International Journal of Business and Management Invention

ISSN (Online): 2319 – 8028, ISSN (Print): 2319 – 801X

www.ijbmi.org Volume 2 Issue 4 ǁ April. 2013ǁ PP.59-67

Assessment of service quality dimensions in healthcare industry

A study on patient’s satisfaction with Bangladeshi private
Hospitals.
1
Md Rajib Rahman, 2Shawgat S. Kutubi
1
Lecturer, School of Business, Independent University, Bangladesh (IUB)
2
Sr. Lecturer, School of Business, Independent University, Bangladesh (IUB)

ABSTRACT : Poor service quality perception toward public hospitals lead to Increasing demand for private
health care in Bangladesh. Observing the growth of private health care sector, it is imperative to measure the
service quality of private hospitals in Bangladesh. This study attempts to identify the service quality factors that
influence patient satisfaction with private hospitals. A survey was conducted on patients of ten different
hospitals in Dhaka city. A self-administered survey method and non-probability judgment sampling was used in
the research to obtain information regarding patients’ perceptions toward 11 service quality dimensions of
private hospitals. Multiple-regression was used to identify the service quality factors that influence patients’
satisfaction. And descriptive statistics represented the patient’s satisfaction level with different service quality
factors.

Keywords: Service quality, health care, hospitals, patients’ perception, patient satisfaction.

I. INTRODUCTION
Consumers today are more aware of alternative offerings and rising standards of service have increased
their expectations. They are also becoming increasingly sensible of the quality of service they experience.
Patient satisfaction is an important indicator of the quality of medical care and a major determinant in the choice
of a care provider in the future (Croucher, 1991). Accurate and reliable survey information provides the basis for
continuous quality improvement in the delivery of services. By meeting the needs of the patient, the institutions
in turn will ultimately ensure its competitive position (Curbow, 1996). Service quality has been increasingly
identified as a key factor in differentiating services and building competitive advantage. Therefore,
understanding, measuring and improving quality is a formidable challenge for all organizations since they
compete to great degree on the basis of service. Customers evaluate service quality both on the outcome of the
service and the process of service delivery. Health care services have a distinct position among other services
due to the highly involving and risky nature of services and the general lack of adequate knowledge possessed
by consumers. This makes conceptualizing and measuring customer satisfaction and service quality in health
care settings more important and at the same time more complex. To maintain and improve the quality of health
care services, besides relying on clinical and economic criteria, healthcare administrators should utilize the
feedback through patient perceptions of care surveys.

While the efforts are in the right direction, the public health sector is plagued by uneven demand and
perceptions of poor quality and the quality perception is driving patients to private healthcare sector (Andaleeb
et al. 2007). This poor service quality is the pivotal cause responsible for declining utilization rate of public
health care facility in Bangladesh. Overall utilization rate for public health care services is as low as 30%
(Ricardo et al. 2004). Dissatisfaction with public health care sector is shifting demand toward private health care
sector in the country. The trend of utilization of public health care services in Bangladesh had been declining
between 1999 and 2003, while the rate of utilization of private health care facilities for the same period had been
increasing (CIET Canada, 2003). The private health care sector (including unqualified providers) also deserves
close scrutiny as about 70% of the patients seek medical care from this sector (World Bank, 2003). Between
1996 and 2000, private hospitals grew around 15% per annum (HEU, 2003b). Massive investments in the
private sector are boosting the growth. In 2005, Apollo hospital alone has invested $35 million (People’s Daily
Online, 2005). Similar investments have been done by other major corporate groups.

Observing at the growth in Bangladesh private health care sector, it’s imperative to identify whether
service is being ignored here. Some of its main drawbacks in private health care in Bangladesh include disregard

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of standard treatment protocols, lack of qualified nurses and unnecessary diagnostic tests (World Bank 2003).
These instances reflect that the problems of the health service delivery system that must be quickly and
responsibly addressed.

A large number of Bangladeshi patients who are able to afford it are going to foreign hospitals. Institute
of Health Economics, University of Dhaka, estimates that Bangladeshis spend approximately $300 million a
year on foreign healthcare services (World Bank, 2003). This results in huge losses of foreign exchange for
Bangladesh. A better understanding of the determinants of patient satisfaction with private hospitals should help
policy and decision-makers adopt and implement strategies to improve health care services in the country and
thus contribute more to country’s GDP. In the competitive market of health care private hospitals in Bangladesh
need to understand the key factors of service quality that have impact on patient satisfaction which will enable
them to gain a competitive advantage in the local market and regional market by assuring better service quality
at home. In this study, the researcher intended to identify the impact of service quality dimensions of
Bangladeshi private hospitals on patient satisfaction.

1.1 Research Objectives

The objectives of the research are:

1. To identify the service quality factors that influence patients’ satisfaction with private hospitals in
Bangladesh.
2. To identify how patients rate the service quality factors of private hospitals in Bangladesh.

II. REVIEW OF LITERATURE AND RELATED STUDIES

2.1 Concepts of Service Quality in Healthcare:
Health care service providers’ effort to determine and improve weaker aspects of their service delivery
system requires a better understanding of how consumers evaluate health care service quality. And service
quality can be enhanced by monitoring patient perceptions and implementing action plan based on patient
feedback. The SERVQUAL framework has guided numerous studies in the service sector that focus on banks,
repair and maintenance services, telephone companies, physicians, hospitals, hotels, academic institutions and
retail stores (Parasuraman et al. 1988; Carman 1990; Boulding et al. 1993). Parasuraman et al. (1988) first
proposed the SERVQUAL framework with five dimensions of service:

(1) Tangibles – physical facilities, equipment and appearance of personnel;

(2) Empathy – being caring, and providing individualized attention;
(3) Assurance – knowledge and courtesy of employees and their ability to convey trust and confidence;
(4) Reliability – ability to perform the promised service dependably and accurately;
(5) Responsiveness – willingness to help customers and provide prompt service.

The SERVQUAL instrument was used by different researchers (Canel and Fletcher, 2001; Lam, 1997;
Donthu, 1991; Sohail, 2003 Andaleeb, 2001, 2007) to evaluate health care service quality. Scardina (1994) and
Arikan (1999) reported that SERVQUAL was superior in validity and reliability for evaluating patient
satisfaction (Sohail, 2003). The SERVQUAL instrument has been empirically evaluated in the hospital
environment and has been shown to be a reliable instrument in that setting (Babakus and Manggold, 1992).
To measure health care service quality and patient satisfaction in Bangladesh few studies were
conducted, and SERVQUAL was used in most of them with or without modification. Andaleeb (2000a, 2001)
used Responsiveness, Assurance, Communication, Discipline, Bakhsesh (facilitation payments) to compare
service quality between public and private hospitals. SERVQUAL framework was advanced by Andaleeb,
Nazlee and Khandakar al., (2007) with variables like, Reliability, Responsiveness, Assurance, Tangibles,
Communication, Empathy, Process features, Cost, Availability/access to explain patient satisfaction with foreign
and local health care service. Sohail (2003) in “Service quality in hospitals: more favorable than you think”
examined and measured the quality of services provided by private hospitals in Malaysia. LeKim (2005) in
“Inpatients’ satisfaction with service quality: A study on the Transport Hospital in Hanoi, Vietnam” measured
the satisfaction level of inpatients.

2.2 Independent variables:

2.2.1 Reliability:
Reliability refers to a providers’ ability to perform the promised service dependably and accurately.
Perceptions of reliability are also lessened when doctors do not provide correct treatment the first time

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(accusation that doctors recommend unnecessary medical tests, irregular supervision of patients by care
providers and specialists are unavailable).

2.2.2 Responsiveness:
Patients expect hospital staff to respond promptly when needed. It is the willingness and promptness of
responding to the patients. They also expect the experts and required equipment to be available, functional and
able to provide quick diagnoses of diseases.
2.2.3 Assurance:
Assurance is the knowledge, skill and courtesy of the service provider that inspire trust and confidence
in consumers’ mind. In the health care setting, assurance is reflected by competencies of diagnosis, skills to
interpret laboratory report, provide appropriate explanations to queries. Well-trained nurses and other support
staffs also play vital roles in providing support to patients’ feelings of assurance and safety.

2.2.4 Tangibles:
Appearance (tangibility) of the physical facilities, equipment, personnel and written materials affects
patients’ satisfaction. A systematized, ordered and clean appearance of hospital premises, restrooms, equipment,
wards, beds and the whole construction or infrastructure can influence patients’ impressions about the hospital.
Tangibles are the physicals representations of intangible service that create the image in customer’s mind.

2.2.5 Communication:
If a patient feels alienated, uninformed or uncertain about his / her health status and outcomes, it may
affect the healing process. When the nature of the treatment is clearly explained, patients’ queries are responded,
and it may alleviate patients’ feelings of uncertainty. Appropriate communication and good rapport can, thus,
help convey important information to influence patient satisfaction.

2.2.6 Empathy:
Empathy represents the sympathy of service provider. Health care providers’ sympathy and
understanding of patients’ problems and needs can greatly influence patient satisfaction. Patients desire the
doctors to be observant, attentive and understanding towards them. Similarly patients expect nurses to provide
personal care and mental support to them. This reflects service providers’ empathy.
2.2.7 Process features:
Process features refer to an orderly management of the overall health care service process. This
constitutes patients’ expectation that doctors will maintain proper visiting schedules and that there will be
structured visiting hours for relatives, friends, etc. Updated patient records and standard patient release
procedures also facilitate patient care.

2.2.8 Cost:
Treatment cost is an important factor that may form patients’ expectation and affects patients’
satisfaction. Andaleeb (2001) and Hasin et al.,(2001), used cost in the SERVQUAL dimensions to assess
patients’ satisfaction. In a developing country like Bangladesh, cost is a continuing concern of consumers for
making purchase decision for services, given their low earnings. In health care setting costs include consultation
fees, laboratory test charges, travel, drugs and accommodation. Private hospitals are costly but their costs vary
markedly across hospitals.
2.2.9 Access:
Availability of doctors, nurses, hospital beds and information round the clock with minimum hassle is
of concern to patients in defining the level of access they have to health care. If hospital inadequate number of
doctors, nurses, beds and cabins may affect patients’ satisfaction because people want health service to be
available to them with minimum hassle.

2.2.10 Billing services:

Billing service can be referred as making or sending out of bills or invoices. A crude, rough and
unpolished billing service it may cause dissatisfaction among patients. Hughes (1991) used billing services in
his attribute based model to measure patient satisfaction.

2.2.11 Treatment outcome:

Treatment outcome reflects the results or effects of medical care. Hughes (1991) used treatment
outcome to assess patient satisfaction. From the patient’s point of view, if they do not feel cured in their mind,
indeed they are not cured. For Bangladeshi patients it is an important factor.

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Zifko-Baliga and Krampf (1997) followed the Williams and Torrens' idea (1988) with a development
of a theoretical framework that is composed of structure, process, and treatment outcome, which a researcher
should consider when studying about health care service quality.

III. RESEARCH FRAMEWORK

This study attempted to examine the impact of service quality dimensions of private hospitals in
Bangladesh on patient satisfaction. Reviewing the literature on the topic from research papers and articles, a
number of service factors were identified. Eleven important attributes (Reliability, Responsiveness, Assurance,
Tangibles, Communication, Empathy, Process features, Cost, Access, Billing service and Treatment outcome)
of health care service quality emerged as latent variables from the literatures and theoretical models described
earlier.
IV. RESEARCH METHODOLOGY
This study identified and obtained information on the patient (outpatient) satisfaction with the service
quality dimensions of ten private hospitals in Dhaka city, Bangladesh. For these reasons, this study can be
considered as descriptive research, which is defined as a type of conclusive research which major objective is to
describe existing phenomena (Hussey, 1997).

4.1 Sampling method:

A non-probability judgment sampling plan was implemented in the study. This method was used in this
research because some judgment on the part of the researcher was necessary in order to make sure the “right”
respondents were chosen among the patients in the ten private hospitals in Bangladesh. Help was given to those
patients who had problems in the interpretation of the questionnaire.

4.2 Data collection procedures:

The researcher used a self-administered questionnaire to collect data for the research. Self-administered
questionnaire is the survey in which respondents take responsibility for reading and answering the questions. It
is considered as a superior mode for minimizing bias and improving response rates (Bell, Halliburton and
Preston, 2004). The effects of independent variables on the dependable variable are assessed by the 5-point
Likert attitude scale.
Secondary information were gathered from different secondary sources such as books, magazines,
journals, newspapers and online databases via internet etc. These data are usually available, can be obtained
quickly and inexpensive. Sample survey or cross-sectional survey was the main method to explore attitudes of
patients’ satisfaction with private hospitals in Bangladesh. This is a method of primary data collection in which
information is based on communication with a representative sample of target population at a point in time
(Churchill, 1996). In this research, a total of 400 questionnaires were distributed to the patients visiting ten
different private hospitals, who met the sampling requirements. A total of 393 questionnaires were returned to
the researcher so the response rate is approximately 98.25%. 390 questionnaires were considered valid for data
analysis; three were rejected due to incomplete information. Data collection took nearly 6 weeks from July 5 th to
August 20th, 2012.

V. PRESENTATION OF DATA AND CRITICAL DISCUSSION OF RESULTS

5.1 Level of patient satisfaction with service quality dimensions of private hospitals:
To measure the levels of patient satisfaction with the dimensions of service quality, the
researcher had to calculate the means of all service quality dimensions. From the statistics in Table 5.1.1, the
researcher found that the patients were satisfied most with assurance (strongly satisfied) followed by billing
services (satisfied), reliability (satisfied), process (satisfied) treatment outcome (satisfied), tangibles (satisfied),
cost ( satisfied), access (satisfied), They were neither satisfied nor dissatisfied with communication,
responsiveness and empathy (neutral).

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Table 5.1.1- Descriptive Statistics of patients’ satisfaction with each service quality dimensions
Service dimensions Mean Std. Deviation N

Reliability 4.0615 .46751 390

Responsive 3.0790 .68575 390

Assurance 4.2134 .52434 390

Tangible 3.9998 .48554 390

Communication 3.3136 .67487 390

Empathy 3.0667 .68765 390

Process 4.0209 .62258 390

Cost 3.7667 .65487 390

Access 3.5662 .64738 390

Billing 4.0934 .60562 390

Outcome 4.0113 .61751 390

5.2 Multiple Regression Analysis:
Table 5.2.1- Regression table:
Model Summary

Change Statistics
R Square
Adjusted

Std. Error R
Model

R of the Square F Sig. F

R Square Estimate Change Change df1 df2 Change
1 .844(a) .713 .702 .18552 .713 84.439 11 378 .000

A Predictors: (Constant), outcome, responsive, billing, process, tangible, assurance, access, reliability, cost,
empathy, communication

Table 5.2.1.1 ANOVA (b)

Sum of
Model Squares Df Mean Square F Sig.
1 Regression 31.932 11 2.903 84.439 .000(a)
Residual 13.010 378 .034
Total 44.942 389
A Predictors: (Constant), outcome, responsive, billing, process, tangible, assurance, access, reliability, cost,
empathy, communication

B Dependent Variable: satisfaction

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Table 5.2.1.2: Coefficients (a)

Model Unstandardized Standardized T Sig.
Coefficients Coefficients
B Std. Error Beta
1 (Constant) .714 .152 4.747 .000
Reliability .137 .023 .197 5.963 .000
Responsiveness .088 .023 .176 3.770 .000
Assurance .072 .026 .130 2.803 .005
Tangible .059 .018 .110 3.301 .001
Communication .073 .028 .128 2.650 .008
Empathy .104 .026 .164 3.963 .000
Process .076 .028 .116 2.724 .007
cost .078 .025 .107 3.092 .002
Access .060 .032 .110 1.856 .065
Billing .084 .025 .082 1.727 .086
Outcome .019 .035 .027 .547 .525

a Dependent Variable: satisfaction

Equation:
Y = a + b1X1+ b2X2+ b3X3 + b4X4+ b5X5+ b6X6 +b7X7+ b8X8+ b9X9 +b10X10+ b11X11

Where Y= Patient satisfaction (Dependent variable)

X1 = Reliability (Independent Variable)
X2 = Responsiveness (Independent Variable)
X3 = Assurance (Independent Variable)
X4= Tangibility (Independent Variable)
X5 = Communication (Independent Variable)
X6 = Empathy (Independent Variable)
X7 = Process features (Independent Variable)
X8 = Cost (Independent Variable)
X9 = Access (Independent Variable)
X10 = Billing services (Independent Variable)
X11 = Treatment outcome (Independent Variable)

Y= 0.714 +.137X1+ .088X2+ .072X3 + .059X4+ .073X5+ .104X6 +.076X7+ .078X8+ .060X9 +.084X10+ .019X11

From the table 5.2.1, it can be observed that Patient satisfaction have high positive relationships with
treatment outcome, responsive, billing, process, tangible, assurance, access, reliability, cost, empathy,
communication as R is equal to 0.844 which is close to “1= strong relationship”. Moreover, patient satisfaction
was explained by all Independent variables equal to 71.3% (R2 = 0.713). From the F-test, the Alternative
hypothesis can be accepted, which means that at least one of independent variables (Reliability, Responsiveness,
Assurance, Tangibles, Communication, Empathy, Process features, Cost, Access, Billing service and Treatment
outcome) has influence on Patient satisfaction (F = 84.439, Sig. = 0.000) at 0.05 confidence levels.

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Table 5.3.: Summary of Hypotheses testing

Hypotheses Sig. Result
H1o: Reliability of private hospital service providers has no impact on patients’
satisfaction .000 Reject Ho /
H1a: Reliability of private hospital service providers has an impact on patients’ Accept Ha
satisfaction.

H2o: Responsiveness of private hospital service providers has no impact on

patients’ satisfaction. .000 Reject Ho
H2a: Responsiveness of private hospital service providers has an impact on /
patients’ satisfaction. Accept Ha

H3o: Assurance from private hospital service providers has no impact on

patients’ satisfaction. .005 Reject Ho /
H3a: Assurance from private hospital service providers has an impact patients’ Accept Ha
satisfaction.

H4o: Physical appearance (tangibility) of the private hospital service providers

has no impact on patients’ satisfaction. .001 Reject Ho /
H4a: Physical appearance (tangibility) of the private hospital service providers Accept Ha
has an impact on patients’ satisfaction.

H5o: The quality of communication has no impact on patients’ satisfaction.

H5a: The quality of communication has an impact on patients’ satisfaction .008 Reject Ho /
Accept Ha
H6o: Empathy received from private hospital service providers has no impact
on patients’ satisfaction. .000 Reject Ho /
H6a: Empathy received from private hospital service providers has an impact on Accept Ha
patients’ satisfaction.

H7o: The process features of private hospital service providers have no impact on
patients’ satisfaction. .007 Reject Ho /
H7a: The process features of private hospital service providers have an impact on Accept Ha
patients’ satisfaction.

H8o: The overall cost of private hospital service providers has no impact on
patients’ satisfaction. .002 Reject Ho /
H8a: The overall cost of private hospital service providers has an impact on Accept Ha
patients’ satisfaction.

H9o: The access to private hospital service has no impact on patients’ satisfaction.
H9a: The access to the private hospital service has an impact on patients’ .065 Fail to
satisfaction. reject Ho /
Accept Ho
H10o: The billing services of private hospital service providers have no impact
on patient satisfaction. .086 Fail to
H10a: The billing services of private hospital service providers have an impact reject Ho /
on patient satisfaction Accept Ho

H11o: The treatment outcome of private hospital service providers has no impact
on patient satisfaction. .525 Fail to
H11a: The treatment outcome of private hospital service providers has an reject Ho /
impact on patient satisfaction. Accept Ho

Reliability (p-values equal to 0.000, which is less than 0.05), responsiveness (p-values equal to 0.000,
which is less than 0.05), assurance (p-values equal to 0.005, which is less than 0.05), tangibles (p-values equal
to 0.001, which is less than 0.05), communication (p-values equal to 0.008, which is less than 0.05), empathy (p-
values equal to 0.000, which is less than 0.05), process features (p-values equal to 0.007, which is less than
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0.05), and costs (p-values equal to 0.002, which is less than 0.05) have positive influence on Patient satisfaction.
Whereas, access (p-values equal to 0.065, which is greater than 0.05), billing services (p-values equal to 0.086,
which is greater than 0.05) and treatment outcome (p-values equal to 0.525, which is greater than 0.05) have no
influence on Patients’ satisfaction.

From the beta value of table 5. 2.1.2 (coefficients), it can be observed that, reliability has the greater
impact on patient satisfaction by beta value is equal 0.197; followed by responsiveness at beta value is equal
0.176; empathy at beta value equal 0.164; assurance at beta value equal 0.130; communication at beta value
equal 0.128; process features at beta value equal 0.116; tangible at beta value equal 0.110; cost at beta value
equal at 0.107;

According to impact based on the beta values the dimensions can be ranked as:
1. Reliability, 2. Responsiveness, 3. Empathy, 4. Assurance, 5. Communication, 6. Process features, 7.
Tangibles, 8. Cost.

VI. CONCLUSION
With the growth of private health care facilities, especially in Dhaka city, it is important to assess the
quality of services delivered by these establishments. The research was conducted to identify the key service
quality factors of private hospitals that affect patients’ satisfaction and assess how patients rate the service
quality dimensions of private hospitals. Eight service quality dimensions have positive impacts on patient
satisfaction. It identifies the important service quality dimensions of the private hospitals to better understand
the requirements of the patients to increase their satisfaction. Therefore, the study suggests that the managers of
private hospitals should pay adequate attention to the service quality dimensions which are critical influencer of
patients’ satisfaction, eventually increase overall patient satisfaction with their services. Correct treatment and
delivering promised service are critical issues to increase reliability in health care setting. Researcher found that
the patients were satisfied with most of the service quality factors except communication, responsiveness and
empathy (neutral). The private hospitals must consider this issue with greater importance. Responding promptly
and being able to provide quick diagnoses of diseases, being caring, attentive and understanding are the desires
of patients from service providers. Knowledge, skills, credentials inspire patients’ trust and confidence. If a
patient feels alienated, uninformed or uncertain about his / her health status and outcomes, it may affect the
healing process. When the nature of the treatment is clearly explained, patients’ queries are responded, and it
may alleviate patients’ feelings of uncertainty. Thus the communication between service providers and patients
has to be improved. Along with that the appearance of the physical facilities, modern and advanced equipment,
and cleanliness of the hospitals increase customer satisfaction. Cost is perceived as the least important factor
influencing patients’ satisfaction. That reflects that their priority is excellent service from private hospitals for
which they are ready to pay fair price. Thus the private hospitals have to put emphasis on the above mentioned
important factors to be more competitive in local and regional market.
In Bangladesh, the total health expenditure in the country is about US$ 12 per capita per anum, of which the
private health expenditure is around US$ 8 (WHO, health system in Bangladesh, 2010). As they private health
sector is having a significant support to country’s economy it is critical for the private hospitals to focus on
improving service quality dimensions and thus contribute more to country’s GDP. Health is universally regarded
as an important index of human development. To achieve sustainable improvement in health and human
development private hospitals should be more service focused.
In this study data were gathered from the patients in ten private hospitals in Dhaka city of Bangladesh. The
results may not be generalizable to all the patients in other private hospitals in Bangladesh. Further study may
include more number of hospitals and also may target hospitals located in different cities in Bangladesh and
regional areas.

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