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Procedia - Social and Behavioral Sciences 42 (2012) 63 73

AcE-Bs 2010 Kuching ASEAN Conference on Environment-Behaviour Studies, Riverside Majestic Hotel, Kuching, Sarawak,, Malaysia, 7-8 July 2010

Towards Healthcare Service Quality: An Understanding of the Usability Concept in Healthcare Design
Siti Norsazlina Harona*, Md Yusof Hamida & Anuar Taliba
a

Faculty Architecture, Planning and Surveying, Universiti Teknologi MARA, Kampus Perak, Malaysia

Abstract The purpose of this paper is to review the literature on usability concept in built environment and healthc are design, and suggest a possible usability conceptual framework in achieving quality service. This paper will focus on three usability keys factors: efficiency, effectiveness and users satisfaction. This overview will help future researchers to investigate the relationship between spatial design and usability concept from the users experience and expectation of the outpatient area as part of the Malaysian Primary Healthcare (MPHC) service in a public hospital. This usability is useful in improving outpatient area service outcome, which is more valuable to the end-users. 2011Published Published Elsevier Ltd. Selection and peer-review under responsibility of Centre for Environment 2012 byby Elsevier B.V. Selection and/or peer-review under responsibility of Centre for EnvironmentBehaviour Studies(cE-Bs), of Architecture, Planning && Surveying, Universiti Teknologi MARA, Malaysia Studies (cE-Bs),Faculty Faculty of Architecture, Planning Surveying, Universiti Teknologi MARA, Malaysia.
Keywords: Healthcare design, Quality service, Spatial design, Usability concept.

1. Introduction Part of a healthcare design is planning a good service for its users and its design complexity is characterised as major. Daily operations in hospitals are affected by the rapid changes and trends. Planning and designing of spaces and facilities in a hospital are influenced by the society and its behavior. In producing a good design, the building process involves the local authorisation, medical planner,

* Corresponding author. E-mail address: aqilmuazumar@yahoo.com.my

1877-0428 2012 Published by Elsevier B.V. Selection and/or peer-review under responsibility of Centre for Environment-Behaviour Studies(cE-Bs), Faculty of Architecture, Planning & Surveying, Universiti Teknologi MARA, Malaysia doi:10.1016/j.sbspro.2012.04.167

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architect, interior designer and facility management to hospital employees and whoever else is involved in the built environment field. However, the success of the design is achieved through the satisfaction of the users to how spaces in the hospital function and influence the quality of the hospital design. In many ways the quality of the hospital depends on the design ability to adapt with organisational, operational and technical changes. In designing a hospital, it is also necessary to consider the expanding number of patients, the lasting effectiveness of the design, efficiency of the design and its flexibility to make changes when required. All those are usability outcome or solution in producing a quality design, guidance for the management process and improve the healthcare service. Malaysia Primary Healthcare (MPHC) has grown actively since the Alma Ata Declaration made in 1978 and one of governments agenda is to prioritise people first and performance now in MPHC service (Razak, 2010).Currently, there are 136 public hospitals, which are considered as outpatient area in MPHC (MOH, 2010). The outpatient area in public hospitals offer all the family specialist clinics, pharmacy, education and promotion health area, rehabilitation, administration, medical laboratory, health record, staff facilities, diagnostic image room, and public facilities which can accept 800 to 1000 patients per day in a total area of 12,000 - 8,500 meter sq (EPU Guideline, 2008). By definition, all outpatient facilities are alike in having no overnight patients. They can range from simple physicians offices that provide primary care to large, independent hospitals without beds (Carr, 2009; 2010). The outpatient area is a main focus where services are delivered to the users who are the daily patients from the various categories and background. This paper is based on the literature studies of the usability theoretical framework to understand the use of the usability concept in built environment. This is a preliminary study, which will later develop research questions for a following PhD-study which will focus on the usability of healthcare spatial design of the outpatient area in the Malaysian public hospitals. 2. Literature review 2.1. General literature on usability principles and its concept in built environment. A lot of usability principles and concepts had been discussed and the definition of it depends on the field of study, but it is mostly determined by the following 3 key factors: x Effectiveness whether users can achieve to get the product. x Efficiency how long it takes them to achieve it. x Satisfaction the users feelings and attitudes towards the product. Usability is the degree to which something service, facility, or product, is easy to use and a good fit for the people who use it as it is a characteristic of the product. It is whether a product is efficient, effective and satisfying for those who use it and it depends on what kind of goals the user holds. The usability definition is adopted from the international standard on usability .effectiveness, efficiency and satisfaction with which a specified set of users can achieve a specified set of tasks in a particular environment (ISO, 1998). Usability is also the extent in measuring a service or organisation in achieving specified goals or mission (Blakstad et al., 2008; Alexander, 2008; Fenker, 2008). Usability is a part of human behaviour study or action. It recognises that humans are lazy, emotional, and disinterested in putting a lot of effort generally preferring things that are easy to do. It shows that usability is focused to how users can complete a task in the easiest way within a short time, it means the service provide is learnability, memorability and those factors refers to the efficiency and the effectiveness of the service or product or task. This is visibly seen through the perspective of Arge (2004), in which the term usability describes whether or not a product is fit for a specific purpose. Usability or functionality in use is concerned with a buildings ability to support the economic and professional objectives of the users organisation. (Alexander, 2008)

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2.2. Efficiency The efficiency of the service provided is to test the amount of effort and the time taken by a user to complete the task. The efficiency is based on a ratio of a systems service work output and its work input. This can be seen through the patients or users experiences with the hospital service, whether they are able to complete every procedure after receiving treatment. These are all due to the accessibility and reachability factors. 2.3. Effectiveness The effectiveness of the service provided is measured by how a user completes the tasks. Often effectiveness is interpreted as the ability to reach a target that has been set up in order to achieve the desired effects of something. Therefore in hospital design the rule of space provision or space workflow and facility arrangement should readily be user friendly, functional, and flexible in design because it will be used by various patients with various health problems and by various types of users both able and disabled people. According to Shaw and Ivens (2002), customer experience is a blend of the companys physical performance and the emotions evoked intuitively measured against customer expectations across all the moments of contact (Nenonen et al., 2008 ). 2.4. User satisfaction User satisfaction in common language has to do with fulfillment of a desire or a need through the users feelings and attitudes towards the service or product. (Bahari & Ling, 2010).The phenomenon of the users experiences involving the users emotions reflects the users satisfaction and that the service outcome is of quality. (Nenonen et al., 2008; Poldma, 2009) 2.5. Usability attribute In some situations, the usability evaluation depends on the usability attribute, which is the users values of culture, time context and his background, and knowledge (Lindahl & Granath, 2006). This factor influences the users needs and satisfaction, familiarity with the service, and the expected fulfillment of the service which tend to influence his behaviour or action. (Blakstad et al., 2008; Gulliksen, 2006; Hignett & Lu, 2009; Alho et al., 2008). The usability measurement outcome also influences the users characteristics, lifestyles, values and demographics (Alho et al., 2008). Those considering factors are more appropriate and improve the usability study in the built environment as well as in the usability studies as a part of cultural phenomenon that can only be improved through a better understanding of the users experience. The conclusion of the understanding of the usability concept, attribute and the outcome from the various literature studies as well as the theoretical background study is shown in figure 1.

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Literature of usability study in built environment

Usability definition ISO: 1998

Usability criteria and principles Efficiency Time consuming

Usability attribute Context

Usability value /outcome Flexibility

Usability of space Wayfinding

Alexander (2008)

Effectiveness Task to get a service/design Users satisfaction Feeling & attitude

Culture

Accessibility

Workflow

Blakstad et al. (2008)

Situation

Positive feeling

Space relationship

Experience

Practicality Facility arrangement and allocation

Fenker (2008)

to the service/design Usability concept Expectation Functionality

Jens (2005) Criteria & parameter Background Memorability Building / technical system.

Garde (2008)

Habits Gulliksen (2006) Stakeholder point of view

Comfort Spatial orientation / layout

Perception

Learn ability

Alho et al. (2008) Serviceability Kazanasmaz (2006) Design management & process Human behavior /action Achieve mission/ goals Problem solution Users friendly Management process

Huelat (2007)

Workplace &

Rosenzweig (2006)

Linda & Granath (2006) Sinkkonen et al. (2002)

Measuring a service performance

Size

Usefulness

Desirability

Time perspective

Credibility

Fig. 1: Literature of usability study in built environment

2.6. Usability concepts in healthcare design A hospital has a complex design and a facility of interrelated functions that must accommodate the constant movement of people, equipment and supplies throughout its structure, which addresses healthcare function with users as the core of its creation. The planning and design of hospitals therefore

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need to focus on creating space and environment for users; thus, sustaining the complete balance that could constitute a healthy organisation vis--vis human management and its human-based facilities. A hospital is designed according to service oriented building and the satisfaction does not come from the use of new technologies but the design should be able to facilitate consumer assignment and it affected by efficiency and effectiveness of the design that includes critical planning to work flow, operational policies, clinical procedures, serviceability and infection control plays a fundamental role in determining the success of the facility and the service provided especially in designing a space based on public users. Although building design is based on speed priority, economy, technology, image and status, it is based on peoples sensitivities and senses.(Jens, 2005).Therefore, in designing or planning a space, it is important that the environment is appropriate to meet human emotion requirements, feelings, behaviours and interactions. The users feedback throughout their experience becomes information or is the key answer to improve service performance. (Alexander, 2008; Fenker, 2008). 2.7. Usability in healthcare spatial design A good hospital design is structured through movement in space and spatial layout is important in shaping the ways in which visitors explore, engage, and understand the function of the facility or space. It is demonstrated that behaviour patterns are systematically linked to spatial characteristics of access and visibility. Furthermore, the healthcare spatial design is also important to understand what people do and think, and it needs "vis--vis" users condition, background and situation in order to increase the effectiveness of the service. Spatial design focuses on the flow of space between the interior or exterior environments and it emphasises the discipline of working with people and space. Configurations of building layouts have great impact on the users behaviours and the design based on spatial design indicator makes space more efficient and effective and it combination of end user experiences and contexts that transform empty spaces into aesthetically functional interior places (Poldma, 2009). The service that comes from this scenario is more satisfactory and of higher quality. (Huelat, 2007). Usability is a part of problem solving (Blakstad, 2008) in creating something new or improving and transforming the present design or organisation. In order to do this, designers or the facility management must know how and why the space works. Understanding how and why things work requires us to analyse and explain (Friedman, 2003). Therefore, it is important to understand and to apply the concepts of usability, in order to provide a better understanding of the users experience of buildings and give positive views to the organisation (Alexander, 2006). After the service has delivered and its space is utilised by the end users, only then can the users judge or respond to the service outcome. In this situation, the facility management is needed in planning a more organised space and facility, and at the same time the strategic facility management process is used to understand the organisation and its flow and mission (Hamid et al., 2008; Becker & Parsons, 2007). This scenario shows that the facility management strategy is important in designing a space or arranging the healthcare facilities or services, so that the use of space becomes more valuable (Garde, 2008). Table 1 shows the previous studies of spatial design.

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Table 1: The usability studies of healthcare design. Author Ayas (2008) Garde (2008) Main focus Affective design of waiting areas in primary healthcare The design of a new NICU Patient Area: Combining design for usability and design for emotion An investigation of the use of health building notes by UK healthcare building designers Sub focus To understand affective values towards the physical environment in servicescape design. To investigate and explore the relation between design for usability and design for emotion in a design process, in order to produce positive ambience experience and satisfy end user. Study on existing principles and concepts behind healthcare building design. To investigate and observe the efficiency planning of space, design process and patient expectation from the design. Wayfinding: Design for understanding the basic ability for people to get from point A to point B, the factors of reach ability, accessibility and learn ability Usability of hospital buildings: Is patient focus leading to usability in hospital buildings? The process of users journey and identify the space and the task the study of spatial behaviour or orientation (predecessor of wayfinding) and relationship to space or the environment. The understanding of the theoretical framework developed by CIB TG51 Usability of buildings and studies of project documents and interviews from the St. Olavs Hospital project. To identify the utility value of built floor area, its allocation to serving and circulation spaces and the relative proportions and space potential-flexibility and adaptability for future changes. The reasons why people have problems finding their way in hospitals. To explore flexibility needs in adult medical-surgical inpatient care with the objective to understand its meaning from an end-user perspective and identify characteristics of the physical environment that promotes or impedes stakeholders' requirements

Hignett & Lu (2009)

Huelat (2007)

Jens (2005)

Kazanasmaz (2006)

Design efficiency in inpatient facilities of hospitals

Mollerup (2009) Pati et al. (2008)

Way showing in hospitals. Describes the causes of the wayfinding problems in hospitals Inpatient unit flexibility design characteristics of a successful flexible unit

2.8. Usability concept and patient focused When people go to hospitals to seek treatment, sometimes when they enter the hospital entrance, the condition of the space makes them feel uncomfortable. Previous studies have shown that good spatial design can reduce stress and physical effort among the patients or hospital users and increase the overall efficiency and effectiveness of the hospital design (Mollerup, 2009). A smooth work flow will affect the users satisfaction (Codinhoto et al., 2008; Wolf & Lehman, 2008) and most of the studies have also shown that the design based on users experience and patients opinions can produce better outcome to the design field, organisation goals or users.(Behkami & Dorr, 2009). In a hospital design, the patients opinions are taken as part of producing a quality management, and the users satisfaction is taken to determine the service quality dimension. Health care is about meeting the physical, psychological and social needs of a person who seeks care (Harun & Ibrahim, 2008). With hospital service quality models, physical, psychological and social needs as a part of the measurement. Consequently, it is only logical to incorporate the elements of social support into the model to reflect the holistic concept of healthcare

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outcome (Rose & Uli, 2004). Table 2 shows previous studies on end user satisfaction to hospital service based on the users opinions.
Table 2: Previous studies of user satisfaction in hospital service. Author Main -focus The development of an instrument for evaluating service excellence in health care settings Factors contributing to customer satisfaction Bahari & Ling (2010) with community pharmacies in Malaysia Hospital facilities and the role of evidence-based design Sub-focus To investigate the characteristics and attribute of service excellence SEVEXCEL in healthcare setting. To investigate customer satisfaction and its relation to demographics factors. Investigate the causes affecting customer satisfaction. Discuss the role of evidence-based design in facility planning and design as a key element in helping the field of facility planning and management continue to strengthen professional practice. To understand children and young peoples experience of a hospital environment and to identify the salient attributes of the physical environment. Identify what constitutes a supportive pediatric environment. To asses level of satisfaction with the service and the relationship between socio- demographic factors and patient attitude factors. To investigate physical characteristics of the space which satisfies user. To identify the emotion and perception of the users experience in hospital waiting area. To explore how patients voices had been taken into account within quality management systems using user satisfaction survey and dealing with patient complaints. To measure outpatients satisfaction on specialist clinic service. To investigate the service quality using SERVQUAL. To investigate patients expectation through their experience of hospital service and how the service influences the level of satisfaction. To investigate patients feelings on services provided by their caregivers.

Abusaid (2007)

Becker & Parsons (2007)

Bishop (2008)

From the perspectives of children and young peoples experience of a pediatric hospital environment and its relationship to their feeling of well-being

Ibrahim (2008)

Patient satisfaction with health service of outpatient department Human-environment relationship study of waiting areas in hospitals using Kansei engineering concept

Harun & Ibrahim (2008)

Hsieh (2009)

Taking patients' voices into account within quality systems: a comparative study Satisfaction of outpatients on service quality: A case study at two specialist clinics An assessment of the service quality expectations and perceptions of the patients of Awali Hospital in the Kingdom of Bahrain Patient satisfaction as an indicator of service quality in Malaysian public hospitals inpatient and outpatient users satisfaction- Two dimensions of service quality- clinical and physical satisfaction Hospital outpatient perceptions of the physical environment of waiting areas: the role of patient characteristics on atmospherics in one academic medical centre

Liong (2009)

Luke (2007)

Manaf & Nooi (2009)

Tsai et al. (2007)

To examine hospital outpatient perceptions of the physical environment of the outpatient waiting areas. Examine the relationship of patients characteristics and their perceptions and needs for outpatient waiting areas.

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2.9. Usability concept and its relation to the quality of service Satisfaction is a part of measurement of the service quality and usability key factors, and is referred to as serviceability. Measuring users satisfaction helps to identify users expectations. Expectations would be vital because users judge quality of care they accept according to standard internal they what state quality. Thus, this internal standard is based on the patients expectations and perceptions through their experience of the service (Cho et al., 2004; Hsieh, 2009). By understanding the expectations and perceptions, we can start in to bridge gap between service delivery and user defines quality service.
User Experience and expectation

Quality of measures

Usability principles: Uses of space and service Efficiency Effectiveness

User satisfaction & expressed satisfaction

Satisfaction level

Service outcome

Service Quality

Perceived service

Expected service Usability Concepts

Design

Usability attribute

Fig. 2: The understanding of the Usability concept in healthcare design through service quality process.

According to Alexander (2004), serviceability is the supply perspective of the building. Usability focuses on the users perceptions of the easiness phenomenon and its efficiency with which they can use the building. Serviceability, on the other hand, describes the capability of a building to provide a range of performances for which it is designed, used or required to be used, over time. While usability states a demand perspective, serviceability states a supply perspective (Jenso, 2005). Quality itself is an ever evolving perception by the users to value the service, be achievable and be able consistently. It is an ongoing judgment process through human relationships and interaction by meeting their needs. It is similar to Voordt and Wegen (2005) that a part of usability meaning and measurement has a relationship to quality achievement key factors reach-ability ,accessibility, efficiency, flexibility, satisfaction. (Voordt, 2009). The relation between user satisfaction and service process, according to Anton and Perouhoff (2002), service quality is level of degree on customer satisfaction through users or consumer experience to the service (rephrase to get clear meaning) (Basri, 2008). Service quality is about the quality of service delivered, according to Parasuraman et al. (1985, 1988) who introduce the SERVQUAL model. SERVQUAL represents that customer experience of the service will affect the service quality. From the study, it is also shown that service quality is all about the end users satisfaction among a users

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expectations of the services offered, the users perceptions and how the service meets the users needs of the service. (Martnez & Martnez, 2010). This model showed that the achievement of service quality depended on the end users background and service goals and its about a process of users experience.. Figure 2 illustrates the relationship between usability and service process. 3. Conclusion In conclusion, the paper developed an understanding of the usability concept and how its benefits could be used as a guideline for the designer and facilities manager. In addition, what perceived service quality is and how to measure it and its relation to usability outcome were also discussed. Therefore, spatial design is important to study especially from the service process and design aspect such as for way finding design and spatial layout, accessibility, workflow and people behaviour. By giving full attention to these factors it will reflect the space setting design and space requirement based on end-users expectation. In addition, the space becomes more efficient, effective, user friendly and comfortable. Furthermore, the hospital is built for a long term design because the service is always needed by the people. That is why most of the usability concept is used with the purpose of measuring the existing design of healthcare services, in order to improve the quality of service and at the same time it becomes a reference to the medical planner in designing a new hospital. Later my studies will focus on users experiences through outpatient area spatial design as part of hospital service, which are using the usability principles- efficiency and the effectiveness of the service. This study will involve on spatial layout of outpatient area in public hospital and human behavior towards that space. It will conduct through the observation, semi structure interview and walkthrough process by considering the factors of user and service distance, relationship between the service to another service, time efficiency to reach the service and to investigate how users satisfied with outpatient area service based on their expectation and emotion through their experience.

Acknowledgements The authors would like to thank the Malaysian Ministry of Health (MOH) and the Malaysian Public Works Department (JKR) for supporting this research.

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