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International Journal of Multidisciplinary Research Vol.1 Issue 8, December 2011, ISSN 2231 5780
ADAPTING THE SERVQUAL SCALE TO HOSPITAL SERVICES: AN EMPIRICAL INVESTIGATION OF PATIENTS PERCEPTIONS OF SERVICE QUALITY
DR. MAMTA BRAHMBHATT*; DR. NARAYAN BASER**; PROF. NISARG JOSHI***
*Associate Professor, National Institute of Cooperative Management, Shri Jairambhai Patel Institute of Business Management and Computer Applications (SJPI- NICM) Gandhinagar, Gujarat. Post Graduate Center of Gujarat Technological University-MBA, Nr. Indroda Circle, Gandhinagar-382007. Gujarat, India. **Associate Professor, National Institute of Cooperative Management, Shri Jairambhai Patel Institute of Business Management and Computer Applications (SJPI- NICM) Gandhinagar, Gujarat. Post Graduate Center of Gujarat Technological University-MBA, Nr. Indroda Circle, Gandhinagar-382007. Gujarat, India. ***Assistant Professor, National Institute of Cooperative Management, Shri Jairambhai Patel Institute of Business Management and Computer Applications (SJPI- NICM) Gandhinagar, Gujarat. Post Graduate Center of Gujarat Technological University-MBA, Nr. Indroda Circle, Gandhinagar-382007. Gujarat, India.
ABSTRACT The customers perception is your reality. - Kate Zabriskie This paper attempts to explore the concept of service quality in a health care setting. Based on Parasuraman et al.s Modified SERVQUAL variables, the authors tried to identify the effects of each variable to satisfaction. Data were collected through field research among 246 patients and the data were analyzed using SPSS and Excel. The paper finds that service quality in health care is very complex as compared to other services. The results revealed that the customers' perceptions did not exceed their expectations, as they were dissatisfied with the level of healthcare services rendered by both public and private sector hospitals. The paper adds a new perspective towards understanding how the concept of service quality is adopted in a hospital sector. The authors wish that this study identifies areas of dissatisfaction that can be quickly remedied and ensures improvement in the areas of satisfaction with ongoing notice and importance. KEYWORDS: Customer expectation, Customer perception, Hospital, Service Quality. ______________________________________________________________________________ 1. INTRODUCTION There is a growing consensus within the NHS of the significance of obtaining feedback from patients in order to improve the quality of health care; consequently, many patient satisfaction surveys are now undertaken by health care sector. Knowledge about the patients' perception
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towards health care quality is one of the most important steps towards introducing reforms in the health care sector. Against a background of growing consumerism, satisfying patients has become a key task for all healthcare activities. Satisfaction in service provision is increasingly being used as a measure of health system performance. Customer satisfaction's importance is well-documented in the marketing literature and is speedily gaining extensive recognition in the healthcare industry. Many hospitals apply modern marketing ideas to serve customer markets in a more efficient and effective way. An important strategic variable in this respect is service quality. This paper attempts to explore the concept of service quality in a health care setting. 2. LITERATURE REVIEW Service quality has become an important research topic in view of its significant relationship to costs (Crosby, 1979), profitability (Rust and Zahorik, 1993), customer satisfaction (Boulding et al., 1993), customer retention (Reichheld and Sasser, 1990), service guarantees (Kandampuly and Butler, 2001), and financial performance (Buttle, 1996). Curry and Stark (2000) studied the use of SERVQUAL across nursing homes in the UK, which provided a useful benchmarking tool. Wan Edura Wan Rashid, Hj. Kamaruzaman Jusoff,1 (2009) attempted to explore the concept of service quality in a health care setting. This paper probes the definition of service quality from technical and functional aspects for a better understanding on how consumers evaluate the quality of health care. It adopts the conceptual model of service quality frequently used by the most researchers in the health care sector. At the end the researcher concluded that service quality in health care is very complex as compared to other services because this sector highly involves risk. Daniel Butler, Sharon L. Oswald, Douglas E. Turner2 (1996) investigated the effects of demographic factors on users and observers of perceived hospital quality and noted that previous research suggests the components of perceived service quality are industry specific, and that calls have been made for academics to integrate their theory into practice. At the end the researcher found that perceived quality is industry specific, users and observers differ in their perceptions of hospital quality and demographic factors do make a difference in perceived hospital quality. Ioannis E. Chaniotakis, Constantine Lymperopoulos 3(2009) aimed to study the effect of service quality (SQ) dimensions on satisfaction and word of mouth (WOM) for maternities in Greece. Based on Parasuraman et al.'s SERVQUAL variables, the authors tried to identify the effects of each variable to satisfaction and WOM. From survey result the author found that in addition to satisfaction, the only service quality dimension that directly affects WOM, is empathy. In addition, empathy affects responsiveness, assurance and tangibles which in turn have only an indirect effect to WOM through satisfaction. Ritu
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Wan Edura Wan Rashid, Hj. Kamaruzaman Jusoff, (2009) "Service quality in health care setting", International Journal of Health Care Quality Assurance, Vol. 22 Iss: 5, pp.471 482 2 Daniel Butler, Sharon L. Oswald, Douglas E. Turner, (1996) "The effects of demographics on determinants of perceived health-care service quality: The case of users and observers", Journal of Management in Medicine, Vol. 10 Iss: 5, pp.8 20 3 Ioannis E. Chaniotakis, Constantine Lymperopoulos, (2009) "Service quality effect on satisfaction and word of mouth in the health care industry", Managing Service Quality, Vol. 19 Iss: 2, pp.229 242
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Narang 4(2011) intended to measure the perception of patients towards quality of services in public health care centres in rural India. A 23-item scale that tested well for reliability and construct validity was employed for the study. Mixed sampling technique was employed to select the sample. The researchers found from the survey result that items, availability of adequate medical equipments and availability of doctors for women are negatively rated. Education, gender and income were found to be significantly associated with user perception. Abdul Majeed Alhashem, Habib Alquraini, Rafiqul I. Chowdhury 5 (2011) aimed to identify factors affecting patient's satisfaction at primary health care clinics. The questionnaires were distributed in primary healthcare clinics that represent all heath care regions in Kuwait. From the survey result researchers found that the majority (87 percent) of the patients responded that the time for communication between physician and patient was not enough. Seventy-nine-percent of the surveyed patients said they would go to the emergency room of the hospital in future if needed instead of going to the primary care clinic. Regarding the quality of the communication relationship between physician and patients most of the patients responded negatively. Norazah Mohd Suki, Jennifer Chiam Chwee Lian, Norbayah Mohd Suki 6(2011) aimed to investigate whether patients' perceptions exceed expectations when seeking treatment in private healthcare settings in the Klang Valley Region of Malaysia. A survey was conducted among 191 patients in the Klang Valley Region of Malaysia to measure service quality of the private healthcare setting in Malaysia using SERVQUAL 5 dimensions model. The results revealed that the customers' perceptions did not exceed their expectations, as they were dissatisfied with the level of healthcare services rendered by private healthcare settings in that they felt that the waiting time of more than an hour to receive the service was excessive and, when there was a problem, the healthcare provider did not provide a response fast enough. Raman Sharma, Meenakshi Sharma, R.K. Sharma7 (2011) aimed to address the issues of patients satisfaction in health care sector. A cross sectional study was conducted to assess the patient satisfaction level visiting the hospital with the objectives to know the behavior and clinical care by the clinicians and para-medical staff and in terms of amenities available. A pre-designed and pre-tested structured questionnaire was given to the respondents after the patients had undergone consultation with the doctor. From the survey result, researchers found that 40.0 per cent were of the view that services were costlier than their affordability.
Ritu Narang, (2011) "Determining quality of public health care services in rural India", Clinical Governance: An International Journal, Vol. 16 Iss: 1, pp.35 49 5 Abdul Majeed Alhashem, Habib Alquraini, Rafiqul I. Chowdhury, (2011) "Factors influencing patient satisfaction in primary healthcare clinics in Kuwait", International Journal of Health Care Quality Assurance, Vol. 24 Iss: 3, pp.249 262 6 Norazah Mohd Suki, Jennifer Chiam Chwee Lian, Norbayah Mohd Suki, (2011) "Do patients' perceptions exceed their expectations in private healthcare settings?", International Journal of Health Care Quality Assurance, Vol. 24 Iss: 1, pp.42 56 7 Raman Sharma, Meenakshi Sharma, R.K. Sharma, (2011) "The patient satisfaction study in a multispecialty tertiary level hospital, PGIMER, Chandigarh, India", Leadership in Health Services, Vol. 24 Iss: 1, pp.64 73
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3. RESEARCH OBJECTIVE The aim of this research is to comparatively examine and measure of service quality of public and private sector hospitals of Ahmedabad and Gandhinagar region of Gujarat state and to offer suggestion based on results of the study. 4. RESEARCH HYPOTHESIS 1. Both public and private hospitals do not meet patients' expectations. 2. There is no difference between public and private hospitals concerning their service quality 3. Private hospitals are not more successful than public hospitals in providing health care services for patients. 5. RESEARCH INSTRUMENT The five dimensions of SERVQUAL as proposed by Parasuraman et al. (1988), Othman and Owen (2001, 2002) and Jabnoun and Al-Tamimi (2003) were adapted and modified in this study. SERVQUAL has emerged as perhaps the most popular standardized questionnaire to measure service quality. The instrument poses a set of 22 structured and paired questions designed to assess customers expectations of service provision and the customers perceptions of what was actually delivered. A five-point Likert-type scale is used in this study, anchored by strongly disagree to strongly agree. Content validity (wording and meaning) was checked carefully by experts. A pre-test was then conducted with a group of patients, and minor changes to the scales were made accordingly to ensure that the questions were not repetitive. The researchers have used the 41 structured and paired questions to measure E and P for service quality of Hospitals. PHYSICAL ASPECTS The first dimension physical aspects encompasses the appearance of the physical facilities (1-14) and the convenience offered to the customer by the layout of the physical facilities (1516). The literature suggests that appearance is important to customers (e.g., Baker, Dhruv and Parasuraman, 1994). It also suggests that customers value the convenience offered during the treatment that physical aspects such as layout offer (Gutman and Alden, 1985; Hummel and Savitt, 1988; Mazursky and Jacoby, 1985; Oliver, 1981). RELIABILITY The second proposed dimension is reliability. It has two sub-dimensions and other variations. Patients view reliability as a combination of doing it right and availability of all the information regarding treatment. So, the sub-dimensions of reliability are promises (statements 17 to 19 in the scale) and information availability (statements 20 to 24 in the scale). ENCOUNTERS The third proposed dimension is Encounters. It has two sub-dimensions responsiveness
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(statements 25 to 26 in the scale) and empathy (statements 27 to 33 in the scale). These subdimensions are very closely related and capture how the customer is treated by the employee. PROCESS The fourth proposed dimension is process (statements 34 to 38 in the scale). Process is critical for the success of any medical service. This dimension does not have any sub-dimension. POLICY The fifth proposed dimension policy (statements 39 to 41 in the scale) captures aspects of service quality that are directly influenced by hospital policy. For example, when customers evaluate a hospital on the basis of convenient hours, it is viewed as whether the hospitals policy is responsive to customers needs. This dimension does not have any sub-dimension.
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FIGURE 1: HOSPITAL SERVICE QUALITY MEASUREMENT MODEL

TANGIBLES (I1-I14) PHYSICAL ASPECTS
Sub-D1
HOSQUAL MODEL
D1
DESIGN (I15-I16)
Sub-D2
RELIABILITY (I17-I24)
Outcome
D2
RESPONSIVENESS (I25-I26)
Sub-D3
ENCOUNTERS SATISFACTION/
D3
DISSATISFACTION DISSATISFACTION PROCESS (I34-I38)

D4
EMPATHY (I27-I33)
Sub-D4
POLICY (I39-I41)
D5
The researchers have used following mentioned 41 structured and paired questions to measure E and P for service quality of Hospitals PHYSICAL ASPECTS 1. It is convenient to reach to this Hospital.
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Based on the above dimensions, the proposed measurement tool may be suitable for measuring the service quality of hospitals, gathering benchmark data regarding current levels of service quality, and conducting periodic checks to measure service improvement. The instrument could also serve as a diagnostic tool to determine service areas that are weak and that need attention. However, in spite of its wide applicability and rigorous development, the use of the instrument should be properly tested under different contexts in order to determine its validity and reliability.
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2. The waiting rooms, clinical and diagnostic test rooms, pre-operative and post-operative (or patient/resident ward) rooms, intensive care units, wards, bathrooms and toilets were adequate, comfortable and clean. 3. The beds, pillows and mattresses were comfortable and clean. 4. The wards are well furnished, decorated, well ventilated and clean all the time. 5. Employees of excellent hospitals will have neat appearing. 6. This hospital has visually appealing Materials associated with the service (promotional brochures, service tracking documents, invoices etc). 7. Wards, beds, operation theatres, intensive/post-operative care units and resident rooms are adequately available for patients in this hospital. 8. Ambulance services are made available to patients with minimal costs in this `hospital. 9. Diagnostic facilities like CT scans, MRI scans, X-rays and ultrasound; telemedicine, patient information and billing, operation theatres, labs, etc. are adequately and effectively available. 10. The waiting rooms, clinical and diagnostic test rooms, pre-operative and post-operative (or patient/resident ward) rooms, intensive care units, wards, bathrooms and toilets were adequate, comfortable and clean. 11. Amenities such as continuous electricity and water supply, housekeeping and sanitation facilities, comfortable conditions such as temperature, ventilation, noise and odour are available. 12. Availability of required drugs in the pharmacy 13. Availability of the desired blood group in the blood bank in the hospital. 14. The meals are offers food which is suitable to the patients
15. The ergonomics (layout) of this hospital is conducive for physically challenged, elderly & emergency patients. 16. This hospital provides for proper safety and comfort measures (e.g: handrails in aisles, rooms and bathrooms, ramps suitably designed for wheelchairs and stretchers, elevators and spacious corridors). RELIABILITY 17. This hospital will insist on error free records.
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18. This hospital performs the service right the first time. 19. Patients feel safe in getting treated by the doctors of this hospital. 20. This hospital provides all the required information and instructions regarding admission, treatment, and discharge clearly to patients and attendants. 21. The patient's attendants are kept informed about the patient's condition. 22. The allergy or reaction to drugs is taken care of in this hospital. 23. Employees of this hospital tell patients exactly when services will be performed. 24. Patients feel safe in getting treated by the doctors of this hospital. ENCOUNTER: RESPONSIVENESS 25. Employees in this hospital are never too busy to respond to customers requests. 26. When patient has a problem, this hospital will show a sincere interest in solving them. ENCOUNTER: EMPATHY 27. Employees in this hospital are curious to know & solve my problems. 28. Employees in this hospital are not rude in conveying the rules of the hospital (i.e. asking attendants of patients to maintain peace). 29. Employees in this hospital understand my requirement and gives individualised attention. 30. This hospital has their patient's best interests at heart. 31. This hospital gives patients individual attention. 32. Employees of this hospital have knowledge to answer patients' questions. 33. Medical staff of this hospital is consistently courteous with people. PROCESS 34. The hospital provides for an inquiry-cum- complaint counter at a prominent place. 35. Extent to which the time spent waiting for diagnostic tests and treatment, at the pharmacy, scan centers, blood banks and laboratories was reasonable. 36. Frequency in delays or cancellation of scheduled surgeries due to reasons such as nonavailability of operation theatres or surgeons, or lack of preparation of patients for surgery.
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37. A proper system of appointment is well-established. 38. Overall process (e.g. Admission, stay and discharge; procurement of drugs and hospital equipments; allocation of operation theatres and beds) are kept short and simple in this hospital. POLICY 39. The hospital provides for significant loyalty rewards through membership cards. 40. This hospital has consulting hours convenient to all their patients. 41. Over all, I am satisfied with the service quality of this hospital. 6. METHODOLOGY This is an analytical study based on the primary data collected through scientifically developed questionnaire. The questionnaire has been personally administered on sample size of 246, chosen on a convenient basis from the two cities of Gujarat state. A literature review was undertaken to identify what parameters to consider in research. The data was collected through questionnaire consisting of 3 parts. The first two parts consist of the SERVQUAL items (Parasuraman et al., 1985), which measure service quality. In Part I, there were 41 statements measuring the expected service quality from excellent hospitals. In Part II, the same items were measuring the service quality perceptions of public/private hospitals in Ahmedabad and Gandhinagar region. Here, respondents were asked to evaluate the statements with regard to the hospital(s). All of the statements in Part I and Part II were measured on a five point "Agree-Disagree" Likert scale. The last part of the questionnaire consisted of demographic questions. A questionnaire was constructed and piloted on 57 patients.Care was taken to minimize the possibility of wrong interpretation and biased views. For the analysis of data statistical methods are applied with the aid of SPSS (Statistical Package for Social Science) software, version 16.0 and excel. Sample size was determined using following formula.
n = 245.8624 246 7. SAMPLE The sample was drawn form the people living in Ahmedabad and Gandhinagar area who were above the age of eighteen. Family members who had benefited from the services of public and private hospitals within a two-year period were asked to complete a self-administered questionnaire. In order to collect quantitative data for the study, a total of 246 questionnaires were printed and distributed to respondents. There are3 public and 5 private hospitals that
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Here Z = 1.96, p = 0.20, q = 0.80, d = 0.05,
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include medium -scale clinics in which surgery is carried out were selected for survey. They are Ahmedabd Civil Hospital, Gandhinagar Civil Hospital, V.S. Hospital, , Sanjivani Hospital, Shrey Hospital, Samved Hospital, Nidhi Hospital , Medi Link Hospital. 8. CHARACTERISTICS OF SAMPLE The following table shows the demographic profile of surveyed respondents. TABLE: 1 CHARACTERISTICS OF SAMPLE Variables Category 18-23 24-29 30-35 Age 35-40 40+ Total 10,000-20,000 20,001-30,000 Monthly 30,001-40,000 Income 40,000+ Total Student Professional Businessman Occupation Housewife Govt. employee Others 17 32 28 74 246 33 109 27
Frequency 46 63 49 41 47 246 58 73 41
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Total Undergraduate Education Level Graduate Postgraduate Total Male Gender Female Total
246 8 78 160 246 183 63 246
9. DATA ANALYSIS AND INTERPRETATIONS Randomly 246 respondents, who have recently benefited from hospital services in Ahmedabad and Gandhinagar regions, were selected to answer a modified version of the SERVQUAL instrument. Results of a sample of 246 patients from 8 hospitals were analyzed thru SPSS and Excel. For all 41 statements of expectation and perception each, weighted arithmetic mean was calculated, and gap score was determined by deducting perception values from expectation values. Dimensions wise Mean Score of Perception and Expectation of Public and Private Hospitals was determined and comparative analysis was prepared keeping in mind the gap score of each dimensions. TABLE: 2 STATEMENTS WISE MEAN SCORE OF PERCEPTION AND EXPECTATION OF PUBLIC AND PRIVATE HOSPITALS Public Hospitals Dimension PA1 PA2 PA3 PA4 PA5 E 4.68 4.75 4.70 3.89 3.69 P 2.77 2.34 2.63 2.87 2.53 G 1.91 2.41 2.07 1.02 1.16 E 3.74 3.37 3.38 3.27 3.52 Private Hospitals P 4.58 4.37 3.97 3.01 3.29 G -0.84 -1.00 -0.59 0.26 0.23
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PA6 PA7 PA8 PA9 PA10 PA11 PA12 PA13 PA14 PA15 PA16 AVG. R17 R18 R19 R20 R21 R22 R23 R24 AVG. Res25 Res26 AVG.
4.43 4.42 4.64 3.98 3.77 4.44 4.54 4.65 4.32 3.32 3.57 4.30 3.62 3.84 4.95 4.77 4.63 4.82 4.86 3.82 4.41 3.91 3.78 3.85
2.58 1.89 2.10 1.91 1.74 2.45 2.76 2.59 2.22 2.98 2.64 2.44 2.98 2.63 1.98 2.03 1.32 1.48 2.42 3.13 2.25 3.43 3.51 3.47
1.85 2.53 2.54 2.07 2.03 1.99 1.78 2.06 2.10 0.34 0.93 1.86 0.64 1.21 2.97 2.74 3.31 3.34 2.44 0.69 2.17 0.48 0.27 0.38
3.17 3.29 3.37 3.88 3.62 2.22 3.32 2.76 3.59 3.58 3.18 3.33 4.24 4.81 4.92 4.75 4.69 4.86 4.91 3.95 4.64 4.87 4.74 4.81
2.43 1.47 1.99 1.62 1.57 2.55 2.35 2.56 2.33 4.22 3.89 2.89 4.01 4.53 1.12 1.34 1.63 1.39 1.37 3.27 2.33 3.44 3.42 3.43
0.74 1.82 1.38 2.26 2.05 -0.33 0.97 0.20 1.26 -0.64 -0.71 0.44 0.23 0.28 3.80 3.41 3.06 3.47
3.54 0.68 2.31 1.43 1.32 1.38
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E27 E28 E29 E30 E31 E32 E33 AVG. Pro34 Pro35 Pro36 Pro37 Pro38 AVG. policy39 policy40 Policy41 AVG.
3.89 3.33 3.56 4.39 4.05 4.61 4.03 3.98 4.15 4.17 4.43 4.65 4.23 4.33 4.45 4.98 4.01 4.48
3.46 3.21 3.48 1.22 2.52 1.62 2.43 2.56 2.98 2.43 2.58 2.01 2.98 2.60 4.28 4.69 3.90 4.29
0.43 0.12 0.08 3.17 1.53 2.99 1.60 1.42 1.17 1.74 1.85 2.64 1.25 1.73 0.17 0.29 0.11 0.19
3.71 3.38 3.52 4.07 4.49 4.98 3.03 3.88 3.14 3.13 3.67 3.89 3.45 3.46 3.34 4.65 4.83 4.61
3.22 3.14 3.29 4.04 2.98 4.79 2.98 3.49 3.01 2.45 2.58 2.65 2.98 2.73 4.13 4.53 4.71 4.79
0.49 0.24 0.23 0.03 1.51 0.19 0.05 0.39 0.13 0.68 1.09 1.24 0.47 0.72 -0.79 0.12 0.12 -0.18
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TABLE: 3 DIMENSIONS WISE SCORE OF PERCEPTION AND EXPECTATION OF PUBLIC AND PRIVATE HOSPITALS Dimensions E Physical Aspects Reliability Responsiveness Empathy Encounter Process Policy 4.30 4.41 3.85 3.98 7.83 4.33 4.48 2.44 2.25 3.47 2.56 6.03 2.60 4.29 1.86 2.17 0.38 1.42 1.80 1.73 0.19 3.33 4.64 4.81 3.88 8.69 3.46 4.61 2.89 2.33 3.43 3.49 6.92 2.73 4.79 0.44 2.31 1.38 0.39 1.77 0.72 -0.18 Public Hospitals P G E Private Hospitals P G
TABLE: 4 DIMENSIONS WISE COMPARATIVE ANALYSIS OF PUBLIC AND PRIVATE HOSPITALS Public Dimensions Hospital -GAP Physical Aspects Reliability Encounter Process Policy 1.86 2.17 1.80 1.73 0.19 Private Best Hospital Performer -Gap
0.44 2.31 1.77 0.72 -0.18
Private Hospital Public Hospital Private Hospital Private Hospital Private Hospital
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10. MAJOR FINDINGS The mean expectation scores were high when compared to the perception scores - ranging from 3.34 to 0.08 for the public hospitals and from 3.80 to -1 for the private hospitals. The lowest public hospital expectation score was obtained from question 15(This hospital provides for proper safety and comfort measures (e.g: handrails in aisles, rooms and bathrooms, ramps suitably designed for wheelchairs and stretchers, elevators and spacious corridors). and highest from question 40.( This hospital has consulting hours convenient to all their patients) The lowest public hospital Perception score was obtained from question 40(This hospital has consulting hours convenient to all their patients) and highest from question30 (This hospital has their patient's best interests at heart). The lowest private hospital expectation score was obtained from question 11 (Amenities such as continuous electricity and water supply, housekeeping and sanitation facilities, comfortable conditions such as temperature, ventilation, noise and odour are available) and the highest private hospital expectation score was obtained from question32. (Employees of this hospital have knowledge to answer patients' questions.) The lowest private hospital perception score was obtained from question 19(Patients feel safe in getting treated by the doctors of this hospital) and the highest private hospital perception score was obtained from question32 (Employees of this hospital have knowledge to answer patients' questions.) Out of five dimensions Private hospitals perform better than public hospital in 4 dimensions namely Physical Aspects, Encounter, Process and Policy, while public sector hospitals perform better than private sector only in one dimension namely Reliability. Overall private sector is performing better in Encounter dimension, but specific Encounter-Responsiveness public sector has lowest score. 11. LIMITATIONS AND FUTURE RESEARCH DIRECTIONS The findings of this study are limited to the two cities Gujarat State. It should be replicated in other part of countries especially with all major cities. Second, for the researchers convenience, the study questionnaire included both expectation and perception questions. In future, the expectation and perception sections should be separated, although this may create difficulties contacting respondents just before their service and just after the service encounter. Future studies should also investigate the effects of service quality dimensions on the overall satisfaction, recommending behavior and loyalty. Replication studies using large diversified samples elsewhere would be useful in order to corroborate our study findings. 12. CONCLUSION AND MANAGERIAL IMPLICATIONS This study set out to expand understanding of how Consumers evaluate service quality in the context of a developing economy, an environment that differs significantly from the European and American context. The current research reinforces the fact that service quality is a complex and multidimensional construct. Our findings have important implications for private hospital and public hospital owners, managers, government officials, academics and other related parties in the hospital services. Hospital administrations need to gather systematic feedback from their patients and to establish visible and transparent complaint procedures so that patients' complaints can be addressed effectively and efficiently. Most customers are reluctant (Ekiz, 2004) to make their needs and expectations explicit, including their complaints, although the opportunity to do so is clearly provided in order to promote healing environment.
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13. REFERNCES 1. Abdul Majeed et.al (2011) "Factors influencing patient satisfaction in primary healthcare clinics in Kuwait", International Journal of Health Care Quality Assurance, Vol. 24 Iss: 3, pp.249 262 2. Daniel Butler et.al (1996) "The effects of demographics on determinants of perceived health-care service quality: The case of users and observers", Journal of Management in Medicine, Vol. 10 Iss: 5, pp.8 20 3. Ioannis E. et.al (2009) "Service quality effect on satisfaction and word of mouth in the health care industry", Managing Service Quality, Vol. 19 Iss: 2, pp.229 242 4. Norazah Mohd et.al (2011) "Do patients' perceptions exceed their expectations in private healthcare settings?", International Journal of Health Care Quality Assurance, Vol. 24 Iss: 1, pp.42 56 5. Raman Sharma, et.al (2011) "The patient satisfaction study in a multispecialty tertiary level hospital, PGIMER, Chandigarh, India", Leadership in Health Services, Vol. 24 Iss: 1, pp.64 73 6. Ritu Narang (2011) "Determining quality of public health care services in rural India", Clinical Governance: An International Journal, Vol. 16 Iss: 1, pp.35 49 7. Rust et.al. (1996), "The satisfaction and retention of frontline employees: a customer satisfaction approach", International Journal of Service Industry Management, Vol. 7 No. 5, pp. 62-80. 8. Sohail, M.S. (2003), "Service quality in hospitals: more favorable than you might think", Managing Service Quality, Vol. 13 No. 3, pp. 197-206. 9. Uzun, O. (2001), "Inpatient satisfaction with nursing care at a university hospital in Turkey", Journal of Nursing Care Quality, Vol. 16 No. 1, pp. 24-33. 10. Valdivia, M.T.R. and Crowe, T.J. (1997), "Achieving hospital operating objectives in the light of inpatient preferences", International Journal of Health Care Quality Assurance, Vol. 10 No. 5, pp. 208-12. 11. Wan Edura Wan Rashid, Hj. Kamaruzaman Jusoff, (2009) "Service quality in health care setting", International Journal of Health Care Quality Assurance, Vol. 22 Iss: 5, pp.471 482
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FIGURE 1: HOSPITAL SERVICE QUALITY MEASUREMENT MODEL

DISSATISFACTION DISSATISFACTION PROCESS (I34-I38)

Here Z = 1.96, p = 0.20, q = 0.80, d = 0.05,

246 8 78 160 246 183 63 246

3.54 0.68 2.31 1.43 1.32 1.38

0.44 2.31 1.77 0.72 -0.18

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