Infrastructure

This dimension assesses the patients perception of quality with regard to the physical facilities
in the hospital. This includes the cleanliness, maintenance and availability of services such as
waiting rooms, diagnostic test rooms, operation theatres, wards, food, beds, resident rooms,
ambulance services, technological capability, pharmacy, blood banks, etc. Several studies have
attempted to study the importance of the physical facilities, IN or tangibles, in service delivery.
In a study on banks, retailers and building societies, Lewis (1990) found that respondents rated
the physical features and facilities as very important, in particular, location, privacy and physical
safety (for bank and building society customers). Retail customers rated the appearance of
buildings, interior decor, atmosphere and layout as important. The highest ratings were given by
customers to convenient location, appearance of buildings and appearance of staff.
Personnel quality
This dimension addresses the patients experience with regard to the kind of care given by the
doctors, nurses, paramedical and support staff, and administrative staff in the hospital. Research
done to study the quality of care given by health-service personnel has highlighted several
dimensions. Gronroos (1990) provided an integrated list of six criteria of good perceived service
quality: professionalism and skills, attitudes and behavior, accessibility and flexibility, reliability
and trustworthiness, recovery, and reputation and credibility.
In the hospital sector, a clinical audit process is often adopted. Clinical audit is designed to
measure the work of medical practitioners against agreed standards to ensure that professional
aspects of patient care are constantly reviewed. Health care providers are now required to
become more responsive to patients needs while working with a clearly established framework
for determining clinical performance.
It is with this theme of assessment and accountability of health-care personnel in mind that the
SERVQUAL model is being increasingly applied to the measurement of service quality in the
healthcare context (Curry and Sinclair, 2002). This study found that patients highest
expectations were with respect to feeling safe during treatment, with staff behaving in such a
way as to instill confidence and having the knowledge to answer patients questions following
close behind in terms of importance.
Doctors care

This dimension measures the patients experience in respect of the quality of care delivered by
the doctors. The medical encounter between a doctor and a patient requires intensive levels of
interaction where the encounter has been shown to have a significant impact on patient
satisfaction (OConnor et al., 1994). These interactions typically involve complex
communication patterns and customer problems (Bitner, 1990). There is often a formal, longterm relationship between doctor and patient, with the doctor having a significant discretion in
meeting customer needs, and evaluation is largely based on credence attributes (Bitner et al.,
1990). Zifko-Baliga and Krampf (1997) found three of five factors affecting service quality
perception of hospitals were related to the interactions with doctors or other staff. These factors
included professional expertise, validation of patient beliefs, interactive communication, image
and antithetical performance (Zifko-Baliga and Krampf, 1997).
Satisfaction and service quality have been found to be conceptually distinct but closely related
constructs (Dabholkar, 1995). Second, service quality is primarily a cognitive, left-brained,
evaluative, objective concept, while satisfaction is combination of an affective, right-brained,
feelings-based and subjective component, with a cognitive, left-brained, evaluative and objective
component. The affective component of satisfaction is expected to be salient, especially in the
domain of physician services. This is particularly true in developing countries where social
interactions and personal connectivity (high touch) are very important (Malhotra et al., 1994).
Ongoing doctor-patient relationships place more emphasis on feelings and emotions rather than
cognitive elements, as would be the case in an analysis of a discrete exchange. Carman (2000)
stated that acute hospital services provide a salient setting to study the dichotomy between the
affective attributes of the service experience (functional) and the technical attributes of outcomes
of physician care.
Nursing care
The dimension on nursing-care quality assesses the perception of the patient with respect to the
quality of nursing-care provided during his/her stay in the hospital. Nursing service is one of the
most important components of hospital services. Researchers have made important discoveries
about the relationship between nursing and patient outcomes. These studies have highlighted the
vital contribution of nurses to the quality of patient care (Needleman and Buerhaus, 2003).
Carman (1990) used a regression model in which the quality of a set of attribute dimensions are
rated and regressed on a rating of overall quality, and reported that PQNC was the most

important attribute of acute hospital care. In another study by Carman (2000), once again,
PQNC, as the core service of a hospital, was consistently rated as the most important.
Paramedical and support staff quality
Patient perception of the quality of care, attention, empathy, and skill of the paramedical and
support staff in the hospital is examined under this dimension. A number of recent studies have
helped us to learn more about patient evaluation of medical encounters (Proctor and Wright,
1998). These studies have underscored the importance of the service encounter (i.e. the
interactive component of service provision) in determining overall satisfaction. Andaleeb (1998)
found that three out of the five factors leading to customer satisfaction with hospitals had to do
with patient-staff interaction (e.g. communication of hospital staff with patients, competence of
the staff, and staff demeanor).
Quality of communication
The PQQC that the patient has with the personnel in the hospital has an important bearing on the
patients overall perception of quality of care. Several studies have examined the importance of
communication in the service interaction. Curry and Sinclair (2002) used SERVQUAL to
improve patient satisfaction by enhancing communication with patients and increasing their
access to information relating to their condition and its treatment. Frohna et al. (2001) stated that
regardless of whether a patient is cured, the outcome of the physician-patient encounter depends
on communication. Through effective communication, physicians are more likely to positively
influence health outcomes for their patients. Bensing et al. (2000) declared that communication
is the pathway to medicine that is patient-oriented instead of disease-oriented. Frohna et al.
(2001) elaborated that effective physician-patient communication is recognized as an essential
skill for physicians in practice. The study recommended physician awareness of the complexity
of the communication process and of the principles that contribute to the overall outcome of
physician-patient communication. The study revealed that to be effective, communication must
be a two-way process both physician and patient need to offer and accept information about
his/her health concerns, even if they do not seem relevant to the physician.
Physician-patient communication typically involves only the patient and the physician, but a
third party, such as a familymember sometimes may be involved (e.g. in the case of the parents
of a pediatric patient or the child, spouse, or friend of an elderly patient with cognitive
impairment). In such situations, the third party can potentially facilitate communication if they

help to identify the needs of the primary patient and to ensure that treatment recommendations
are followed correctly. The study by Frohna et al. (2001) noted that non-verbal cues can speak as
powerfully as verbal cues. The study recommended a collaborative style of communication to
allow physicians to sustain mutually respectful relationships with their patients. Stein et al.
(2005) conducted a longitudinal study of a large health-care organization, with the aim of
enhancing the clinical communication and relationship skills of the clinicians.
Graugaard et al. (2005) examined the changes in physician-patient communication over time.
Consultations were found to be generally physician dominated and task-focused. While the
amount of task-focused communication was significantly reduced between the initial and the
return visits, the amount of socio-emotional communication remained quite stable.
In return visits, patients with more severe diagnoses were given longer consultations and they
provided more task-focused information to a less verbally dominant physician.
Process of clinical care
A critical dimension of health-care quality is the experience of the patient with different
processes that are a part of his/her stay in hospital. This dimension covers the clinical and AP and
processes in the hospital. Many studies have been carried out with regard to process management
in services. Lewis (1990) stated that a process refers to service delivery systems, the various
physical features associated with an organization and is services, and the role of the
organizations employees (both customer contact and backroom staff) in the service encounter
and the delivery of service quality. Zeithamlet al. (1990) described a process (in the service
context) as the actual procedures, mechanisms and flow of activities by which the service is
delivered, i.e. the service delivery and the operating system. Process management examines the
perception of the patient with regard to the treatment process and the outcome of the treatment
process.
Administrative procedures
Administrative processes (AP) in a hospital set-up include the processes during admission,
procedures during stay in hospital, and the procedures involved in the exit and discharge stage of
the patients stay in hospital. Curry and Sinclair (2002) stated that patients would feel less
inconvenienced by their treatment if access to the service itself were improved. One of the
important dimensions of administrative processes is the delay at different stages of the patients
hospital stay. Studies in the service sector have shown that delays perceived to be unreasonable

or unnecessary by the patients could result in not just dissatisfaction, but also anger. Diaz and
Ruiz (2002) concluded from their study of passengers reactions to delays in the airline industry
that anger is the dominant emotional reaction to delays in service. Studer (2003) supported
discharge phone calls and post-visit calls to patients because these calls accomplish several
goals. In this study, post discharge phone calls were found to demonstrate empathy and ensure
that discharge instructions are being followed, provide an opportunity to learn about the patients
perception of service, gather information to recognize staff, improve clinical outcomes and
generate ideas for process improvement. Thus, examining the patients views of AP is an integral
element in understanding patients views on healthcare service quality.
Safety indicators (SI)
The kind of safety measures that a hospital has in place to safeguard the patients physically,
influences the perception of the patients with respect to hospital quality. Massaro (2003) stated
that health care leaders and trustees must ensure that patient safety becomes (and stays) one of
the organizations primary goals and business imperatives. The ethical imperative for patient
safety represents the fundamental philosophy of medical care dating back to ancient Greece and
the physicians Hippocratic Oath.
Overall, experience of medical care received
This dimension assesses the patients view of the overall experience of medical care he/she
received at this hospital. de Man et al. (2002) stated that actively managing consumer
perceptions of healthcare quality is important for several reasons. First, evaluations of higher
quality are related to satisfaction, intention to use a service again in the future if necessary,
compliance with advice and treatment regimens, choice of provider or plan, decreased turnover
and malpractice law suits, and possibly better health outcomes. In addition, high levels of
consumer-perceived quality have been shown to be positively related to financial performance in
healthcare organizations. This study also shows the strong relationship between overall servicequality perception and patient satisfaction. Press (2002) stated that patient satisfaction results
in higher quality of care, higher satisfaction of employees, lower employee turnover, improved
financial health, strengthened competitive position, enhanced placebo effect, and better risk
management.
Polluste et al. (2000) found that patients opinions are an important tool in evaluation of health
care systems. The factors related to patient-doctor communication were considered more

important than amenities in this study. Patients evaluation of the doctors competence,
comprehensibility of explanations given by the doctor, and cleanliness and comfort of the clinic
were factors which significantly influenced degree of satisfaction. Thus, the dimension on
overall experience with healthcare delivery encompasses different elements of the patients
experience of the treatment.
Social responsibility
An important contributor to the measure of patient satisfaction with regard to the quality of care
delivered by the hospital is whether the hospital fulfills its responsibility to society. This is
manifested in terms of its role as a facilitator of social welfare and growth. This dimension
assesses the patients views in respect of the SR of the hospital. Wensing and Elwyn (2003)
stated that it is an ethical and legal rule that patients should be informed and involved in their
health care. Many patients wish to take part in the decision processes. When the aim is to include
patients in decision making, it is the process of involvement rather than its outcome that is
crucial. The criteria of effectiveness are therefore defined by the ethical principles and patients
preferences. For instance, shared decision making can be evaluated in terms of information
delivered on treatment options, checking of understanding and preferences, and making a shared
decision. Other areas where a hospital can demonstrate its SR is by offering free or subsidized
medical services to the poor, operating in remote areas of the country, conducting awareness
programmes for the poor, etc
Behavioral Intentions
Patient behavioral intensions are hypothesized to be determined by perceived urgent care quality
and patient satisfaction in this study. The definition and items of patient satisfaction has been
introduced in the previous section. The following is a brief review of behavioral intentions.
Behavioral Intentions
Behavioral intentions are the predisposition to future behaviors (John, 1992). A customer with
favorable service experiences would remain loyal to the service provider, recommend it to
friends and relatives, and pay price premium (Zeithaml et al., 1996). Some studies use one or two
items to measure behavioral intentions (e.g. Cronin & Taylor, 1992; Boulding et al., 1993). The
dominant view however is that behavioral intention is a multifacet construct, which includes
five dimensions: loyalty to company, propensity to switch, willingness to pay more, external

response to problem, and internal response to problem (Zeithaml et al., 1996). A corresponding
13item measurement is created by Zeithaml et al. (1996), which will be used in this study too.
The items are listed in Table 6. Table 7 lists the sources of items for each construct.