Linking Service Quality, Patients' Satisfaction and Behavioral ...

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ScienceDirect Procedia - Social and Behavioral Sciences 224 (2016) 141 – 148

6th International Research Symposium in Service Management, IRSSM-6 2015, 11-15 August 2015, UiTM Sarawak, Kuching, Malaysia

Linking Service Quality, Patients’ Satisfaction and Behavioral Intentions: An investigation on Private Healthcare in Malaysia Nor Khasimah Alimana,*, Wan Normila Mohamadb a,b

Faculty of Business Management, Universiti Teknologi MARA, Perak, Malaysia

Abstract The purpose of this paper is to examine the association between perceived service quality, patients’ satisfaction and behavioral intentions in the private health care industry in M alaysia, a developing country. Hospital outpatients were selected as respondents for this study using the convenience sampling technique. Survey questionnaires were distributed to 300 hospital outpatients who had received health care treatment at the private hospitals in 2010 and 2011. Two hundred and seventy -three (273) completed data was analyzed using descriptive and inferential statistics. M ultiple regressions were employed to test th e hypotheses. The results indicated that service quality dimensions positively affected the intention behaviors. All service factors had positive relationships with patients’ satisfaction. However, only three dimensions of service quality (tangibles, assuran ce and empathy) showed significant relationships with intention. In addition, tangibles, reliability and assurance had significant relationship with satisfaction. Assurance dimension was considered very important in influencing both satisfaction and behavioral intentions of the patients. Satisfaction had strong positive effects on intention behavior. In short, both service quality dimensions and patients’ satisfaction were positively related to behavioral intentions. Thus, strong managerial orientations should be introduced in the private hospitals in order to deliver a high quality service, to increase patient satisfaction, and consequently encourage intentions to revisit and recommend to others. © Published by by Elsevier Ltd.Ltd. This is an open access article under the CC BY-NC-ND license © 2016 2016The TheAuthors. Authors. Published Elsevier (http://creativecommons.org/licenses/by-nc-nd/4.0/). Peer-reviewunder underresponsibility responsibility of Universiti TeknologiMARA M ARA Sarawak. Peer-review of the Universiti Teknologi Sarawak Keywords: service quality; satisfaction; behavioral intentions; private hospitals

* Corresponding author. Tel.: +6-019-566-8808; fax: +6-053-743-610. E-mail address: [email protected]

1877-0428 © 2016 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Peer-review under responsibility of the Universiti Teknologi MARA Sarawak doi:10.1016/j.sbspro.2016.05.419

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Nor Khasimah Aliman and Wan Normila Mohamad / Procedia - Social and Behavioral Sciences 224 (2016) 141 – 148

1. Introducti on The role of service quality is widely recognized as being a critical determinant for the success and survival of any organization in today’s competitive environ ment. Although there are many factors affect ing the attitude and intention of the consumer, it is widely recognized that perception of service quality is the most important among them. According to Nelson et al. (2004), patients’ perceptions of quality have been shown to account for 17 -27 per cent of the variation in a hospital’s financial measures such as earnings, net revenue, and return on assets. Yong (2000) found that the revenue from private hospitals contributed close to 50 percent of the health-care industry’s total earnings. As such, the importance of service management and service quality in the health care industry is also expected to increase in future. Naturally, any decline in customer satisfaction due to poor service quality would be a matter of concern. Thus, with a rising and aging population, the government of Malaysia s trives to improve many areas in the health care industry. Sohail (2003) indicated that Malaysian health-care providers seem to be doing a co mmendable job in achieving customer satisfaction with regards to service quality. His study proves that hospitals in Malaysia provide services that often exceed the expectations of most patients, imply ing that Malaysians have positive perceptions of the service quality. In many countries, research on health care quality and patient satisfaction has gained increasing attention in recent years (Abdul Majeed et al., 2011; Navid et al., 2010; Owusu -Frimpong et al., 2010; Halil et al., 2010; Badri et al., 2009; Elleuch, 2008). Likewise, a few studies have investigated this issue in the Malaysian context (Norazah et al., 2011; Navid et al., 2010; Ah mad A zmi et al., 2008; Rose et al., 2004; Sohail, 2003). Ho wever, none of them have investigated service quality, patient satisfaction and intention behaviors of patients in Malaysian private hospitals. Since service quality, satisfaction and behavioral intentions are considered very important in market ing, this study attempts to fill the gap by examin ing the relationship between the three concepts among private hospital outpatients from each state in the country. 2. Previous research Wilson et al. (2008) noted that understanding customers’ views on service quality is critical for any service provider interested in ensuring that they are being responsive to clients. Further, Musalem and Joshi (2009) indicated that any business entity interested in being co mpetitive in a market place must be responsive to its customers. 2.1. Service quality, patient satisfaction and behavioral intentions Service quality determinants can be divided into two main categories : the tangible and intangible factors. Tangible factors refer to technology, physical facilities, personnel, commun ication materials and others. Intangible factors, on the other hand, consist of four sub-sectors which comprise reliability, responsiveness, assurance and empathy (Parasuraman et al., 1985; Halil et al., 2010). Behavior intentions are defined as “patients’ potential behaviors likely to be trig gered by service quality and satisfaction” (Zeithaml et al., 1996). Most researchers agree that behavioral intentions constitute three dimensions : worth of mouth (WOM ) co mmun ications, patronage intentions and complaining behavior. The favorable behavioral intentions include elements such as saying positive things and recommending the services to others, paying the premium price to the company, and expressing cognitive loyalty to the organization. Customer satisfaction has been defined in a variety of ways. Oliver (1997, p. 13) defined satisfaction as “the consumer’s fulfillment response”: it is a judgment that a product or service feature, or the product or service itself, provides a pleasurable level of consumption-related fulfillment. Customer satisfaction is about nurturing and meet ing customer preferences and expectation in order to enhance customer delivered value (Owusu-Frimpong et al., 2010). Patient satisfaction with medical care is a multid imensional concept, with dimension s that correspond to the major characteristics of providers such as technical, functional, infrastructure, interaction, at mosphere and also


services (Zineldine, 2006; Elleuch, 2008). Patient satisfaction positively influences the patient’s trust (Moliner, 2008; Alrubaiee & Alkaa’ida, 2011) and enhances hospital image, which in turn translates into increased service use and market share (Andaleeb, 1998; 2001; Tho mas, 1994). To gain a co mpetit ive advantage, service firms which include hospitals should focus on achieving customer satisfaction and loyalty by delivering superior value (Woodruff, 1997). Satisfied customers are likely to exh ibit favorable behavioral intentions, which are beneficial to the healthcare provider’s long term success. 2.2. Relationship between predictor and criterion variables Fishbein and Ajzen (1975) and Ajzen and Fishbein (1980) suggested that behavioral intentions, when properly measured, could lead to a large degree pred ict actual behavior. Zeithaml et al. (1996) proposed that perceived service quality was related to positive behavioral intentions, which could be v iewed as signals of retention or defection. The effects of service quality on behavioral intentions take on different forms: d irect effect, indirect effect through satisfaction, or moderating effect by satisfaction (Boshoff & Gray, 2004; Olorunniwo et al., 2006). For the direct effect, many studies in different industries have shown that service quality is an antecedent to behavioral intentions (Parasuraman et al., 1985, 1988; Zeithaml et al., 199 6; Boshoff & Gray, 2004). Overall service quality perception was positively related to willingness to recommend and negatively related to switching and complaining behavior. In health care settings, much ev idence also show that the direct impact exists (Wu et al., 2008). A few researchers have explored the potential predictors of satisfaction such as product/service quality ( Lee et al., 2000) and service hospitality experiences design (Pullman & Gross, 2004). It is generally believed that higher levels of service quality lead to higher levels o f customer satisfaction (Oliver, 1997; Taner & Antony, 2006; Pollack, 2008). A nu mber of studies in the health care setting found a causal lin kage between service quality and satisfaction, and concluded that service quality was an antecedent to satisfaction (Woodside et al., 1989; Bo wers et al., 1994; Wilson et al., 2008; Mpinganjira, 2011). Research in the United Arab Emirates (UAE) revealed that perceived health care quality had a positive in fluence on patient satisfaction (Badri et al., 2009). Elluech (2008) indicated that quality attributes depicted by service process were antecedents to overall satisfaction among the Japanese. Research by Navid et al. (2010) among international patients who received treatment in p rivate hospitals in Penang, Malaysia, revealed that except for the tangible d imension, the other four service quality dimensions had significant positive relat ionships with customer satisfaction. On the other hand, Halil et al. (2010), through an investigation in Turkish hospitals, indicated that tangibility, reliability, courtesy and empathy were important criteria for customer satisfaction whereas responsiveness and assurance factors were not identified as important predictors of satisfaction. In Japan, outpatient satisfaction was unaffected by physical appearance/tangibles attribute but patient satisfaction was affected by process characteristics – service speed, quality of interaction with staff and the setting’s appearance (Elluech, 2008). In Johannesbu rg, South Africa, Mp inganjira (2011) indicated that there were positive relationships between perceived service quality at each of the d imensional levels and patients’ overall satisfaction with a med ical practice. Her study concluded that empathy dimension had the highest predictive power, followed by assurance, tangibles, responsiveness and reliability. Research in A mman, Jordon by Alrubaiee and Alkaa’ida (2011) indicated that all five dimensions of healthcare quality were significant in explaining patient satisfaction. Researchers insist on the importance of satisfaction as a key predictor of patients’ intentional behaviors. Bendall-Lyon and Powers (2004) revealed that health care consumers often assess their satisfaction in terms of structure and process that influence satisfaction, which in turn influences behavioral intentions. In Japan, Elluech (2008) concluded that overall, satisfaction positively influenced behavioral intentions. Naidu (2009) found that healthcare quality affects patient satisfaction, which then influences positive patient behavior such as loyalty.

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3. Methodol ogy The SERVQUAL scale is a widely accepted tool for measuring service quality (Sohail, 2003; Ladhari, 2008). Based on Parasuraman, et al. (1988), five dimensions of service quality were t reated as predictor variables in this study. The quality dimensions, satisfaction and intentions were measured using the 7-point Likert scale. Perception of service quality was measured using 22 item statements as proposed by Parasuraman et al. (1985, 1988). Patients’ satisfaction was measured using 7 item statements adapted fro m Oliver (1980), Taylor and Baker (1994), and Wu et al. (2008) which cover both relative and overall satisfaction. The multi-dimensional model of the behavioral intentions proposed by Zeithaml et al. (1996) was used to measure behavioral intentions. Based on the literature discussion, the following hypotheses were tested: H1: Service quality perception positively affects behavioral intentions. H1 (a): Tangibility dimension is positively related to behavioral intentions. H1 (b): Responsiveness dimension is positively related to behavioral intentions. H1 (c): Reliability dimension is positively related to behavioral intentions. H1 (d): Empathy dimension is positively related to behavioral intentions. H1 (e): Assurance dimension is positively related to behavioral intentions. H2: Service quality perception is an antecedent of patients’ satisfaction. H2 (a): Tangibility dimension is positively related to patients’ satisfaction. H2 (b): Responsiveness dimension is positively related to patient s’ satisfaction. H2 (c): Reliability dimension is positively related to patients’ satisfaction. H2 (d): Empathy dimension is positively related to patients’ satisfaction. H2 (e): Assurance dimension is positively related to patients’ satisfaction. H3: Patients’ satisfaction positively affects behavioral intentions. Using structured survey questionnaires, data was collected fro m a targeted sample of 300 private hospital outpatients all over Malaysia. Plentiful research in private healthcare service quality elicited between 200-500 respondents (Alrubaiee & A lkaa’ida, 2011 – 290 usable questionnaires; Badri et al., 2009 – 244 usable questionnaires; Ahmad Azmi & Norzalita, 2008 – 210 usable questionnaires; Lim & Tang, 2000 – 252 usable questionnaires). This samp le size followed the one proposed by Roscoe (1975), wh o states that “sample sizes larger than 30 and less than 500 are appropriate for most research” (Sekaran & Bougie, 2013: p. 269). Co mpleted data were analyzed using both descriptive and inferential statistics. 4. Data analysis and presentation of findings 4.1. Respondents’ profiles Out of the 273 respondents, 148 (54.2%) were females and 125 (45.8%) were males. About 70% of them were Malay and Bu miputra, and the remaining were Ch inese and Indian. The majority (70%) of the respondents were aged between 21 to 49 years old. One hundred and thirty -three (48%) respondents earned monthly incomes of between RM2000 to RM 4999 while 74 (27.1%) of them earned RM 5000 and above. More than 70% were married and working. 4.2. Reliability analysis The alpha values were calculated to assess the internal consistency reliab ilities of the scales (see Table 1). These values are more than 0.70 and indicate that the items used to measure the constructs are reliable and satisfactory (Nunnally & Bernstein, 1994; Sekaran & Bougie, 2013).

Nor Khasimah Aliman and Wan Normila Mohamad / Procedia - Social and Behavioral Sciences 224 (2016) 141 – 148 T able 1. Descriptive and reliability analysis results. Variable s T angibles Reliability Responsiveness Assurance Empathy O verall Service Quality Behavioral Intentions Patient Satisfaction

No. of Ite ms 4 4 5 4 5 22 6 7

Me an 5.85 5.60 5.46 5.56 5.52

SD 0.77 0.89 0.94 0.91 0.96

5.63 5.65

1.01 7.02

Coe fficie nt Alpha (α) 0.81 0.86 0.89 0.89 0.91 0.96 0.96 0.96

4.3. Regression analysis Table 2 links the service quality with behavioral intentions. The results of regression analyses show that quality dimensions contribute significantly (F=46.6, F-sig=0.00) and predict 47% of the variation in behavioral intentions. The relationship between service quality and behavioral intentions is significant, positive and considered strong (R=0.69). Thus, H1 is supported. T able 2. Regression analysis of service quality dimensions with behavioral intentions. B Constant 1. T angibles 2. Reliability 3. Responsiveness 4. Assurance 5. Empathy

4.31 0.23 0.02 0.06 0.55 0.26

β 0.12 0.01 0.05 0.35 0.22

t-value 2.14 1.93 0.19 0.60 3.68 2.49

R

R2

0.69

0.47

Sig. 0.03 0.05 0.85 0.55 0.00 0.01

F-value

F-sig.

46.6

0.00

Note: Significant at the 0.05 level

Out of the five dimensions of service quality, tangibility, assurance, and empathy are positively significant and account for a significant change in the behavioral intentions. Assurance (B=0.55; t=3.68; p =0.00) prevails as the most important predictor, fo llowed by empathy (B=0.26; t=2.49; p=0.01) and tangibility (B=0.23; t=1.93; p=0.05). The results lend support to H1 (a), H1 (d) and H1 (e). Table 3 links the service quality with patients’ satisfaction. The results of regression analyses show that quality dimensions contribute significantly (F=79.53, F-sig =0.00) and predict 60% o f the variat ion in patients’ satisfaction. The relat ionship between service quality and satisfaction proves to be significant, positive and considered strong (R=0.77). Thus, H2 is supported. T able 3. Regression analysis of service quality dimensions with satisfaction. B Constant 1.T angibles 2.Reliability 3.Responsiveness 4.Assurance 5.Empathy

1.58 0.25 0.44 0.09 0.67 0.18

β

t-value

Sig.

R

R2

F-value

F-sig.

0.46 0.04 0.00 0.44 0.00 0.11

0.77

0.60

79.53

0.00

0.11 0.23 0.06 0.35 0.12

0.74 2.01 3.35 0.77 4.30 1.60


Out of the five d imensions of service quality, tangibility, reliability and assurance are positively significant and account for a significant change in patients’ satisfaction. Assurance (B=0.67; t=4.30; p=0.00) emerges as the most important predictor, followed by reliab ility (B=0.44; t=3.35; p=0.0) and tangibility (B= 0.25; t=2.01; p=0.04). These findings suggest that H2 (a), H2 (c) and H2 (e) are supported.

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T able 4. Regression analysis of satisfaction with behavioral intentions.

Constant Satisfaction

B 7.86 0.59

β 0.72

t-value 5.70 17.07

Sig. 0.00 0.00

R 0.72

R2 0.52

F-value 291.24

F-sig. 0.00


Table 4 links the patients’ satisfaction and behavioral intentions. The results of regression analyses show that satisfaction contributes significantly (F = 291.24, F-sig = 0.00) and predicts 52% of variat ion in behavioral intentions. The relationship between satisfaction and intentions is significant, positive and considered strong (R=0.72). Thus, H3 is supported. 4. Discussions and recommendati ons The present study demonstrates that service quality dimensions affect both satisfaction and behavioral intentions. Consistent with other research findings, the service quality-satisfaction relationship (R=0.72) was found to be stronger compared to the service quality-behavioral intentions relationship (R=0.69). Ho wever, only three dimensions of service quality predicted behavioral intentions and satisfaction significantly. Tangibility, reliab ility and assurance are the most powerful predictors of customer satisfaction. On the other hand, tangibility, empathy, and assurance dimensions appear as the most powerful predictors of behavioral intentions. Assurance dimension proves to be the most important predictor for both intentions and satisfaction. The physical service aspects such as the appearance of employees, equipment and facilities are classified as tangibles. Tangible dimension affects both satisfaction and intentions. The effect of tangibles on satisfaction (B=0.25, t=2.01) is stronger compared to the effect of tangibles on behavioral intentions (B=0.23, t=1.93). As such, the service providers should initiate strong measures to ensure that the hospital is equipped with modern physical facilit ies and materials that are visually appealing to both inpatients and outpatients. In addition, the hospital management must consistently ensure that their staff appear neat and presentable during their wo rk hours. Fro m time to t ime, the hospital should continue to invest in equipment, physical facilit ies and materials to ensure that those tangible factors are sufficient in terms of quantity. Assurance refers to employees' knowledge and courtesy, and their ability to inspire trust and confidence. In this study, the effect of assurance on satisfaction (B=0.67, t=4.30) was found to be stronger compared to the effect of assurance on behavioral intentions (B=0.55, t=3.68). Managers could use this strategy to attract and sustain customers for a lifelong relationship. The management can train the employees to help their customers by improving skills through continuous training and facilitation o f organ izat ional learn ing. Improving the communicat ion skills of front-line employees, nurses, and complaints handling officers is important since these emp loyees interact with the customers. When employees are well equipped with skills to serve customers satisfactorily in an environment that promotes excellence, reliable services will inevitably follow. There are several suggestions relating to building the empathy dimension, namely individualizing attention given to the needs of customers and providing convenient services. This may require access to detailed information about target markets, their varying needs and expectations, and putting oneself in the position of the customers (empathizing) to understand how one can best help them. Such an effort often requires market research informat ion, and probably going an ext ra mile for the sake o f the customer, but the outcome is worth the effort, as it will give managers reliab le in formation to design customized services, and add value to the mundane mass produced healthcare services. Reliab ility refers to accurate, dependable and consistent performance of the service (service outcome). Reliab ility is considered as the second most important dimension in determining satisfaction. Patients definitely expect the hospital to deliver services at the time it is pro mised. In addition, patients also expect the hospital staff to be capable of handling patients and to be co mpetent enough to provide accurate services. Therefore , all staff should manage their time properly and be able to provide excellent service to customers. On the other hand, responsiveness is the willingness to help customers and provide pro mpt service. Responsiveness has no significant


influence on behavioral intentions and satisfaction. It might happen because all hospitals have an emergency unit and all emergency cases are given top priority for treatment. 5. Conclusion In conclusion, the current research suggests that the ability of perceived service quality to predict behavioral intentions cannot be underestimated. Perceived service quality d imensions such as tangibles, assurance, and empathy are strong predictors of behavioral intentions. Responsiveness and reliability have no in fluence on behavioral intentions ; however, tangibles, reliability and assurance strongly predict patient satisfaction. The strengths of the relationship between satisfaction and behavioral intentions are stronger co mpared to the service quality-intentions relationship. 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