The Service Quality Of Private Healthcare In Mauritius Marketing Essay

5439 words (22 pages) Essay

1st Jan 1970 Marketing Reference this

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1.0 Introduction

Health care form part of the fastest rising sectors in the service economy (Andaleeb 2001). This is caused by the increase of the aging population, subjected to competitive pressures (Abramowitz, Coté, and Berry 1987), increase in purchase power together with the emergence of new treatments and technologies (O’Connor, Trinh, and Shewchuk 2000). The importance of service quality has gained much concern in many fields in Mauritius during the previous 5 years namely; the hospitality industry, banking, the sales and marketing industry, the construction industry and healthcare namely. Healthcare quality is presently one of the main concern of professional medical bodies and the government as well as the general public. Quality has been recognized as a medium of competitiveness and superiority in terms of service. However when we relate service quality to the healthcare sector there are threats involved due to its risky nature independent of culture. Traditionally healthcare quality was perceived differently by the public and was perceived and as the level of mortality in a hospital. However now the case is not same, the public is well informed together with the increase in the educated population with respect to healthcare service provision. People are more concerned with the manner that the healthcare is delivered rather than on the rate of mortality . Moreover, due to the greater awareness of service and facility delivered through directly or indirect marketing means, the public has gained better comprehensiveness but this, however result in an increase in the expectations of the well informed individual (Lim and Tang, 2000) . Lynch and Schuler, 1990, stated that quality is an important component of customer’s selection of private hospitals. 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. Research have shown that the public has a greater expectation of quality institutions who are better concerned with customer satisfaction (Boscarino, 1992; Hays, 1987). However as at now, no concrete research have not been done in terms of the healthcare service quality in Mauritius which justifies the main objective of the research, to assess the service quality delivered by the private healthcare firms in Mauritius.

1.2Definitions

For this research a consumer, patient or customer will be referred as someone who has ever paid or undergone any treatment whatsoever in a private hospital healthcare facility in Mauritius

1.3 Aims 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:

1.4 Research objectives:

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

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.

2.0 Service quality in the healthcare settings

2.1Service 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 and television respectively. 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)  capitalized on the importance of 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. 2 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, these however do not enable 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 further 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). Grönroos, 1984 established 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. 3 Dimensions of healthcare service quality

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). 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.

2. 4 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 and Lim and Tang 2000 respectively. 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 drawbacks in the system (Pakdil and Harwood, 2005).

2.5 Customer satisfaction

In 1980, Oliver  defined satisfaction as the function of the disconfirmation 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 . In order to determine the service gap, a contrast should be made between the customer expectation and perception service (Oliver, 1996), in other words customers can evaluate the service only after they have consumed it. 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 where 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 customers are empowered are becoming more informed justified by the increase in competition of today’s healthcare industry,(Fisk, Brown, Cannizzaro and Naftal, 1990; Burns and Beach, 1994; Bigelow and Arndt, 1995; Gustafson and Hundt, 1995; Lee, 2005). In turn, customer’s loyalty leads to enhanced brand equity and higher profits (Gilbert et al 2004).

2.6 Customer expectation

Customer expectations is considered as desires or wants of customers about what they expect a service provider to offer them more than they are expecting to offer. Parasuraman et al. (1991) suggested that , if a firm correctly understands a consumers expectations, service is delivered adequately . 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). Consumer expectations are primordial in order to assess the level of service quality. Although there is a general accord about the importance of customer’s expectations in service quality and customer satisfaction, much research need to be done with respect to the process (Coye, 2004). Various research have found different outcomes of expectations and disconfirmation on satisfaction ( Andreessen, 2000; Oliver, 1980). In 1988, Oliver and DeSarbo  provided theoretical support for these effects which suggest that expectations cause an assimilation effect thus narrowing the gap (leading to an assimilation of expectations with perceptions) while inconsistency causes an opposite effect. When patients recognize a gap, the latter try to reduce it. However if the disconfirmation is consequent; the consumer may capitalize on his negative perception resulting to the widening of the gap.

Furthermore, expectations are responsive to the emotional experience of the patient; likely to have positive emotion if his expectations are met especially when those are highly expected satisfaction. Likewise if their perception does not match their expectation this in turn result in strong negative emotions. So a patient’s experience whether pleasing or terrible depends on their expected levels of satisfaction (Vinagre and Neves, 2007). 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. Comprehending the expectations of customer satisfaction is a complex process as patients either do not know what they want or do not convey directly what they want which in turn affects the perception of quality (Lim and Tang, 2000).

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It is known that expectations are not stable in the sense that they may change over time due to changes in aspiration levels or need at a particular moment in time. Customers’ expectations about what constitutes good service vary from one business to another. Expectations are not determined by individuals themselves but also by reference groups, external situations, norms, values, time and service provider. In fact, expectations change over time influenced by both supplier-controlled factors such as advertising, pricing, new technologies and service innovation as well as social trends advocacy by consumer organization and increased access to information through the media and the internet ( Zeithaml et al., 1993).Further studies shows that researchers kept developing and extending the initial conceptual model of expectations, while putting a emphasis on important elements relative to customer expectations. (Zeithaml et al., 1993; Walker and Baker, 2000).

2.7 Customer perceptions

Customer perception is the actual experience of the customer while consuming the service and satisfaction begins from the first encounter with the service and proceeds along the actual consumption of the overall service experience. When the customer perceptions are lower than their expectation expectations, this represents poor quality and likewise the reverse indicates good quality (Lim and Tang, 2000). The service provider always strives to maintain a good relationship with his customers independent of the positive or negative perception of the customer with reference to the service. If the customers need or expectations are met these tend to foster customer loyalty (Gilbert et al 2004).

2.8Customer Loyalty

Ehigie (2006) states that customer loyalty is an important concept in the contemporary competitive market and loyalty is viewed as a strong element on the on the performance of firms (Lam et al., 2004). As Ehigie (2006), suggests, satisfied consumers are more prone to sustain the relationship between the service provider and the satisfied customers. Consequently, the management of organizations needs to develop effective strategies and complaint-handling policies and procedures in order foster customer loyalty. According to previous researches, customer loyalty can uplift the enterprise’s profitability 25 to 80 per cent (Lee et al.,1997). As a result, customer loyalty is direct determinant of relationship marketing as Ehigie (2006) indicates that loyalty is an influential aspect of relationship marketing.

2.8 SERVICE ENCOUNTER

The most immediate evidence of service quality occurs during the service encounter or “moment of truth” (Gronroos, 1990) where the customer and service provider interacted with one another. Memorable incidents that occur during this encounter whether can determine whether a customer leaves satisfied or dissatisfied and ultimately whether he or she returns. Besides, the service encounter involves at least two people, it is important to understand the encounter from multiple perspectives in or to uncover some of the underlying reasons for poor service quality.

2.9 Characteristics of services

2.9.1 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.

2.9.2 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 operation as coupled with the fact that customers are different and experienced differently, they tend to judge services on different aspect ( Zeithmal 1981).

2.9.3 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. (Parasuraman et al., 1985)

2.9.4 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.

2.9.5 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.

3.0 The five 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.

3.1 Tangibility

Tangibles are important dimensions which has been regularly adopted in various studies on service quality (Tomes and Ng (1995),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).

Reliability

Parasuraman et al., 1986 defined reliability as the ability to perform the service dependably and accurately.Reliability further refers to the ability of the services to be delivered as promised and this includes the quality of the personnal in the provision of the service including, doctors, nurses, paramedical and also support staff. In the healthcare field, the personnel are expected to be responsive, reliable, friendly, sincere and competent towards customers. The friendliness and courtesy of the staff may prove to improve the perception of the hospital (Sower, Duffy, Kilbourne, Kohers, Jones, 2001).

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.( Parasuraman et al., 1986)

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 the customer to the company, for example, the marketing department. Thus, employees are aware of the importance to create trust and confidence from the customers to gain competitive advantage and for customers’ loyalty. ( Parasuraman et al., 1986)

2.3.5 Empathy

It means to provide caring individualized attention the firm provide its customers. In some countries, it is essential to provide individual attention to show to the customer that the company does best to satisfy his needs. Empathy is an additional plus that the trust and confidence of the customers and at the same time increase the loyalty. In this competitive world, the customer’s requirements are rising day after day and it is the companies’ duties to their maximum to meet the demands of customers, else customers who do not receive individual attention will search elsewhere. ( Parasuraman et al., 1986)

3.0 Model of Service Quality Gaps

http://www.emeraldinsight.com/content_images/fig/2860150506001.png

Figure 1. Parasuraman et al. 1995 Quality gaps

4.1. The SERVQUAL Model

The SERVQUAL instrument consists of 22 statements for assessing consumer perceptions and expectations regarding the quality of a service. Respondent are asked to rate their level of agreement or disagreement with the given statements on a 7-point Likert scale. Consumers’ perceptions are based on the actual service they receive, while consumers’ expectations are based on past experiences and information received. The statements represent the determinants or dimensions of service quality. Refinement of his work reduced the original service dimensions used by consumers to judge the quality of a service from ten to five.

The five key dimensions (Parasuraman et al. 1991) that were identified are as follows:

1. Assurance – the knowledge and courtesy of employees and their ability to convey trust and confidence.

2. Empathy – the provision of caring, individualized attention to consumers.

3. Reliability – the ability to perform the promised service dependably and accurately.

4. Responsiveness – the willingness to help consumers and to provide prompt service.

5. Tangibles – the appearance of physical facilities, equipment, personnel and communications materials.

One of the purposes of the SERVQUAL instrument is to ascertain the level of service quality based on the five key dimensions and to identify where gaps in service exist and to what extent.

T

1.0 Introduction

Health care form part of the fastest rising sectors in the service economy (Andaleeb 2001). This is caused by the increase of the aging population, subjected to competitive pressures (Abramowitz, Coté, and Berry 1987), increase in purchase power together with the emergence of new treatments and technologies (O’Connor, Trinh, and Shewchuk 2000). The importance of service quality has gained much concern in many fields in Mauritius during the previous 5 years namely; the hospitality industry, banking, the sales and marketing industry, the construction industry and healthcare namely. Healthcare quality is presently one of the main concern of professional medical bodies and the government as well as the general public. Quality has been recognized as a medium of competitiveness and superiority in terms of service. However when we relate service quality to the healthcare sector there are threats involved due to its risky nature independent of culture. Traditionally healthcare quality was perceived differently by the public and was perceived and as the level of mortality in a hospital. However now the case is not same, the public is well informed together with the increase in the educated population with respect to healthcare service provision. People are more concerned with the manner that the healthcare is delivered rather than on the rate of mortality . Moreover, due to the greater awareness of service and facility delivered through directly or indirect marketing means, the public has gained better comprehensiveness but this, however result in an increase in the expectations of the well informed individual (Lim and Tang, 2000) . Lynch and Schuler, 1990, stated that quality is an important component of customer’s selection of private hospitals. 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. Research have shown that the public has a greater expectation of quality institutions who are better concerned with customer satisfaction (Boscarino, 1992; Hays, 1987). However as at now, no concrete research have not been done in terms of the healthcare service quality in Mauritius which justifies the main objective of the research, to assess the service quality delivered by the private healthcare firms in Mauritius.

1.2Definitions

For this research a consumer, patient or customer will be referred as someone who has ever paid or undergone any treatment whatsoever in a private hospital healthcare facility in Mauritius

1.3 Aims 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:

1.4 Research objectives:

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

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.

2.0 Service quality in the healthcare settings

2.1Service 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).

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 and television respectively. 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)  capitalized on the importance of 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. 2 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, these however do not enable 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 further 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). Grönroos, 1984 established 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. 3 Dimensions of healthcare service quality

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). 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.

2. 4 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 and Lim and Tang 2000 respectively. 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 drawbacks in the system (Pakdil and Harwood, 2005).

2.5 Customer satisfaction

In 1980, Oliver  defined satisfaction as the function of the disconfirmation 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 . In order to determine the service gap, a contrast should be made between the customer expectation and perception service (Oliver, 1996), in other words customers can evaluate the service only after they have consumed it. 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 where 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 customers are empowered are becoming more informed justified by the increase in competition of today’s healthcare industry,(Fisk, Brown, Cannizzaro and Naftal, 1990; Burns and Beach, 1994; Bigelow and Arndt, 1995; Gustafson and Hundt, 1995; Lee, 2005). In turn, customer’s loyalty leads to enhanced brand equity and higher profits (Gilbert et al 2004).

2.6 Customer expectation

Customer expectations is considered as desires or wants of customers about what they expect a service provider to offer them more than they are expecting to offer. Parasuraman et al. (1991) suggested that , if a firm correctly understands a consumers expectations, service is delivered adequately . 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). Consumer expectations are primordial in order to assess the level of service quality. Although there is a general accord about the importance of customer’s expectations in service quality and customer satisfaction, much research need to be done with respect to the process (Coye, 2004). Various research have found different outcomes of expectations and disconfirmation on satisfaction ( Andreessen, 2000; Oliver, 1980). In 1988, Oliver and DeSarbo  provided theoretical support for these effects which suggest that expectations cause an assimilation effect thus narrowing the gap (leading to an assimilation of expectations with perceptions) while inconsistency causes an opposite effect. When patients recognize a gap, the latter try to reduce it. However if the disconfirmation is consequent; the consumer may capitalize on his negative perception resulting to the widening of the gap.

Furthermore, expectations are responsive to the emotional experience of the patient; likely to have positive emotion if his expectations are met especially when those are highly expected satisfaction. Likewise if their perception does not match their expectation this in turn result in strong negative emotions. So a patient’s experience whether pleasing or terrible depends on their expected levels of satisfaction (Vinagre and Neves, 2007). 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. Comprehending the expectations of customer satisfaction is a complex process as patients either do not know what they want or do not convey directly what they want which in turn affects the perception of quality (Lim and Tang, 2000).

It is known that expectations are not stable in the sense that they may change over time due to changes in aspiration levels or need at a particular moment in time. Customers’ expectations about what constitutes good service vary from one business to another. Expectations are not determined by individuals themselves but also by reference groups, external situations, norms, values, time and service provider. In fact, expectations change over time influenced by both supplier-controlled factors such as advertising, pricing, new technologies and service innovation as well as social trends advocacy by consumer organization and increased access to information through the media and the internet ( Zeithaml et al., 1993).Further studies shows that researchers kept developing and extending the initial conceptual model of expectations, while putting a emphasis on important elements relative to customer expectations. (Zeithaml et al., 1993; Walker and Baker, 2000).

2.7 Customer perceptions

Customer perception is the actual experience of the customer while consuming the service and satisfaction begins from the first encounter with the service and proceeds along the actual consumption of the overall service experience. When the customer perceptions are lower than their expectation expectations, this represents poor quality and likewise the reverse indicates good quality (Lim and Tang, 2000). The service provider always strives to maintain a good relationship with his customers independent of the positive or negative perception of the customer with reference to the service. If the customers need or expectations are met these tend to foster customer loyalty (Gilbert et al 2004).

2.8Customer Loyalty

Ehigie (2006) states that customer loyalty is an important concept in the contemporary competitive market and loyalty is viewed as a strong element on the on the performance of firms (Lam et al., 2004). As Ehigie (2006), suggests, satisfied consumers are more prone to sustain the relationship between the service provider and the satisfied customers. Consequently, the management of organizations needs to develop effective strategies and complaint-handling policies and procedures in order foster customer loyalty. According to previous researches, customer loyalty can uplift the enterprise’s profitability 25 to 80 per cent (Lee et al.,1997). As a result, customer loyalty is direct determinant of relationship marketing as Ehigie (2006) indicates that loyalty is an influential aspect of relationship marketing.

2.8 SERVICE ENCOUNTER

The most immediate evidence of service quality occurs during the service encounter or “moment of truth” (Gronroos, 1990) where the customer and service provider interacted with one another. Memorable incidents that occur during this encounter whether can determine whether a customer leaves satisfied or dissatisfied and ultimately whether he or she returns. Besides, the service encounter involves at least two people, it is important to understand the encounter from multiple perspectives in or to uncover some of the underlying reasons for poor service quality.

2.9 Characteristics of services

2.9.1 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.

2.9.2 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 operation as coupled with the fact that customers are different and experienced differently, they tend to judge services on different aspect ( Zeithmal 1981).

2.9.3 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. (Parasuraman et al., 1985)

2.9.4 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.

2.9.5 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.

3.0 The five 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.

3.1 Tangibility

Tangibles are important dimensions which has been regularly adopted in various studies on service quality (Tomes and Ng (1995),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).

Reliability

Parasuraman et al., 1986 defined reliability as the ability to perform the service dependably and accurately.Reliability further refers to the ability of the services to be delivered as promised and this includes the quality of the personnal in the provision of the service including, doctors, nurses, paramedical and also support staff. In the healthcare field, the personnel are expected to be responsive, reliable, friendly, sincere and competent towards customers. The friendliness and courtesy of the staff may prove to improve the perception of the hospital (Sower, Duffy, Kilbourne, Kohers, Jones, 2001).

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.( Parasuraman et al., 1986)

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 the customer to the company, for example, the marketing department. Thus, employees are aware of the importance to create trust and confidence from the customers to gain competitive advantage and for customers’ loyalty. ( Parasuraman et al., 1986)

2.3.5 Empathy

It means to provide caring individualized attention the firm provide its customers. In some countries, it is essential to provide individual attention to show to the customer that the company does best to satisfy his needs. Empathy is an additional plus that the trust and confidence of the customers and at the same time increase the loyalty. In this competitive world, the customer’s requirements are rising day after day and it is the companies’ duties to their maximum to meet the demands of customers, else customers who do not receive individual attention will search elsewhere. ( Parasuraman et al., 1986)

3.0 Model of Service Quality Gaps

http://www.emeraldinsight.com/content_images/fig/2860150506001.png

Figure 1. Parasuraman et al. 1995 Quality gaps

4.1. The SERVQUAL Model

The SERVQUAL instrument consists of 22 statements for assessing consumer perceptions and expectations regarding the quality of a service. Respondent are asked to rate their level of agreement or disagreement with the given statements on a 7-point Likert scale. Consumers’ perceptions are based on the actual service they receive, while consumers’ expectations are based on past experiences and information received. The statements represent the determinants or dimensions of service quality. Refinement of his work reduced the original service dimensions used by consumers to judge the quality of a service from ten to five.

The five key dimensions (Parasuraman et al. 1991) that were identified are as follows:

1. Assurance – the knowledge and courtesy of employees and their ability to convey trust and confidence.

2. Empathy – the provision of caring, individualized attention to consumers.

3. Reliability – the ability to perform the promised service dependably and accurately.

4. Responsiveness – the willingness to help consumers and to provide prompt service.

5. Tangibles – the appearance of physical facilities, equipment, personnel and communications materials.

One of the purposes of the SERVQUAL instrument is to ascertain the level of service quality based on the five key dimensions and to identify where gaps in service exist and to what extent.

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