The Importance of Service Quality

Through the past years, the importance of service quality has gained much concern in many fields in Mauritius namely; the hospitality industry, banking, the sales and marketing industry, the construction industry and healthcare. Excellent service quality has been recognized as a medium of competitiveness and supremacy in terms of service. However when we relate service quality to the healthcare sector specially in Mauritius, there are threats involved due to its risky nature. As a result this leads to more complex situation resulting to the measurement of healthcare service quality. Every consumer of private healthcare facilities have their own perception of what the organization shall cater for, foremost to the major objective of many firms; to minimize the gap between the patients perception and expectation thus leading to the satisfied customer. Lynch and Schuler, 1990, stated that quality is an important component of customer’s selection of private hospitals. According to Reichheld and Sasser, 1990, in order to maximize customer satisfaction hospitals need to tend towards zero defection while striving to satisfy all customers. However zero defection requires continuous improvement of service delivery (Lim and Tang, 2000), where the intangibility, variability and inseparability factors have to be assessed (Zeithaml et al., 1990). Research have shown that the public has a greater expectation of quality institutions who are better concerned with customer satisfaction (Boscarino, 1992; Hays, 1987). As per Koeck, 1997 and Pickering, 1991, healthcare service providers in developing countries have started to emphasize on the adoption of quality assurance either all 3 or part of them namely; quality design, quality control and quality improvement.

As information are more and more available to the general public with respect to healthcare service provision, adjoining to the increase in the educated population, this result in greater awareness of service and facility delivered which tends to the need to meet the rise in expectations of the well informed individual (Lim and Tang, 2000) . As a matter of fact, no research has not been done in terms of the healthcare service quality in Mauritius leading to the main objective of the research, to assess the service quality delivered by the private healthcare firms in Mauritius.

1.1 Definitions

For this research a consumer, patient or customer is defined as For the purposes of this research, a manager is defined as a paid employee charged with the responsibility of leading an organization or one of its subunits; the manager may or may not have staff to supervise or budgets to manage. A manager may be a member of senior executive, the chief executive officer, or a vice-president who manages a portfolio of services, a director who oversees services of two or more departments, or a department manager. Those in a fourth category, termed “junior leader”, oversee specific initiatives within a department or service, such as injury prevention, health planning, or infection control but do not supervise staff or manage budgets.

A manager’s information behaviour is defined as:

“how individuals approach and handle information. This includes searching for it, using it, modifying it, sharing it, hoarding it, even ignoring it. Consequently, when we manage information behavior, we’re attempting to improve the overall effectiveness of an organization’s information environment through concerted action” (Davenport and Prusak, 1997).

2. Aims and Objectives of the research

This study attempts to assess the service quality delivered by investigating whether patients’ perceptions exceed their expectation when seeking treatment in the main private healthcare settings in Mauritius by using the SERVQUAL method. The objectives are as follows:

To assess the patients’ perception of the service delivered by the private hospital?

To assess the patients’ expectation of the service delivered by the private hospital?

To measure the level of service quality delivered in private healthcare settings in Mauritius

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2. LITERATURE REVIEW

2.0 Definitions of healthcare

Oxford dictionary defines healthcare as the organized provision of medical care to individuals or a community:

The medical dictionary defines healthcare as: The prevention, treatment, and management of illness and the preservation of mental and physical well-being through the services offered by the medical and allied health professions.

Health service quality is a multi-dimensional.

In 1996, Youseff, F., Nel, D., Bovaird, T. suggest that, healthcare service providers cater for the same type of services, but they do not offer the same quality in terms of services. Health care service quality is a multidimensional theory (Griffith and Alexander , 2002) and those dimensions are closely associated to service quality ( Vandamme and Leunis, 1993).

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2.1 Service quality in the healthcare settings

2.1.1 Service quality

As per Parasuraman, A., Zeithaml, V.A. and Berry, L.L. (1985), service quality can be defined as the dissimilarity between customer expectations and customer perceptions. Expectation is defined as the wants of the customers which they feel the service provider should offer. Service quality rotates around the classification and satisfaction of customer needs and requirements (Cronin and Taylor, 1992; Parasuraman et al., 1988, 1985). Perceptions can be defined as the consumers’ evaluation of the service provider (Lim and Tang, 2000).

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Assessing quality in healthcare service provider has numerous benefits for both the customer and the service provider (Strawderman, 2005). Service quality is reputed as medium for satisfying and retaining customers (Sprens and Olshavasky, 1996). Thus healthcare service providers should emphasize on service quality improvement if they want to have a competitive advantage on the long term.

In 1997, Lam established that patients considered physical facilities of hospitals as the last of their concerns, but capitalized mostly on functional constituents: food, rapidity and precision of the service, noise, room temperature, privacy, cleanliness and parking were parts of interpersonal care. In 2005, Pakdil and Harwood studied the pre-operative service was studied and demonstrated that hospital should provide quick service while limiting waiting time, at the same time making patients more comfortable during their wait, through news papers, t.v. However patients also want to be well treated, served well, have comfortable rooms in addition to polite and sympathetic staff at their service (Angelopoulou, Kangis and Babis ,1998). Similarly many authors namely, Andaleeb (1998), Curry and Sinclair (2002), Otani and Kurz (2004), Pakdil and Harwood (2005) and Ramsaran-Fowdar (2008) have capitalized on the functional aspect of quality of healthcare services while some authors namely, McGorry (1999), Carman (2000), have found that hat technical quality was the most important factor.

2.1.2 The SERVQUAL instrument

In 1985, Parasuraman, A., Zeithaml, V.A. and Berry, L.L. identified have originally identified ten major constituent of service quality relative to the service industry. These were tangibles, reliability, responsiveness, competence, courtesy, credibility, security, access, communication, and understanding the customer. In 1988 Parasuraman et al. developed the SERVQUAL instrument which reputed for the measurement of service quality. The SERVQUAL instrument items consist of the following the five dimensions and are explained below:

(1) Reliability. This dimension denotes the potential to perform the service reliably and accurately.

(2) Responsiveness. This dimension represents the willingness to help customers/guests while providing prompt service.

(3) Tangibles. This dimension refers to the visual factors, i.e. the Physical facilities, equipment, and appearance of employees.

(4) Assurance. This dimension refers to employees’ awareness/knowledge of the service in addition to courtesy and their ability to communicate trust and confidence.

(5) Empathy. This dimension refers to the extent to which the employees care and provide personal/personalised attention to his customers.

The majority of studies done in relation to health care have been based upon the SERVQUAL scale (Suki and Chiam Chwee Lian (2011); Rohini and Mahadevappa 2006; Strawderman (2005); Lim and Tang 2000). Even though there has been many criticism of the SERVQUAL model, service quality literature in healthcare still suggests that SERVQUAL has a good reliability and provides a suitable measurement for perceived service quality (Kilbourne, Duffy, and Giarchi, 2004; Wong, 2002; Lam, 1997; Babakus and Mangold, 1992; Taylor and Cronin, 1994; Reidenbach and Sandifer-Smallwood, 1990) Rohini et al., 2006 used the SERVQUAL framework and applied SERVQUAL factors in their study, they assessed both the perceptions of patients and the hospital management. The study showed that there was a gap between patient’s perceptions and expectations in addition to management’s perception of patients’ expectations and patient’s expectations. Moreover, SERVQUAL was also used as a functional method used to evaluate the gap between patients’ preferences and their actual experience, which identified areas for improvement (Pakdil and Harwood, 2005).

The SERVQUAL instrument has proved to effective in showing the gap between patients’ perception and their actual experience, which resulted in the identification drawback in the system (Pakdil and Harwood, 2005).

2.1.3 Aspects of Healthcare service quality

Healthcare service could be divided into two major aspects, functional and technical quality. These two aspects are vital to the success of the organizations (Grönroos, 1984). Technical quality referring to the extent of technical accuracy in relation to the medical diagnosis and procedures and functional quality referring to the healthcare service delivered to the patients (Donabedian, 1980).

Technical quality refers to the extent of technical accuracy in relation to the medical diagnosis and procedures and functional quality referring to the healthcare service delivered to the patients (Donabedian, 1980) or of the conformity to requirements established by the medical literature (Lam, 1997). In addition technical quality relates to the ability of healthcare staff to perform their tasks effectively including the clinical and operating skills together with their proper knowledge of drug administration and the extent to which laboratory technician are competent and effectual in analysing blood samples (Tomes and Ng, 1995).

Functional quality corresponds to the process through which service is delivered to the patients. In the health care setting, patients usually capitalise on the functional aspects of hospitals which includes the facilities, foods quality of the hospital, cleanliness and staff approach to the patients usually rather than only technical aspects when they evaluate quality of service. Even though technical quality is the main concern of the patients, this however do not enables them to assess the quality of the diagnostic and therapeutic intervention properly due to their lack of knowledge of the procedures and expertise in the matter (Babakus and Boller, 1991; Lanning and O’Connor, 1990). Subsequently, patients evaluation of quality is based upon interpersonal and environmental constituents, which medical bodies regards as less improbable (Lam, 1997). This is justified by the fact that the majority of patients cannot differentiate between technical and functional quality being the curing and caring quality between the “caring” (functional) performance and the “curing” (technical) performance of medical care providers (Ware and Snyder, 1975). Groonroos 1984 demonstrated that patients’ perception of service quality is mainly based upon their experience of the functional quality aspect after receiving a medical treatment. Consequently the medical service encounter impacts on the patients perception of service quality if it meets or exceed their expectation (Lam, 1997).

2.1.4 Dimensions of healthcare service quality

Duggirala, Rajendran and Anantharaman (2008), suggested that healthcare service quality consisted of seven dimensions, namely, access to the Hospital, infrastructure, employees approach and service, procedures, administrative processes, safety signage, overall experience in the healthcare facility and social responsibility. When considering service quality subjective to hospitals, studies have targeted the 2 main stakeholders, the management and the patients. Various studies have analyzed the gaps between the service providers’ perceptions and patients’ perceptions, however the fact that Healthcare services, is readily associated to physiological or psychological discomfort (Duggirala et al., 2008), it is not practical to await a positive critical response from patients in terms of service evaluation.

Strasser, Schweikhart, Welch and Burge (1995) emphasized on the importance of family and friends in respect to studies associated to healthcare, they analyzed the gap between the level of satisfaction of patients to that of family members. The resulting outcome showed that patients were more satisfied with the service than their family members and friends which can be explained with the fact that both of them were not receiving the same service irrespective of their concern with the hospital, where most of the time they have contact for a short span either with the admission of the person to the facility or during visits to the patients. In 1996, Butler, Oswald and Turner assessed the gap between the perception of the patients (during their stay) and their family/friends (during visit time) in terms of service quality. Indeed there was a consequent difference between the perceptions of the two targeted group.

In 1990 Reidenbach and Sandifer-Smallwood analysed patients needs through the analysis of the different perception of service in relation to 3 services of the of the hospital, the Emergency section, the inpatient section and the out-patient section.they conducted a factor analysis and studied service quality on the basis of patients trust of the Hospital services ,its business capability, the quality of the treatment delivered, the support services, physical appearance of the hospital, the waiting time and empathy. Hasin, Seeluangsawat, and Shareef, (2001), demonstrated that responsiveness, courtesy, cost and cleanliness were the major constituent of service quality in hospitals. However even if the hospitals provided good service on the overall the human factor of service was yet to be improved. In 2004 Otani and Kurz conducted their study on hospital services in the USA where they found that the admission process, physician care, nursing care, empathy, appeal of surroundings and discharge process to be the essential dimensions of Service quality. In addition, this is also supported by Ramsaran-Fowdar in 2008 who found that aesthetic of the facilities, staff grooming, doctors’ approach to the patients as well as the timeliness of appointments, together with other factors may prove may be medical care quality indicators.

Patients’ satisfaction

In 1980, Oliver defined satisfaction is the function of the dis-confirmation of performance from expectation. In 1989, Oliver defined satisfaction as the response resulting from an evaluative, and emotional response of the customers’ experience or interpretation of the service . So customers can evaluate the object only after they interpret the object. Studies have demonstrated that the public tend to pay more for care from quality organisations as these are ready to satisfy their customers’ needs (Boscarino, 1992; Hays, 1987). Studies have demonstrated that the public tend to pay more for care from quality organisations as these are ready to satisfy their customers’ needs (Boscarino, 1992; Hays, 1987). Thus, Donabedian (1988) suggests that information about customer satisfaction is very important as this constitute a major aspect of care. Hospitals with better reputations have capitalised on this factor thus leading to an efficient service and increased market share (Boscarino, 1992; Gregory, 1986). Andaleeb (1998) suggests that customer satisfaction is a must factor as present consumers of healthcare services are well aware and informed. Subsequently knowing exactly what they need, healthcare consumers carefully analyse and evaluate various possibilities available. These changes are being driven by the abundance of information that is available to them from public and private sources. The importune of customer satisfaction is a well known concept in the field of management and marketing specially in respect to service consumption (Meirovich and Bahnan, 2008). In 2008, Ammar ,Moore and Wright established that customer satisfaction is valued as a key component as research has shown that that there was a close link between customer satisfaction, customer loyalty and long-term profit maximization (Anderson, 1995) which justifies the fact that firms spend significant resources upon assessing and managing customer satisfaction (John, 1992; Zviran, 1992; Davis, 1999; Hasin, 2001; Lee, 2005). Due to the increase in healthcare competition, customer satisfaction has gained high concern of hospitals managers as as customers are now becoming informed responding to the increase in competition in today’s healthcare industry, which has empowered customers ( Fisk, Brown, Cannizzaro, Naftal,1990, Brown, Cannizzaro, Naftal ,1990; Burns and Beach, 1994; Bigelow and Arndt, 1995; Gustafson and Hundt, 1995; Lee, 2005)

2.2 Customer expectation

In order to determine the service gap, a contrast should be made between the customer expectation and perception service (Oliver, 1996). In contrast to other service fields, patients usually mould their expectation of the physician from friends and family prior to their first visit (Rabin, 2008). Patients base their experience of the service on enjoyment or uneasiness associated with actual experience associated with interpersonal qualities; friendliness of the doctors and attentiveness of the nurses together with their emotional correlation to the medical and non medical staff (Turner and Pol, 1995) rather than based upon set service standards in respect to their experience.

A more relevant theory for explaining patient satisfaction cognition may be Petty and Cacioppo’s (1984) elaboration likelihood model (ELM). Their argument is that attitude change, attributable to message strength, depends on the likelihood that an issue will be elaborated. According to the authors, there are two attitude change routes. If the ability to process a persuasive message is relatively high then it is more likely to be a function of carefully considered arguments (direct route). In contrast, when the ability to process a message is relatively low, individuals conserve cognitive effort by relying on simple inferences using indirect information such as source characteristics, rather than carefully scrutinizing issue-relevant information (Petty and Cacioppo, 1984). In short, ELM suggests that consumers form either positive or negative impressions based on either direct (information) or indirect (cues) signals (Petty and Cacioppo, 1984). In our view, this latter indirect route more accurately describes the way patients select physicians. Because patients are not likely to have direct information about clinic or physician quality, their choices are more likely to be made via peripheral route processing, which underscores indirect cues’ importance when choosing a healthcare provider and thus the need to focus not only on patient satisfaction ratings but also specific reasons underlying their ratings.

Oliver (1980) proposed that satisfaction is a function of the disconfirmation of performance from expectation. Oliver (1989) defined satisfaction as an evaluative, affective, or emotional response. So customers can evaluate the object only after they interpret the object. Hence, satisfaction is the post-purchase evaluation of products or services given the expectations before purchase (Kotler, 1991). Satisfaction is dependent on the ability of the supplier to meet the customer’s norms and expectations and no matter how good the services are, customers will continually expect better services (Dwyeret al., 1987; Fornell, 1992; Oliva et al., 1992). While CS could be related to values and prices, SQ generally does not depend on prices (Anderson et al., 1994). While SQ judgements are quite specific to the service delivered, satisfaction can be determined by a broader set of factors including those which are outside the immediate service delivery experience (e.g. his/her mood is good on that particular day). Perceptions on SQ do not depend on experiences with the service environment or service providers, while judgements for satisfaction depend on past experiences (Oliver, 1993).

Perceptions

A customer’s perception of value and satisfaction begins with an initial purchase and continues throughout the actual ownership and the overall service experience. Regardless of whether the perception is positive or negative, a customer’s thoughts and desires will influence what the company provides as it strives to maintain a healthy relationship with its customers. This relationship can be built on trust, confidence, and customer loyalty towards the company, providing the company continues to meet or exceed the customers’ expectations.

Perceptions refer to the consumers’ evaluation of the service provided. When perceived performance ratings are lower than expectations, this is a sign of poor quality; the reverse indicates good quality (Lim and Tang, 2000). The construct of quality is conceptualized in service literature, measured by SERVQUAL, as perceived quality. Perceived quality is a global judgement, or attitude rating regarding the service. In short, perceived quality involves the subjective response of people and is therefore highly realistic. It is a form of attitude, related but not equivalent to satisfaction, and results from the comparison of expectation with perceptions of performance (Parasuraman et al., 1988).

2.2 Characteristics of services

Service is an intangible which is characterised by the experience derived from the consumption of the service. The service literature capitalise on the differences in the nature of services in opposition to products which is believed to create special challenge for service marketers and for consumers buying services.

2.2.1 Tangibility

Tangibles are important dimensions which has been regularly adopted in various studies on service quality (Grönroos, 1984; Lehtinen and Lehtinen, 1991; Parasuraman et al., 1985). Tangibles refers to many factors, namely: Physical product (appearance of the physical facilities, tools and equipment, personnel appearance) and physical support, the means by which the service is delivered and with other factors used to provide the service and other customers in the outlet (Lehtinen and Lehtinen,1991)..

Intangibility

In 1995, Johnson argued that the intangible facet of customer-employee contact have considerable impact on the service quality both directly and indirectly, where he splits the tangible into 2 major features, the aesthetic of the outlet combined with the cleanliness factors and the comfort being the facilities of the outlet coupled with the atmosphere of the service.In 2000 Bebko established that there was a need for the better comprehension of effects of intangibility on customer expectations of service quality. Regan (1963) introduced the idea of services as being activities, benefits or satisfactions which are offered for sale, or are provided as extras with the sale of goods. Services are activities delivered by the service provider whereby in comparison to products, service can only be experienced; its evaluation is incoherent before the consumption of the actual service. Service marketers cannot rely on the same formula for product based marketing as the consumer generally makes an assessment of the actual product prior to its purchase. So, teaching, Consulting, legal advices, restaurants, fast food centres, hotels and hospitals are considered as services which are not assessed prior to its consumption.

2.2.2 Variability

The variability of services is highly dependent on the service provider in his capacity to maintain continuity in the delivery of his services. Due to the variability aspect of services many marketers face problems while provide consistency of service each and every time they are in operationas coupled with the fact that customers are different and experienced differently, they tend to judge services on different aspects.

2.2.3 Inseparability

Inseparability is said to reflect the spontaneous delivery and consumption of services (Regan 1963) and is believed to enable consumers to affect or shape the performance and quality of service, (Gronroos, 1978; Zeithmal 1981). Services are typically produced and consumed simultaneously. In case of physical goods, they are manufactured into products, distributed through multiple resellers and consumed later. But, in case of services, it cannot be separated from the service provider. Thus, the service provider would become a part of a service. For example: taxi operator drives taxi, and the passenger uses it. The presence of taxi driver is essential to provide the service. The services cannot be produced now for consumption at a later stage/ time. This produces a new dimension to service marketing. The physical presence of consumer is essential in services. For example: to use the services of an airline, hotel, doctor a customer must be physically present. Inseparability of production and consumption increases the importance of the quality in services. Therefore, service marketers not only need to develop task-related, technical competence of service personnel, but also require a great input of skilled personnel to improve their marketing and inter personal skills.

2.2.4 Heterogeneity

Heterogeneity reflects the potential for high variability in service delivery (Zeithmal et al 1985). This is a particular problem for services with a high labour content, as the service performance is delivered by different people and the performance of people can vary from day to day (Zeithmal 1985). Since services are performed by human beings, they have different performances at different times of the day unlike tangible goods are standardized. Hence service offered vary accordingly to performances or change in humour by those providing them. The idea of heterogeneity arises from the assumption that no two customers are alike, hence their demands are unique and the way they will experience the service will differ from another person. So, the service firms should make an effort to deliver high and consistent quality in their service; and this is attained by selecting good and qualified personnel for rendering the service.

2.2.5 Perishability

The fourth characteristic of services highlighted in the literature is perish -ability. In general, services cannot be stored and carried forward to a future time period (Rathmell 1966). In 1987 Onkvisit suggest that services are time dependent and time important which make them very perishable. Services are deeds, performance or act whose consumption take place simultaneously; they tend to perish on the absence of consumption. Hence, services cannot be stored. The services go waste if they are not consumed simultaneously i.e value of service exists at the point when it is required. The perishable character of services adds to the service marketer’s problems. The inability of service sector to regulate supply with the changes in demand; poses many quality management problems. Hence, service quality level deteriorates during peak hours in restaurants, banks, transportation. This is a challenge for a service marketer. Therefore, a marketer should effectively utilize the capacity without deteriorating the quality to meet the demand.

2.3.6 Food quality search importance of food quality in Hospitals

In cases of the hospitality and tourism industry, food quality is an important pre requisite on the assessment of fast food restaurant and as stated by many previous studies. Food quality is closely related to satisfaction within FFRs ( Johns and Howard, 1998; Kivela et al.,1999; Law et al., 2004) Food being a tangible element and in the case of fast food restaurant, whereby it is the main element of concentration by customers, much emphasis have to be laid upon this main aspect. So food quality has been integrated as one dimensions to the assessment of service quality in the fast food industry..

2.3 Service Quality Dimensions

Gronroos (1984) identified two service quality dimensions the technical aspect that is “what” service is provided and functional aspect and “how” the service is provided. The customers perceive what he/she receives as the outcome of the process in which the resources are used that is the technical quality. But he also and more often importantly, perceives how the process itself functions that is the functions quality.

The Six dimensions of service quality measured by the SERVQUAL Instrument

The SERVQUAL Instrument measures the five dimensions of Service Quality. These five dimensions are: tangibility, reliability, responsiveness, assurance and empathy.

2.3.1 Tangibility

Since services are tangible, customers derive their perception of service quality by comparing the tangible associated with these services provided. It is the appearance of the physical facilities, equipment, personnel and communication materials. In this survey, on the questionnaire designed, the customers respond to the questions about the physical layout and the facilities that FFR offers to its customers.

2.3.2 Reliability

It is the ability to perform the promised service dependably and accurately. Reliability means that the company delivers on its promises-promises about delivery, sevice provision, problem resolutions and pricing. Customers want to do business with companies that keep their promises, particularly their promises about the service outcomes and core service attributes. All companies need to be aware of customer expectation of reliability. Firms that do not provide the core service that customers think they are buying fail their customers in the most direct way.

2.3.3 Responsiveness

It is the willingness to help customers and provide prompt service. This dimension emphasizes attentiveness and promptness in dealing with customer’s requests, questions, complaints and problems. Responsiveness is communicated to customers by length of time they have to wait for assistance, answers to questions or attention to problems. Responsiveness also captures the notion of flexibility and ability to customize the service to customer needs.

2.3.4 Assurance

It means to inspire trust and confidence. Assurance is defined as employees’ knowledge of courtesy and the ability of the firm and its employees to inspire trust and confidence. This dimension is likely to be particularly important for the services that the customers perceives as involving high rising and/or about which they feel uncertain about the ability to evaluate. Trust and confidence may be embodied in the person who links t