The TQM Journal

Interrelationships among quality enablers, service quality, patients’ satisfaction

and loyalty in hospitals
Ehsan Sadeh
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To cite this document:
Ehsan Sadeh , (2017)," Interrelationships among quality enablers, service quality, patients’
satisfaction and loyalty in hospitals ", The TQM Journal, Vol. 29 Iss 1 pp. 101 - 117
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Patients’
Interrelationships among quality satisfaction
enablers, service quality,
patients’ satisfaction and
loyalty in hospitals 101

Ehsan Sadeh Received 26 February 2015

Revised 19 August 2015
Department of Management, Aliabad Katoul Branch, Islamic Azad University, 2 January 2016
16 March 2016
Aliabad Katoul, Iran Accepted 4 May 2016
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Abstract
Purpose – The purpose of this paper is to clarify how enablers of quality management can secure the
satisfaction and loyalty of patients through increasing service quality in hospitals.
Design/methodology/approach – The current study conducted a review of the existing literature to
identify operational dimensions of the research variables. As a result of the review, 17 dimensions were
identified; five European foundation for quality management enablers, five SERVQUAL service quality
dimensions, four patients’ satisfaction elements and three patients’ loyalty components. To evaluate
interrelationships among these 17 research dimensions, decision-making trial and evaluation laboratory
technique was applied using experts’ opinions.
Findings – Several key relations were found among research dimensions. Research findings could provide a
scientific insight for hospital managers to understand how they could increase the level of patients’
satisfaction and loyalty through high-quality services provided by quality management enablers.
Research limitations/implications – This study has been conducted based on the expert’s opinions from
private hospitals located in Tehran and Alborz provinces, Iran. Although the results could be useful for
hospital managers in different places and could provide them a valuable insight and knowledge, findings are
limited to Iranian private hospitals.
Originality/value – It is taken for granted that patients’ satisfaction and loyalty could increase as a result of
high-quality medical and treatment services in hospitals. On the other hand, offering excellent services
meeting all the needs and expectations of customers could be consequence product of quality management
enablers. Even though satisfaction and loyalty of customers, i.e. patients, is the primary target of quality
management, there is little research in the literature as to how enablers of quality management can secure the
satisfaction and loyalty through increasing service quality in hospitals. The gap is more critical because the
specialized dimensions of four research variables have not been previously integrated into a coherent
framework and interrelationships among them have not been studied and clarified in detail. The current
study attempts to bridge this gap.
Keywords Hospitals, EFQM, DEMATEL, Service quality, Loyalty, Patients’ satisfaction
Paper type Research paper

1. Introduction
1.1 Overview
Implementation of quality management tools in healthcare institutes is not a new issue.
Several healthcare organizations have started to implement quality management in order to
improve their operations (Lagrosen et al., 2007). Various studies have investigated the
application of quality management in the healthcare sector such as hospitals. Furthermore,
different benefits for healthcare organizations have also been documented by researchers.
Horng and Huarng (2002) focussed on the extent of total quality management (TQM)
adoption by the Taiwanese hospitals. They found there are positive relationships between
the extent of TQM adoption in hospitals and both nature of the network relationship and The TQM Journal
prospector strategy. Miguel (2006) stated that the application of quality management helps Vol. 29 No. 1, 2017
pp. 101-117
improve quality awareness in hospitals and increase the level of their quality services and © Emerald Publishing Limited
1754-2731
subsequently enhance their performance. Sanguesa et al. (2007) found some relevant DOI 10.1108/TQM-02-2015-0032
 TQM selection criteria for hospital managers when deciding on implementation of a quality
29,1 management system. They concluded hospital managers choose the quality management
system based on the priority they attribute to those selection criteria. Also, Zaim et al. (2008)
measured the efficiency of some Turkish hospitals using TQM factors as inputs of the
model and financial and non-financial performance as outputs through application of
multi-criteria data envelopment analysis technique. Alolayyan et al. (2011) emphasized on
102 the role of TQM implementation and operational flexibility dimensions in improving
hospital performance and reducing costs and medical errors. On the other hand, Nwabueze
(2011) concentrated on the role of leadership traits in successful implementation of TQM in
healthcare institutes. Li et al. (2015) investigated the patients’ perception of service quality at
hospitals in nine Chinese cities using SERVQUAL approach and suggested some
improvement points. Talib et al. (2011) indicated that eight TQM practices are vital for
successful TQM implementation in the healthcare organizations and will lead to enhanced
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performance, promoted quality of care, reduced operating cost and improved patient
satisfaction. Mohamed and Azizan (2015) aimed to explore the effects of service quality
dimensions on behavioural compliance and patient satisfaction in Malaysian hospitals.
Patient satisfaction is an interesting topic for healthcare organizations because patients
are their real customers. In fact, the person in need of healthcare is no longer seen as a
patient but rather as a client (Moeller et al., 2000). As it is the case in other different sectors,
satisfaction of customers, i.e. patients, is crucial to the business survival of healthcare
organizations. On the other hand, customer satisfaction is one of the main targets of all
quality management programmes. TQM is necessary for a healthcare system to satisfy the
needs of customers, staff and other stakeholders. In other words, application of quality
management programmes in healthcare organizations will yield excellent results for
different stakeholders, especially for customers.
There is a general consensus that satisfaction of customers results in their loyalty. There
is mounting evidence that if patients are satisfied with a service delivered by a hospital, they
are willing to use that service again in the future. Kessler and Mylod (2011) believe that there
is a positive correlation between satisfaction of patients and their loyalty such that the more
satisfied they are with the services, the more loyal they are to them.
Even though the satisfaction and loyalty of customers, i.e. patients, are the primary targets
of quality management programmes, there is little research in the literature as to how enablers
of quality management can support patients’ satisfaction and loyalty through increasing
service quality in hospitals. The gap is more critical because the specialized dimensions of
research variables has not been previously integrated into a coherent framework and
interrelationships among them have not been studied and clarified in detail. In order to bridge
this gap, the study attempts to explore causal relations among four research variable and their
17 specialized dimensions and integrate them in a causal framework derived from decision-
making trial and evaluation laboratory (DEMATEL) method. As the theoretical contribution
in the area of quality management in healthcare sector, findings could clarify the role of
service quality as a bridge between quality enablers and both patients’ satisfaction and
loyalty. Results of this study could provide knowledge for hospital managers to understand
how they could increase the level of service quality in their hospitals through application of
quality management enablers that eventually ends in satisfaction and loyalty of the patients.
In Iran like in many other countries, European foundation for quality management (EFQM)
excellence model is the official and frequently used excellence model in healthcare
organizations. There are some studies addressing service quality in Iranian hospitals but there
is lack of a comprehensive research investigating the supportive role of EFQM enablers in
improving service quality and achieving patients’ satisfaction and loyalty. For instance, Zarei
(2015) aimed to evaluate service quality of hospital outpatient departments affiliated to Shahid
Beheshti University of Medical Sciences (Iran) from the patients’ perspective. As a case study,
 Aghamolaei et al. (2014) assessed service quality in a referral hospital in Southern Iran Patients’
from patients’ perspective by SERVQUAL scale. Meanwhile, Hashjin et al. (2015) provide an satisfaction
overview of applied hospital quality assurance (QA) policies in Iran to improve quality.
Consequently, improvement of patient satisfaction and loyalty through enablers of the EFQM
needs to be investigated in Iran.
Against this backdrop, the following items are the questions that the current study
attempts to answer: 103
(1) What are the relationships between quality management enablers and service
quality dimensions in hospitals?
(2) What are the relationships between quality management enablers and elements of
patients’ satisfaction in hospitals?
(3) What are the relationships between quality management enablers and components
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of patients’ loyalty in hospitals?

(4) What are the relationships between service quality dimensions and elements of
patients’ satisfaction in hospitals?
(5) What are the relationships between service quality dimensions and components of
patients’ loyalty in hospitals?
(6) What are the relationships between elements of patients’ satisfaction and
components of patients’ loyalty in hospitals?

1.2 Quality management in healthcare organizations

A review of quality management in healthcare organizations reveals that the application
of TQM tools in the healthcare sector has positive ramifications for these organizations.
However, by no means does that mean that this application does not pose any
particular challenges.
The philosophy of total quality prevails within healthcare organizations (Ennis and
Harrington, 1999). TQM addresses several aspects of healthcare organizations and leads
different activities towards good results. According to Miguel (2006), with an increase in
demand for quality and expenditure in hospitals, authorities need to apply quality tools to
enhance their services and optimize their resources. There are few quality management
frameworks like EFQM model and Malcolm Baldrige National Quality Award model that
represent quality philosophy and are applicable in healthcare organizations. These quality
management models conceptualize and categorize different aspects of organizations through
the development of a few quality dimensions and try to present relationships among them.
Also, these dimensions are usually broken down into several sub-dimensions to operationalize
them. These measures address the issue of the quality of treatment as well as the process of
medical care and treatment results (Moeller et al., 2000). In order to implement a quality
management system, organizations in the healthcare sector should empower themselves in
criteria of the model. Quality management discipline holds that enhancement of the
organization in quality criteria will inevitably lead to a better performance.

2. Literature review
2.1 Quality management enablers
According to Manaf (2005), leadership and management commitment, supplier partnership,
continuous improvement, employee involvement and training, management by fact,
strategic planning, teamwork, and, finally, QA constitute quality management dimensions
in hospitals. EFQM is a world-class quality management model that represents TQM theory
(Sadeh and Garkaz, 2015). The EFQM model is a useful tool for a cultural change towards a
 TQM TQM strategy in healthcare services. In fact, the EFQM model provides a generic
29,1 framework of quality criteria which can be successfully applied in the health sector
(Arcelay et al., 1999). EFQM excellence model includes nine excellence criteria broken down
into five enablers and four result factors. EFQM is based on the idea that an organization
should effectively manage five quality enablers to achieve excellent results (Rodriguez and
Alvarez, 2013). According to the assumptions of the EFQM model, excellent results are
104 achieved through leadership, driving policy and strategy, people, partnership and resources,
and processes. These enabler variables reflect levels of quality management in different
organizational domains (Dijkstra, 1997). In fact, enablers are concerned with what
organizations should do and how to do it (Gomez et al., 2015).
According to Sadeh and Arumugam (2010), EFQM model assumes that effective enablers
empower the organization to enhance the achievements of stakeholders. One of the most
significant results addressed by the EFQM framework is customer satisfaction. In fact EFQM
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is based on the premise that enablers can increase satisfaction level. As patients typically
search for higher quality of care, hospitals try to improve the quality of care and patient safety
and satisfaction as their primary goals. In view of this, EFQM model can be applied by
hospitals to improve their services and gain a competitive edge (Moreno-Rodriguez et al., 2013).
In fact, the quality programme increases the ability to meet the requirement of the clients and
enhance their satisfaction (Kristianto et al., 2012).

2.2 Service quality

Implementation of TQM in medical organizations has many benefits, such as a considerable
rise in service quality (Yang, 2003). In fact, TQM is tied to service quality since the
implementation of TQM is to ensure that company can meet the genuine needs and
expectations of customers (Lam et al., 2012).
According to Chaniotakis and Lymperopoulos (2009), in a competitive healthcare
environment, hospitals are obliged to evaluate both their financial and non-financial
performance (quality of their services). There is no value for service quality unless it is
delivered to a customer. When medical services are delivered to a patient, he or she starts to
compare the experience with his or her expectation (Rashid and Jusoff, 2009). It fact, service
quality could be defined based on the consumers’ experience. Patient satisfaction is
consequence function of the gap between expected and perceived specifications and quality
of services (Raposo et al., 2009). Thus, service quality and image could be defined through
customer usage, assessment and word-of-mouth advertising (Buyukozkan et al., 2011).

2.3 Patient satisfaction

Patients could be considered as real customers of the hospitals because they pay for the
services which are directly delivered to them by hospitals. Patient satisfaction is the
psychological state of patients involving their positive or negative feelings or attitudes
towards their experience and some specific aspects in service provision (Chang et al., 2013).
One of the lasting and significant consequences of quality management in the healthcare
sector is focussing on continuous improvement and customer satisfaction. In fact, patient
satisfaction is the primary target for hospitals; therefore, satisfaction with each service
should be explained (Hasin et al., 2001). TQM theory holds that a high level of customer
satisfaction can be achieved through effective enabler dimensions. In other words, patient
satisfaction can be considered as a function of effective enablers. Customer satisfaction is
also a target for healthcare organizations too. In this regard, according to Mortazavi et al.
(2009), with an increase in competition among healthcare organizations, patient satisfaction
has become a critical issue. One of the main parts of the healthcare sector is services offered
by hospitals. Consequently, satisfaction of patients with the services is a key factor in
success of the hospitals. In fact, satisfied customers are likely to exhibit favourable
 behavioural intentions which are beneficial to the healthcare provider’s long-term Patients’
success (Naidu, 2009). According to Alhashem et al. (2011), patients’ satisfaction can be satisfaction
defined as a judgement made by a recipient of care as to whether their expectations for care
have been met or not. From the definition, it is perceived that patients’ satisfaction is related
to two issues. One is patients’ expectation before receiving the services and the other
has to do with patients’ perceptions after receiving the services. In fact, Patient satisfaction
enhances hospital image, which in turn translates into increased service use and 105
market share because satisfied patients usually exhibit favourable behavioural intentions
(Naidu, 2009).
There is mounting evidence that when patients receive high-quality services in a
hospital, they are more likely to return to the same hospital in the future, say positive things
about it to others, and recommend it to their friends and relatives (Arab et al., 2012). This is
extremely important because attracting new customers is usually costly but word-of-mouth
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recommendations of services to others can provide a free platform for promoting the
services offered by a hospital.

2.4 Patient loyalty

Loyalty helps an organization not to fall apart in the face of many uncertainty problems in an
intense competitive market (Amin et al., 2012). According to Mortazavi et al. (2009), patient
loyalty can be defined as their commitment in reusing the services consistently in the future.
Loyal customers, i.e. patients, will not only use the particular services again but also
recommend them to other prospective customers. Consequently, loyal customers help any
business survive tough market and competition conditions. Researchers like Santouridis and
Trivellas (2010) strong believe that loyalty is a function of service quality and customer
satisfaction. Besides, some scholars such as Ooi et al. (2011) believe that implementation of
TQM practices can increase both service quality and customer satisfaction.
Several scholars such as Kessler and Mylod (2011) and Mortazavi et al. (2009) argue that
satisfaction of customers inevitably lead to their loyalty. This is based on the assumption
that if patients are satisfied with the services delivered by a hospital, they are highly
likely to choose this particular hospital in the future and recommend the services of the
hospital to others. Consequently, increasing the level of loyalty among patients is a goal for
all hospitals.

2.5 Research variables and their operationalized dimensions

Quality management enablers. There is a general consensus among scholars that five
enablers of EFQM model (leadership, policy and strategy, people, partnership and
resources, and processes) could serve as a yardstick for measuring the competency level of
hospital in quality management. In fact, EFQM enablers indicate how the organization is
expected to operate based on the TQM philosophy (Sadeh et al., 2013). Several researchers,
e.g. Jackson (2001), Stewart (2003) and Moreno-Rodriguez et al. (2013), have studied quality
management in healthcare organizations from five perspectives based on the five enablers
of EFQM model.
Service quality dimensions. SERVQUAL is an instrument that has been frequently
applied to measure the level of service quality (Liao, 2012). Several authors, e.g. Sohail
(2003), Naidu (2009), Badri et al. (2009), Hu et al. (2010), Nekoei-Moghadam and Amiresmaili
(2011), Haque et al. (2012), Altuntas and Yener (2012), Ramez (2012), and Al-Borie and
Damanhouri (2013), have successfully applied the SERVQUAL instrument to measure
service quality in the healthcare sector. SERVQUAL instrument could operationalize the
concept of service quality from five perspectives including tangibles, reliability,
responsiveness, safety and empathy.
 TQM Patients’ satisfaction elements. According to Naidu (2009), satisfaction of patients could
29,1 be measured in terms of access, healthcare output, behaviour, cost, tangibles, etc. Alhashem
et al. (2011) considers the concept of patient satisfaction from six points of view,
i.e. interpersonal relations, technicality, accessibility, convenience, availability and overall
quality. Kessler and Mylod (2011) postulated four dimensions for patient satisfaction
including satisfaction with process, people, treatment as well as place. Haque et al. (2012)
106 broke down patient satisfaction with service quality in hospitals into three dimensions,
i.e. satisfaction with personal support, hospital facilities and attention to patients. Lei and
Jolibert (2012) also categorized the concept of patient satisfaction into three dimensions,
namely, satisfaction with the paid money, received services and overall satisfaction.
In addition, Grondahl et al. (2013) focussed on some service quality that could result in
patient satisfaction including medical-technical competence, physical competence, cultural
atmosphere, etc. And finally, Senarath et al. (2013) studied patients satisfaction with nursing
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care from five perspectives including interpersonal aspects, comfort and environment,
cleanliness and sanitation, personal instructions, as well as efficiency and competency.
In light of this review, the present study considers four major aspects of patient satisfaction
as presented in Table I.
Patients’ loyalty components. Naidu (2009) defined three aspects for patient satisfaction
including positive word-of-mouth, compliance as well as utilization. Badri et al. (2009)
believed that satisfied patients reveal their loyalty through two ways; their willingness to
return to the hospital and recommending it to others. Lei and Jolibert (2012) consider
patients’ loyalty merely as recommending hospital to someone who seeks the advice. Three
components of patients’ loyalty considered by the current study are presented in Table I.
Table I presents six research variables which are operationalized by 17 dimensions.

3. Methodology
According to Tzeng et al. (2007), the original DEMATEL was developed between the years
1972 and 1976 by the Science and Human Affairs Programme of the Battelle Memorial
Institute of Geneva to study, analyse and solve sophisticated and intertwined problem
groups. According to Li and Tzeng (2009), the most prominent speciality of DEMATEL
technique as a multi-criteria decision-making (MCDM) method is to build interrelations

Variables Dimensions

Quality management enablers (QE) QE1: leadership

QE2: policy and strategy
QE3: people
QE4: partnership and resources
QE5: processes
Service quality (SQ) SQ1: tangibles
SQ2: reliability
SQ3: responsiveness
SQ4: safety
SQ5: empathy
Patient satisfaction (PS) PS1: satisfaction with physical facilities
PS2: satisfaction with staff performance
PS3: satisfaction with technical and medical services
Table I. PS4: satisfaction with cost
Variables and Patient loyalty (PL) PL1: positive word-of-mouth
operationalized PL2: recommending to others
dimensions PL3: willingness to reuse
 among criteria. In this regard, Hu et al. (2009) argue that DEMATEL is able to transform Patients’
complicated systems into structurally precise causal linkages. satisfaction
According to Shih et al. (2010), DEMATEL is able to create a structural system based
on experts’ opinions and knowledge. To perform DEMATEL technique, this study
gathered the opinions of those experts who not only have academic qualifications in a
relevant field, but also have at least a ten-year work experience in managing hospitals.
This approach is adapted to ensure that the experts have both an in-depth knowledge of 107
quality management and a considerable experience in managing Iranian hospitals. This
study collected opinions of 23 experts including nine doctors and 14 managers who have
an extensive background in administrating hospitals. These respondents were selected
from those available experts from some private hospitals in Tehran and Alborz provinces
who had willingness to involve in the current study. Each expert was asked to fill in a
matrix-based questionnaire (see Table AI) through an interview independently. In order to
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provide some usable information for the experts that help them in conducting the survey
more accurate and confident, a text was enclosed to the questionnaire containing a
summary of the theoretical background (e.g. definitions of the research variables) as well
as the steps of the study. This questionnaire is called direct-relation matrix in DEMATEL
procedure. Since DEMATEL is a MCDM method, experts involved in the study are
considered as a decision team. Subsequently, an average matrix A, each element of which
is the arithmetic mean of the same elements in all matrix questionnaires which were
collected from the experts, was considered for performing DEMATEL. MATLAB
software was used to run the DEMATEL technique.
There are steps in DEMATEL procedure:
• Step 1. Creating the direct-relation matrix: initially, the comparison scale needs to be
designed in four levels in order to measure the linkages among criteria. These four
levels include: 0 (no influence), 1 (low influence), 2 (high influence) and 3 (very high
influence). Then, the pair-wise comparisons are conducted by the experts to measure
the impact and direction between criteria. Next, the direct-relation matrix, which is an
n × n matrix, is created based on the initial data which were collected through these
evaluations. Then, an average matrix A, each element of which is the arithmetic mean
of the same elements in all collected direct-relation matrices, is calculated.
• Step 2. Normalizing the direct-relation matrix: the normalized direct-relation matrix X
is calculated based on the direct-relation matrix A through the formulas (1) and (2)
which are mentioned as follows:
X ¼ kUA (1)

1
k¼ Pn ; i; j ¼ 1; 2; :::; n (2)
max j¼1 aij
1pipn

• Step 3. Obtaining the total-relation matrix: the total-relation matrix T can be achieved
based on the normalized direct-relation matrix X through applying formula (3).
In formula (3), the I indicates the identity matrix:

T ¼ X ðI X Þ1 (3)
• Step 4. Generating a causal diagram: through applying formulas (4)-(6), vectors D and
R are obtained which are the sum of rows and the sum of columns, respectively. Next,
“prominence”, which is the horizontal axis vector (D + R), is obtained through adding
D to R. The “prominence” indicates the degree of significance of each criterion.
 TQM Similarly, “relation”, which is the vertical axis (D−R), is calculated through
29,1 subtracting D from R. When the calculated (D−R) has a positive numerical value, it
means that the criterion pertains to the cause group. Conversely, when the calculated
(D−R) has a negative numerical value, it means that the criterion pertains to the effect
group. Consequently, the causal diagram can be delineated based on the (D + R) and
the (D−R) values of criteria:
108  
T ¼ t ij nn ; i; j ¼ 1; 2; :::; n (4)

" #
X
n
D¼ t ij ¼ ½t i n1 (5)
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j¼1 n1

" #t
Xn
R¼ t ij ¼ ½tjn1 (6)
i¼1 1n

Justification on the results: according to Tzeng et al. (2007) and Li and Tzeng (2009), a
threshold value (ρ) should be determined based on the experts’ opinions. Only the
interrelationships whose influence level in total-relation matrix is higher than the threshold
value are suggested. Based on the experts’ opinions, a threshold value equal to 0.1 is
considered in this study (see Table IV).

4. Results
In the current study, data were collected from experts. The experts evaluated the degree of
influence among research criteria. They provided their opinions in a matrix-based
questionnaire called direct-relation matrix. In the next step, the average matrix A, each
element of which is the arithmetic mean of the same elements in all received direct-relation
matrices, was calculated. Table II presents the average matrix.
Based on matrix A, normalized-relation matrix (matrix X) was calculated. Matrix X was
obtained using formulas (1) and (2) (Table III).
Total-relation matrix (matrix T) was calculated through formula (3). Table IV
presents matrix T. Since a threshold equal to 0.1 is designated by the experts, those
impacts with values higher than 0.1 are highlighted and proposed as considerable
effects by this study.
Then, the prominence and relation matrix was calculated (see Table V). As can be seen in
table, policy and strategy (2.228), people (2.370), partnership and resources (2.361) as well as
patients’ willingness to reuse (2.347) which has the highest value in D + R column are the
most prominent elements. Further, those variables which have positive values in column
D−R belong to the cause group and those with negative values belong to the effect group.
Among others, people (1.185) and partnership and resources (1.216) are the most effective
variables. On the other hand, willingness to reuse (−1.663) receives the highest impacts from
other variables
Figure 1 presents the causal diagram. In the following figure, the variables located above
the horizontal axis (zero line) pertain to the cause group and those under the axis are
subsumed under the effect group. Also, variables closer to the right side of horizontal axis
are more prominent.
 QE1 QE2 QE3 QE4 QE5 SQ1 SQ2 SQ3 SQ4
Patients’
QE1 0 2.36 0.84 1.32 0.66 0.36 0.52 0.48 0.44 satisfaction
QE2 0.06 0 2.44 2.64 1.72 1.44 1.52 1.24 1.56
QE3 0.04 0.02 0 0.52 2.24 1.16 1.88 2.52 2.2
QE4 0.02 0.16 0.44 0 2.2 2.71 1.88 1.12 2.04
QE5 0.02 0.08 1.08 0.84 0 0.36 1.42 1.6 1.84
SQ1 0 0.02 0.06 1.16 0.96 0 0.88 0.96 0.72
SQ2 0.04 0.06 0.32 0.28 0.4 0.84 0 1.84 1.32 109
SQ3 0.02 0.08 0.42 0.24 1.2 0.92 0.96 0 0.84
SQ4 0 0.04 0.72 0.86 0.8 1.08 0.96 0.92 0
SQ5 0.28 0.16 1.18 0.08 0.12 0.52 0.82 0.6 0.88
PS1 0.02 0.06 0.06 0.28 0.16 0.12 0.02 0.02 0.06
PS2 0.12 0.32 0.48 0.04 0.08 0.1 0.08 0.16 0.04
PS3 0.1 0.28 0.68 0.36 0.42 0.28 0.08 0.06 0.16
PS4 0.08 0.12 0 0.02 0.02 0.06 0.08 0.08 0.02
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PL1 0.98 1.2 0.02 0.04 0.06 0.08 0.04 0.02 0.02
PL2 0.88 1.16 0.06 0.02 0.04 0.08 0.06 0.08 0
PL3 1.12 1.68 0.08 0.06 0.48 0.02 0.06 0.04 0.06
SQ5 PS1 PS2 PS3 PS4 PL1 PL2 PL3
QE1 1.08 0.16 0.24 0.2 0.32 0.28 0.24 0.16
QE2 1.72 0.76 1.12 0.88 1.04 0.64 0.52 0.44
QE3 2.48 0.84 1.96 0.44 2.42 2.24 2.32 2.52
QE4 0.92 2.84 0.8 2.6 0.96 2.24 2.12 2.48
QE5 0.68 1.86 1.72 1.68 0.72 1.96 1.68 2.28
SQ1 0.24 2.64 2.04 1.84 2.12 1.94 1.98 2.08
SQ2 0.44 0.52 2.16 0.92 0.72 1.42 1.28 1.12
SQ3 0.76 1.04 1.68 1.52 1.32 1.24 1.16 1.36
SQ4 0.82 1.84 1.72 1.64 1.52 1.16 1.04 1.24
SQ5 0 0.84 1.12 0.96 0.8 0.6 0.52 0.56
PS1 0.02 0 0.16 0.86 2.24 1.84 1.96 2.12
PS2 0.02 0.28 0 0.98 2.08 2.16 2.24 2.48
PS3 0.08 0.24 0.18 0 2.36 2.36 2.16 2.6
PS4 0.04 0.12 0.16 0.16 0 2.48 2.04 2.64
PL1 0 0 0.04 0.02 0.04 0 1.12 1.48 Table II.
PL2 0.02 0.02 0.04 0.08 0.02 1.24 0 1.36 Direct-relation matrix
PL3 0.02 0 0.02 0.04 0.08 0.06 0.08 0 (average matrix A)

5. Discussion and conclusion

5.1 Relationships between quality management enablers and service quality dimensions in
hospitals
This study identified several causal relations between enablers and service quality
dimensions. Those relations with values more than 0.1 are suggested by the study
(see Table IV). Among identified relations, the effect of people element on responsiveness
(0.132) and the influence of partnership and resources on reliability (0.130) have the highest
value and are the most significant and considerable relations. People who work in hospitals
are those who respond to patients’ primary needs. Specially, nursing and paramedical staff
are among those who have a direct and continuous contact with patients during the
treatment process. Obviously, empowered and well-trained people could increase the level of
responsiveness in hospitals. Further, competent employees could provide different kinds of
consultation as well as useful information for patients. This point has been considered by
the study conducted by Zarei (2015) that found physician consultation and information
provided to the patient by specialists, doctors and nurses (medical staff) as the most
significant service quality factors. Furthermore, the resources which a hospital uses to
satisfy patients could significantly enhance the degree of reliability in that hospital.
 TQM QE1 QE2 QE3 QE4 QE5 SQ1 SQ2 SQ3 SQ4
29,1 QE1 0.000 0.091 0.033 0.051 0.026 0.014 0.020 0.019 0.017
QE2 0.002 0.000 0.095 0.102 0.067 0.056 0.059 0.048 0.060
QE3 0.002 0.001 0.000 0.020 0.087 0.045 0.073 0.098 0.085
QE4 0.001 0.006 0.017 0.000 0.085 0.105 0.073 0.043 0.079
QE5 0.001 0.003 0.042 0.033 0.000 0.014 0.055 0.062 0.071
SQ1 0.000 0.001 0.002 0.045 0.037 0.000 0.034 0.037 0.028
110 SQ2 0.002 0.002 0.012 0.011 0.016 0.033 0.000 0.071 0.051
SQ3 0.001 0.003 0.016 0.009 0.047 0.036 0.037 0.000 0.033
SQ4 0.000 0.002 0.028 0.033 0.031 0.042 0.037 0.036 0.000
SQ5 0.011 0.006 0.046 0.003 0.005 0.020 0.032 0.023 0.034
PS1 0.001 0.002 0.002 0.011 0.006 0.005 0.001 0.001 0.002
PS2 0.005 0.012 0.019 0.002 0.003 0.004 0.003 0.006 0.002
PS3 0.004 0.011 0.026 0.014 0.016 0.011 0.003 0.002 0.006
PS4 0.003 0.005 0.000 0.001 0.001 0.002 0.003 0.003 0.001
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PL1 0.038 0.047 0.001 0.002 0.002 0.003 0.002 0.001 0.001
PL2 0.034 0.045 0.002 0.001 0.002 0.003 0.002 0.003 0.000
PL3 0.043 0.065 0.003 0.002 0.019 0.001 0.002 0.002 0.002
SQ5 PS1 PS2 PS3 PS4 PL1 PL2 PL3
QE1 0.042 0.006 0.009 0.008 0.012 0.011 0.009 0.006
QE2 0.067 0.029 0.043 0.034 0.040 0.025 0.020 0.017
QE3 0.096 0.033 0.076 0.017 0.094 0.087 0.090 0.098
QE4 0.036 0.110 0.031 0.101 0.037 0.087 0.082 0.096
QE5 0.026 0.072 0.067 0.065 0.028 0.076 0.065 0.088
SQ1 0.009 0.102 0.079 0.071 0.082 0.075 0.077 0.081
SQ2 0.017 0.020 0.084 0.036 0.028 0.055 0.050 0.043
SQ3 0.029 0.040 0.065 0.059 0.051 0.048 0.045 0.053
SQ4 0.032 0.071 0.067 0.064 0.059 0.045 0.040 0.048
SQ5 0.000 0.033 0.043 0.037 0.031 0.023 0.020 0.022
PS1 0.001 0.000 0.006 0.033 0.087 0.071 0.076 0.082
PS2 0.001 0.011 0.000 0.038 0.081 0.084 0.087 0.096
PS3 0.003 0.009 0.007 0.000 0.091 0.091 0.084 0.101
Table III. PS4 0.002 0.005 0.006 0.006 0.000 0.096 0.079 0.102
Normalized direct- PL1 0.000 0.000 0.002 0.001 0.002 0.000 0.043 0.057
relation matrix PL2 0.001 0.001 0.002 0.003 0.001 0.048 0.000 0.053
(matrix X) PL3 0.001 0.000 0.001 0.002 0.003 0.002 0.003 0.000

5.2 Relationships between quality management enablers and elements of patients’

satisfaction in hospitals
This research highlighted a variety of linkages between enablers and patients’ satisfaction
dimensions. Among the high-value relations in this regard (⩾ 0.1), the impact of partnership and
resources on satisfaction with physical facilities (0.156) and satisfaction with technical and
medical services (0.150) have the highest level. Further, the effect of people element on satisfaction
with cost (0.154) is a considerable linkage. It is a clear fact that hospitals’ resources are the most
important dimension which could satisfy patients with their physical facilities. Besides, the use of
up-to-date resources and cutting-edge technology are encouraged because this could elevate the
level of patients’ satisfaction with technical and medical services. The results are compatible with
the findings of Dagger et al. (2007) that focussed on the importance of technical quality as one of
the four primary quality dimensions in hospitals. On the other hand, competent and empowered
staff, particularly doctors and specialists, are the main element in patients’ perception of the cost.
Experienced and reputable doctors and medical team members are the effective dimensions
which could impact the patients’ perception and justification of the price of treatment. This is the
reason that Sabella et al. (2015) indicated that human resources element has been always the area
of concern for hospitals in implementation of quality management.
 QE1 QE2 QE3 QE4 QE5 SQ1 SQ2 SQ3 SQ4
Patients’
QE1 0.008 0.103 0.054 0.070 0.051 0.038 0.046 0.044 0.045 satisfaction
QE2 0.019 0.026 0.120 0.125 0.108 0.093 0.100 0.092 0.106
QE3 0.026 0.038 0.028 0.043 0.117 0.074 0.105 0.132 0.119
QE4 0.025 0.043 0.043 0.027 0.117 0.130 0.103 0.078 0.112
QE5 0.020 0.033 0.061 0.049 0.028 0.038 0.078 0.087 0.096
SQ1 0.019 0.031 0.019 0.059 0.059 0.019 0.053 0.056 0.048
SQ2 0.015 0.023 0.026 0.023 0.034 0.047 0.017 0.086 0.066 111
SQ3 0.015 0.025 0.031 0.023 0.063 0.050 0.054 0.020 0.051
SQ4 0.015 0.025 0.043 0.047 0.053 0.060 0.057 0.057 0.022
SQ5 0.019 0.021 0.056 0.014 0.021 0.033 0.045 0.040 0.049
PS1 0.014 0.021 0.008 0.017 0.015 0.011 0.007 0.007 0.009
PS2 0.019 0.035 0.027 0.010 0.015 0.012 0.012 0.015 0.011
PS3 0.020 0.034 0.035 0.023 0.030 0.021 0.015 0.015 0.019
PS4 0.016 0.024 0.005 0.006 0.007 0.007 0.008 0.008 0.005
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PL1 0.044 0.059 0.010 0.012 0.012 0.011 0.010 0.009 0.009
PL2 0.040 0.057 0.011 0.011 0.011 0.010 0.010 0.011 0.009
PL3 0.046 0.073 0.015 0.015 0.030 0.010 0.013 0.012 0.014
SQ5 PS1 PS2 PS3 PS4 PL1 PL2 PL3
QE1 0.062 0.035 0.040 0.038 0.047 0.056 0.051 0.057
QE2 0.097 0.084 0.100 0.091 0.109 0.118 0.108 0.124
QE3 0.118 0.078 0.128 0.069 0.154 0.175 0.172 0.202
QE4 0.058 0.156 0.082 0.150 0.108 0.180 0.170 0.206
QE5 0.046 0.103 0.102 0.101 0.082 0.145 0.131 0.171
SQ1 0.023 0.127 0.104 0.103 0.128 0.144 0.141 0.163
SQ2 0.029 0.043 0.108 0.062 0.065 0.104 0.096 0.102
SQ3 0.041 0.063 0.090 0.085 0.090 0.103 0.096 0.117
SQ4 0.046 0.098 0.095 0.094 0.105 0.109 0.101 0.123
SQ5 0.013 0.049 0.065 0.056 0.063 0.064 0.059 0.069
PS1 0.006 0.007 0.013 0.041 0.098 0.097 0.099 0.115
PS2 0.009 0.019 0.011 0.047 0.096 0.114 0.114 0.134
PS3 0.013 0.022 0.021 0.014 0.108 0.125 0.115 0.144
PS4 0.005 0.009 0.011 0.011 0.007 0.108 0.091 0.121
PL1 0.008 0.007 0.010 0.009 0.011 0.013 0.054 0.071 Table IV.
PL2 0.009 0.008 0.010 0.011 0.011 0.059 0.013 0.067 Total-relation matrix
PL3 0.012 0.010 0.012 0.012 0.016 0.018 0.017 0.017 (matrix T)

D R D+R D−R

QE1 0.380 0.845 1.224 0.465

QE2 0.669 1.619 2.288 0.951
QE3 0.593 1.777 2.370 1.185
QE4 0.572 1.788 2.361 1.216
QE5 0.771 1.373 2.145 0.602
SQ1 0.663 1.296 1.959 0.633
SQ2 0.732 0.947 1.679 0.214
SQ3 0.766 1.017 1.783 0.250
SQ4 0.789 1.148 1.937 0.360
SQ5 0.596 0.736 1.332 0.140
PS1 0.919 0.585 1.504 −0.334
PS2 1.004 0.699 1.702 −0.305
PS3 0.995 0.773 1.768 −0.222
PS4 1.298 0.448 1.746 −0.850
PL1 1.730 0.359 2.089 −1.370 Table V.
PL2 1.628 0.359 1.987 −1.269 Prominence and
PL3 2.005 0.342 2.347 −1.663 relation matrix
 TQM 1.5
QE3
29,1 1
QE4
SQ1 QE2
QE1 SQ3
0.5
QE5
SQ2 SQ4
SQ5
0
D–R

0 0.5 1 1.5 PS2 PS3 2 2.5

112 –0.5
PS1

PS4
–1
PL2 PL1
–1.5
PL3
Figure 1.
Causal diagram –2
D+R
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5.3 Relationships between quality management enablers and components of patients’

loyalty in hospitals
The current study proposed some relationships between enablers and patients’ loyalty
components. Among others, the influences of people element (0.202) and partnership and
resources (0.206) on patients’ willingness to reuse the services of a hospital have the
highest values. Despite the fact that medical technology is advancing in leaps and bound
and despite the ever-increasing role technology plays in the medical world on a
regular basis, human resources, particularly doctors and medical teams, are still the
most important capital and the mainstay of hospitals. In fact, it is doctors and their
competence that motivate patients to reuse hospital services. Supportively, Zigan et al.
(2007) indicated that intangible resources including human resources and relationships
between hospitals and external strategic organizations (partners) could affect their
performance. Also, adequate resources of hospitals could motivate a patient to use
services of that hospital again.

5.4 Relationships between service quality dimensions and elements of patients’ satisfaction
in hospitals
This enquiry suggested various relations between service quality dimensions and
patients’ satisfaction elements. Among the identified linkages, the effects of
tangibles dimension on satisfaction with physical facilities (0.127) and satisfaction
with the cost of treatment (0.128) have the highest values and are considered the most
significant. This means that tangible assets of a hospital are the most effective elements in
appraising the quality of the physical facilities and perception of fair cost. The effect of
service quality dimensions on Patients’ satisfaction has been approved by other
studies. For instance, findings of Amin and Nasharuddin (2013) showed that
establishment of higher levels of hospital service quality will lead patients to have a
high level of satisfaction.

5.6 Relationships between service quality dimensions and components of patients’ loyalty in
hospitals
This investigation proposed a number of relations between service quality dimensions and
patients’ loyalty components. Among others, the effects of tangibles dimensions on positive
word-of-mouth (0.144) and willingness to reuse (0.163) have the highest values and are the
most considerable relations. This is extracted from the results that desired tangibles of a
hospital could catch the eyes of the patients and could motivate them in reusing the services
 again as well as encouraging others to use these services. This has been advocated by the Patients’
results of Kondasani and Panda (2015) that indicated the quality of facilities (tangibles) satisfaction
could positively affect patients’ satisfaction and loyalty.

5.7 Relationships between elements of patients’ satisfaction and components of patients’

loyalty in hospitals
Our study highlighted some linkages between patients’ satisfaction elements and patients’ 113
loyalty components. Among others, the influence of satisfaction with staff performance
(0.134) and satisfaction with technical and medical services (0.144) on patients’ willingness
to reuse possess the highest levels and are the most important. This was found out that that
the most effective motives for patients to reuse the services of a particular hospital are their
satisfaction with staff, nursing team and doctors, as well as their satisfaction with technical
and medical services. This could confirm the results of some previous studies such as
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Kessler and Mylod (2011) that concluded satisfaction of patients with place, people and
treatment influence their loyalty.
Overall, with the implementation of quality management, enablers can improve the level
of medical and treatment services in hospitals. Further, achieving good results in patients’
satisfaction and loyalty could be an immediate product of quality management application
in hospitals. Findings of this study could provide a valuable insight for hospital managers to
understand how they could increase the level of service quality as well as patients’
satisfaction and loyalty through quality management enablers.

5.8 Research limitation

This study has been conducted based on the expert’s opinions from private hospitals
located in Tehran and Alborz provinces, Iran. Although the results could be useful for
hospital managers in different places and could provide them a valuable insight and
knowledge, findings are limited to Iranian private hospitals.

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 Appendix Patients’
satisfaction

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Table AI.
Matrix-based
questionnaire of
DEMATEL technique

Corresponding author
Ehsan Sadeh can be contacted at: ehsan.sadeh@yahoo.com

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