVQUAL factors. Reliability means ability to perform the necessary medical services dependably and accurately. To improve reliability in hospitals, I can recommend these things; first, recruit qualified doctors and nurses. The patients who visit hospitals might probably suffer more serious illness that can’t be treated or difficult to treat in clinics. So, compared to clinics, the knowledge or expertise of doctors and staffs in hospitals must be better than that of doctors and staffs in clinics. Performing the service by the promised time and accuracy of the bills are important. Cost compared with competing hospitals is important factor.


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Sungjin Yoo, Inje University, Korea


AP - Asia Pacific Advances in Consumer Research Volume 6 | 2005

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