Hyde Margaret - Understanding Dimensionality in Health Care

8/12/2019 Hyde Margaret - Understanding Dimensionality in Health Care

1/32

Understanding quality of care

1

Margaret Hyde

UNDERSTANDING DIMENSIONALITY IN HEALTH CARE

Abstract

In recent years, the quality of non-clinical elements of health care has beenchallenged in the UK. While elements such as communications, empathy,

environment etc. all contribute hugely to care of patients, they often fall short of what

they should be. This paper considers how these are currently evaluated

operationally before a review of extant literature on dimensionality in services

generally. It goes on to describe the methodology behind the exploratory phase of a

larger project to generate a greater understanding of the dimensionality of health

care with the ultimate aim of devising an evaluation model designed specifically for

the health sector.

Key words: quality, health, service, SERVQUAL, dimensionality

1. Aim and Objectives

Aim

To understand the dimensionality of quality in health services

Objectives

I. Review existing means of evaluating the quality of non-clinical elements of

care in health services

II. Critique the SERVQUAL model with particular reference to health services

III. Identify what dimensions are important to service users.

2. Introduction

The service sector is an important part of the UK economy with a workforce of

25.76m out of a total UK workforce of 31.26m. Of this the public sector represents

21% of the overall UK workforce (Office for National Statistics, 2011). Economically,

the NHS alone accounts for a budget of 114bn (Department of Health, 2010).

With one million people accessing health services every 36 hours (Triggle, 2012),

health services is a major contributor to both social and economic influences, yet

despite ongoing debate, service quality in this sector remains an enigmatic elementand has attracted little academic progression in its measurement since the

development of SERVQUAL 25 years ago.


2/32


2

Margaret Hyde

3. Review of the Evaluation of Health Care

Health care organisations are facing pressures from a variety of directions, one of

which is the introduction of competition in the sector. This new phenomenon is

pushing hospitals and community services to take a hard look at the quality of the

services they offer as they face increasing demands to meet or exceed patient

expectations (Dougall et al., 1999). This is a difficult aspiration, especially in an

environment where some elements of patient dissatisfaction may be out of their

control (Vukmir, 2006), such as the needs of different demographic groups, the

involvement of partner agencies, government intervention, etc.

The quality of health care remains a problem (Gummesson, 2001) and in the UK,

where the National Health Service (NHS) has an almost monopolistic place in the

sector, the challenges it faces are many and varied and have been categorised as:

(O'Connor et al., 1988)

i. Service elusiveness the nature of health care often means that the patient

does not know what to expect; it is difficult for them to assimilate what the service

means (Berry et al., 1988).

ii. Employee diversity health care is dependent on a huge diversity of

employees with different skills and personalities who have to work together (Bellou,

2007). Each plays a crucial role contributing to the patients perception of quality.

iii. Interrelatedness patients require education to help them to understand the

service and thus help them in their evaluation (O'Connor et al., 1988).

The complexities of delivering health care means that its evaluation is challenging

with a lack of resources, resistance by staff to data collection and inexperience andpoor training for managers and staff (Eiriz & Figueiredo, 2005). Often those who are

delegated the responsibility of managing quality are given the role as an add on to

their main job (Desombre & Eccles, 1998).

While numerous attempts are made to measure quality in health care, they are

often complex in nature, are usually national and based on political issues such as

targets rather than elements of care based on qualitative work with patients

(Goodrich & Cornwell, 2008). The NHS has been said to be awash with data but

short on information (Dr. Foster, 2009). It measures performance rather than

quality.

Of the plethora of measures used to monitor health care, the four key ones are

through Dr. Foster, Care Quality Commission (CQC), National Patient Survey and

Quality and Outcomes Framework (QOF). None of these have strong local

ownership or are designed with local priorities in mind.


3/32


3

Margaret Hyde

2.1 Dr Foster

Dr Foster is an independent organisation which provides comparative records for

every hospital in the country, on-line tools for the public to complete and records

data in consumer guides allowing prospective patients to make informed decisions

on which hospital they wish to attend. Data is used to benchmark trusts against

national trends in quality, safety and efficiency.

An on-line tool allows the public to prioritise six pre-selected elements that areimportant to them by use of a Likert scale.

Cleanliness

Comfort

Right information, participation in decisions, confident and in control

Timely and well co-ordinated care

Respect and honesty

Treated with compassion

2.2. Care Quality Commission

This Commission monitors care offered by all health care providers to ensure they

meet government standards of quality and safety.

The Care Quality Commission (CQC) offers integrated regulation for health and

social care in England. Its aim is to ensure better care for everyone in hospital, in a

care home and at home. (Care Quality Commission, 2011a).

All NHS trusts are required to register with the CQC, which in turn monitors their

performance through annual self completion assessments, visits, surveys, MPs, local

authorities, LINks (Local Involvement Networks), Patient Advice Liaison Services(PALS), comments from the public etc. The Commission has the power to remove

registration from any trust failing to comply with essential standards. Nevertheless

there have been concerns that the organisation is toothless after reports of poor care

following visits.

Trusts are measured against a number of essential standards which they state are

based on the type of care provided rather than systems and processes.

Patients can expect to be involved and told what is happening at every stageof their care

Patients can expect care, treatment and support which meets their needs Patients can expect to be safe

Patients can expect to be cared for by qualified staff

Patients can expect their hospital to constantly check the quality of itsservices

(Care Quality Commission, 2011b).


4/32


4

Margaret Hyde

The dimensions are limited in some aspects of overall patient experience,particularly around empathy and the complexities of communications.

2.3. Patient surveys on behalf of the Department of Health (DoH)

Patient surveys are underpinned by research to determine priorities that the public

place on service elements. Since 1997 hospitals in the UK have been required tocarry out a survey annually. The CQC determines the core questions which fall into

seven categories: admission to hospital; hospital and ward; staff; care and

treatment; operations and procedures; leaving hospital and overall. These can be

augmented at local level though this opportunity is treated with caution since the

core questionnaire is unduly long. Unfortunately, more recently there has been a

tendency to incorporate questions of a political essence such as waiting times,

cleanliness and mixed sex wards going against the spirit of the original framework

(Goodrich & Cornwell, 2008).

The survey is annual through which longitudinal trends can be extracted at each

trust. One of the major challenges of the survey is that a patient merely registersdissatisfaction with an element rather than being able to explain what they were

unhappy about (Coulter et al., 2009; Goodrich & Cornwell, 2008; Richards & Coulter,

2007).

Vigilance is also recommended since studies have indicated that even where a

patient has perceived their care as excellent they have often experienced a number

of problems (Goodrich & Cornwell, 2008). This may be because of the inherent

trust that patients have in the medical profession (Richards & Coulter, 2007) and do

not feel in a position to be critical.

2.4. Quality Outcomes Framework.

This process assesses general practice on behalf of the Department of Health. It is

carried out by panels of clinicians and lay people who visit each general practice on

an annual basis. It provides the basis for an incentive programme through scoring

management of common chronic diseases; practice organisation, how patients view

their experience and extra services offered. The QOF accounts for up to 20% of the

income of participating practices.

The process has been criticized for removing the autonomy of general practitioners;

micromanagement by the state; ignoring elements patients value such as trust and

results in coercing patients to accept specific treatments (Mangin & Toop, 2007).


5/32


5

Margaret Hyde

4. Critique of SERVQUAL

Until the development of SERVQUAL in 1985 by Parasuraman et al. the

measurement of service quality traditionally came from theory around the marketing

of goods. The SERVQUAL model employs the theoretical framework of expectation

versus satisfaction and measures five gaps:

Management perceptions of customer expectation and actual customer

expectation

1. Management perceptions of customer expectations and company stated

service specification

2. Company stated service specification and service delivery

3. Company stated service specification and the external communication of this

4. Customer expectation and customer experience. This gap is influenced by

gaps 1-4

(Parasuraman et al., 1985)

It comprises first a set of 22 questions which asks the respondent the extent to which

the firm delivering the service should possess each feature followed by a similar

series of 22 questions, this time asking the extent to which the respondent feels the

firm possesses each item. It does not, however, ask respondents to place the

priority they would place on each item. With almost 200 questions to answer, the

process is lengthy and potentially unwieldy. The first model comprised 10 factors

(Table 1) In either model, with almost 200 questions to answer, the process was

lengthy and potentially unwieldy.


6/32


6

Margaret Hyde

Table 1 SERVQUAL Determinants of service quality(Ten dimensions)DIMENSION DEFINITION

Reliability Consistency of performance and dependability. It means that the firm performsthe service right for the first time. It also means that the firm honours its promises.Specifically, it involves:

- Accuracy in billing;- Keeping records correctly

- Performing the service at the designated time.Responsiveness Willingness or readiness of employees to provide service. It involves timeliness

of service:- Mailing a transaction slip immediately;- Calling the customer back quickly;- Giving prompt service (e.g. setting up appointments quickly).

Competence Possession of the required skills and knowledge to perform the service. Itinvolves:

- Knowledge and skill of the contact personnel;- Knowledge and skill of operational support personnel;- Research capability of the organisation, e.g. securities brokerage firm.

Access Approachability and ease of contact. It means:- The service is easily accessible by telephone (lines are not busy and

they dont put you on hold);

- Waiting time to receive service (e.g. at a bank) is not excessive;- Convenience hours of operation;- Convenient location of service facility.

Courtesy Politeness, respect, consideration and friendliness of contact personnel (includingreceptionists, telephone operators etc.). It includes:

- Consideration or the consumers property (e.g. no muddy shoes on thecarpet)

- Clean and neat appearance of public contact personnel.

Communication Keeping customers informed in language they can understand and listening tothem. It may mean that the company has to adjust its language for differentconsumers increasing the level of sophistication with a well-educated customerand speaking simply and plainly with a novice. It involves:

- Explaining the service itself;- Explaining how much the service will cost;

- Explaining the trade-offs between service and costly;- Assuring the consumer that a problem will be handled.

Credibility Trustworthiness, believability, honesty. It involves having the customers bestinterests at heart. Contributing the credibility are:

- Company name;- Company reputation;- Personal characteristics of the contact personnel;- The degree of hard sell involved in interactions with the customer.

Security Freedom from danger, risk or doubt. It involves:- Physical safety (Will I get mugged at the automatic teller machine?);- Financial security (Does the company know where my documents are?);- Confidentiality. (Are my dealings with the company private?

Understanding/Knowing the

customer

Making the effort to understand the customers needs. It involves:- Learning the customers specific requirements;

- Providing individualised attention;- Recognising the regular customer.

Tangibles Physical evidence of the service:- Physical facilities;- Appearance of personnel;- Tools or equipment used to provide the service;- Physical representations of the service - plastic credit card or a bank

statement;- Other customers in the service facility.

(Parasuraman et al., 1985)


7/32


7

Margaret Hyde

A later piece of work refined these to five dimensions (Table 2). This was based on

a study of 200 respondents, each of whom had used one of the five sectors included

in the research appliance repair/maintenance, retail banking, long-distance

telephone, securities brokerage and credit cards.

Table 2 SERVQUAL Determinants of service quality (five dimensions)

DIMENSION DEFINITION DIMENSION DEFINITION

Tangibles: up-to-date equipmentphysical facilitiesvisually appealing

staff well dressed and

neat polite

appearance of facilitiesin keeping with theservice

Assurance: customers can truststaff

customers feel safe

polite staff

staff get support fromfirm

Reliability: staff should be

sympathetic if customerexperiences problems

when firm promisessomething by a certaintime it is achieved

dependability

provide service at timethey promise

records kept accurately

Empathy: staff know what

needs of customerare

staff have customersbest interests at heart

staff give personalattention

staff give individualattention

convenient openinghours

Responsiveness: provide prompt service

tell customers when toexpect service

willing to help customers

staff not too busy toprovide prompt service

4.1. Challenging the Model

SERVQUAL is widely accepted as having made an enormous contribution to theory

around the measurement of service quality with claims that service quality has

become SERVQUAL. (Woodall, 2001, pg 596). It has, nevertheless, received

considerable critical analysis over the years. A review of extent literature raises a

number of concerns as described in Table 3. Omitted from these are a number of

potential methodological flaws.

4.1.1. Sectors Used - The authors state the firms they used represented both high

and low contact services; a debatable claim since high contact services are those

where transactions involve consumers and staff in complex interactions as

contextualised by the theory of co-creation (Vargo & Lusch, 2004). None of those

selected acknowledge the true complexities of professional services such as health


8/32


8

Margaret Hyde

care where human elements such as courtesy, empathy or the communication skills

which are so important, especially where services are tailored to individual needs.

4.1.2 Sample - the sample of participants used in the work was limited. Fourteen

senior executives were interviewed across the four sectors. No front of house staff

were included. This risks losing rich and valuable data gleaned from their working

relationships with consumers. The later work to refine the model in 1988 targeted

just 200 respondents across the sectors collectively. For such a seminal piece of

work, this was a modest sample

4.1.3. Dimensions Dimensionality is a pragmatic way of measuring service quality

but a question lies in the nature of the dimensions. The influence of SERVQUAL is

diminished since sector specific dimensions were omitted from the research, only

general dimensions being deemed relevant (Parasuraman et al., 1985). While this

ensures a more flexible model across services, it misses some key components

relevant to specific sector contexts where items are not transferable from one sector

to another.

4.1.4. Validity of Expectations - Fundamental to the model is the gap between

expectations and perceptions, a concept which has attracted debate over its validity

(Robinson, 1999; Buttle, 1996; Cronin & Taylor, 1994; Babakus & Boller, 1992).

Problems arise around what people base their expectations on, when they form them

or whether these can be carried across sectors. Expectations can change with

familiarity (Rosen et al., 2003) which will alter perceived level of quality and affect

the validity of the disconfirmation model on which SERVQUAL is based. Experience

is also polysemic with a variety of meanings and using the concept alone is too

simplistic.

An alternative model is SERVPERF (Cronin & Taylor, 1994) which, while based on

the same 22 attributes as SERVQUAL,questions the concept of comparing

experience with expectation (Cronin & Taylor, 1994). The model is more

parsimonious, removing expectation and relying on data around performance only.

This pragmatic advantage over SERVQUAL cannot be ignored since only one

questionnaire is required (Jain & Gupta, 2004).


9/32


9

Margaret Hyde

Table 3 Validity of SERVQUAL

AUTHORS LIMITATIONS

(Ladhari, 2009) SERVQUAL limitations: scoring, reliability, validity, emphasis on process rather thanoutcome, hierarchical service quality constructs, reflective scales, use of generic scalefor all sectors, applicability for online use and culturally. It can be useful if adapted forspecific industry use and it is validated through reliability and validity analysis.

(Rhee & Rha,2009)

SERVQUAL does not explore the validity of its constructs in the public sector whereservice issues are more complex and there is a greater diversity of stakeholders.

(Carrillat et al.,2007)

SERVQUAL and SERVPERF are of equal validity for diagnostic purposes, althoughSERVQUAL required more adaptation for different sectors. The choice between thetwo should be based on if the tool is to be used for diagnostic uses andoperationalisation taking into consideration the length of the SERQUAL model.

(Jain & Gupta,2004)

SERVPERF is simpler to use and explains variations in overall quality service,SERVQUAL is better diagnostically. SERVPERF is preferable for assessing overallservice quality; SERVQUAL is superior in identifying quality shortfalls.

(Kilbourne etal., 2004)

The use of SERVQUAL in care homes across the USA identified limitations in theoriginal version Some items were irrelevant. They conclude that SERVQUAL isconvenient and reliable in measuring quality across countries, but more work is

needed in cross national reliability in healthcare.(G.S.Sureshchandaret al., 2002b)

SERVQUAL model overlooks key factors of service quality: the core service,systemization/standardization of service delivery (non-human) and social responsibilityof the provider

(Winsted,2000)

SERVQUAL doesnt ask what consumers want service providers to do; constructs arepredetermined; service literature is still confused about the meanings of some ofSERVQUAL constructs; it is not as effective as service specific models

(Robinson,1999)

While SERVQUAL has been the preferred method of measuring service quality sincethe 1980s, too many questions arise concerning its efficacy for it to retain its primeposition. Concerns include: generalisability across sectors; the measurement ofcustomer satisfaction rather than service quality; the wording of questions, therelevance of measuring expectation.

SERVQUAL has a major impact on business. But there are limitations around validity

of constructs; doubts consumers assess quality as perception v expectations (hey donot consider expectations); dimensions are not universal; moments of truth can varyfrom event to event; use of two questionnaires causes confusion.

(Buttle, 1996) There is little evidence of the validity of customers evaluating service quality based onexpectation versus performance. Concern is also raised about the global use of thedimensions across sectors.

(Cronin &Taylor, 1994)

Published SERVPERF model as an alternative to SERVQUAL. Saw the SERVQUALmodel as too subjective relying on the transitory element of customer satisfactionrather than long term service quality.

(McAlexanderet al., 1994)

SERVPERF is superior as predictive tool and looks at weighting performance items.They question the inclusion of SERVQUALS expectations in health care whereexpectations are high across all dimensions; they also consider it the more useful as adiagnostic tool for managers.

(Carman,

1990)

The dimensions of SERVQUAL cannot be applied cross industry.


10/32


10

Margaret Hyde

5. Dimensionality

Understanding dimensionality underpins everything else in evaluating service quality.

This section explores the dimensions identified by literature and their relation to

functional and technical elements of service. It also reflects on the importance of

relationships in the process.

Table 4 Service quality dimensions an overview

AUTHORS ELEMENTS

(Wright et al., 2011) Service Interpersonal

(Rhee & Rha, 2009) Process quality,Outcome quality

Design qualityRelationship quality

(Sanchez-Hernandez et al., 2009) Functional efficiencyRelational - empathy

Tangibles

(Howden & Pressey, 2008) Know-how (technicalexpertise)Trust

Personal interaction

Service fulfillmentLocationDirect/indirect costs

(Dagger et al., 2007) Interpersonal quality interaction, relationshipTechnical quality outcome, expertiseEnvironmental quality atmosphere, tangibles

Administrative quality timeliness, operation,support

(Kang, 2006) Process Outcome

(G.S. Sureshchandar et al., 2002a) Core service/serviceproductHuman elementSystematisation ofservice delivery: non-human element

Tangibles of service servicescapesSocial responsibility

(Brady & Cronin, 2001) OutcomeInteraction

Environment

(Daley, 2001) Technical(processes, procedures)

Service(interpersonal)

(Mels et al., 1997) Intrinsic -reliabilityresponsivenessassuranceempathy

Extrinsic -tangiblestechnical

(Rust & Oliver, 1994) Customer-employeeinteraction(function or processquality)

Service environmentOutcome (technicalquality

(Lehtinen, 1991) Interactive quality

Corporate quality

Physical quality

(Gronroos, 1990) Technical Functional

(Parasuraman et al., 1988) ReliabilityResponsivenessAssurance

TangiblesEmpathy

(Parasuraman et al., 1985) ResponsivenessReliabilityCompetenceAccessCourtesy

CommunicationCredibilitySecurityUnderstandingTangibles


11/32


11

Margaret Hyde

5.2. Defining Dimensions

Theorists have come up with numerous variations of these core dimensions, (Table

4) and while similarities do exist, there is no overall consensus about them, or

whether they can be generalised across sectors (Brady & Cronin, 2001). Some

have attempted to categorise dimensions into the Nordic approach, technical and

functional, or the US school of thought as in SERVQUAL, but this is an

oversimplification where neither fully define the service quality construct (Brady &

Cronin, 2001). Dimensions often comprise a number of items, each of which may

influence more than one dimension. While these offer a more detailed and well

defined construct, they do not overcome the complexities of use across sectors.

While authors present a variety of sets of dimensions they see as relevant (Table 5),

there is some consensus that the technical and functional dimensions come together

to contribute to the overall experience in health care (Dagger et al., 2007; Zineldin,

2006; Lytle & Mokwa, 1992). These have been described as care and cure (Conway

& Huffcutt, 2003) where care is conceptualised as the functional elements such asthe environment, interactions, comfort etc and are deemed as contributing to the

overall concept of service quality (McAlexander et al., 1994). Being at ease with an

employee can reduce anxiety as well as make the customer feel respected (Lloyd,

2009; Macintosh, 2009). This is particularly relevant in the case of health care where

dignity and respect are high on the agenda and often quoted in official guidelines

and regulations. Where comfort or intimacy exists, it is more likely that the customer

will provide the necessary information to help the provider deliver the most

appropriate service (Lloyd, 2009) especially in health care where patients are

anxious and may feel uneasy in confiding everything or fail to identify important

snippets of information.

Dimensionality in health care is difficult to contextualise as it is such a complex

service. It can be delivered from a range of environments including hospitals, clinics,

and surgeries and even from the home. It includes every citizen since everyone is a

potential patient and it covers a huge range of services and professionals.

WHO use the word responsiveness to express a patients experience of health care

in its widest context, defining this as including: dignity, autonomy, confidentiality,

information, prompt attention, access to social support, quality of amenities and

choice (Gostin et al., 2003).

Key to health care are respect and dignity, each of which features surprisingly

infrequently in extent academic models. Together, these allow patients to feel in

control, valued, confident, comfortable and able to make decisions for themselves

(Scrivener, 2011). These omissions need addressing to reflect the priority most UK

Government papers referring to health care place on them. Nor is privacy mentioned

which is a basic human right and is an antecedent of dignity (Tabak & Ozon, 2004).


12/32


12

Margaret Hyde

5.2. Relationships rapport, respect and trust

The nature of services makes the proposition of value and quality especially

unpredictable. There are many opportunities for something to go wrong when the

service provider and the customer interact, when both parties experience and

respond to each others mannerisms, attitude, competence, mood, dress, language,

and so forth. (Berry et al., 1988 p.38). Service is based on the interaction between

two parties to create value and the importance of them, especially in professional

and high contact services is clear (Lehtinen, 1991; G.S. Sureshchandar et al.,

2002), since interactions help build professional relationships which should ultimately

lead to trust. Drawing on literature suggests a basic hierarchy of constructs (Fig 1)

although these will vary according to the nature of the service.

Fig 1 Hierarchy of Constructs

Compiled by the author

5.2.1. Respect and Rapport

Of the five dimensions central to SERVQUAL, four of these are based on the human

element of service: responsiveness, reliability, assurance and empathy of which

responsiveness and reliability have been seen to be especially crucial (Rhee & Rha,

2009; Angelopoulou et al., 1998; Berry et al., 1988; Parasuraman et al., 1988).

Missing from the model, however, are rapport and respect which, although may be

implicit within assurance or empathy (polite staff and understanding/knowing theclient), they should be first order constructs in their own right (Macintosh, 2009) and

explicit as dimensions.

Respect is giving attention to a person and valuing them, understanding the

individual, responsibility, an interest in humanity and acceptance of differences in

people beyond tolerance (Abbott, 1991). Rapport goes much further than polite

staff and understanding or knowing the client as defined by SERVQUAL. It has been

Trust

Relationships

Interactions/Human elements

Ra ort res ect reliabilit res onsiveness assurance em ath


13/32


13

Margaret Hyde

deconstructed to include mutual self-disclosure (shared information and open

communications); extras (responses to simple requests for customisation or

exemplary behaviours) civility/courtesy (Macintosh, 2009) and interaction (Gremler &

Gwinner, 2000). It creates a bond and cohesiveness which in turn generates trust

and can help consumers relax (Macintosh, 2009).

To ignore the significance of either respect or rapport leaves the organisation

vulnerable to poor relationships with the customer/client, potentially breaking down

levels of trust.

5.2.2. Credence and Trust

Trust is a construct that should be inherent in all professional services but is one that

does not appear as a dimension in its own right in much of the literature. This may

be because it is assumed that the customer has a right to be able to trust the

integrity, knowledge, experience, skills and expertise of the professional providing

the service. Confidence in expertise, dependability of staff and familiarity are each

antecedents to trust (Macintosh, 2009). The fact that rofessionals are bound by

regulations set by governing bodies such as the UK Law Society, General Medical

Council, and Royal Colleges helps in building confidence for customers/clients.

Perhaps more than any other sector, health care is one sector that is highly

specialised and personal demanding immense trust leading to an assumption that

this construct should be reflected in dimensionality. Quality in health care has been

conceptualised as the provision of appropriate and technically sound care that

produces the anticipated effect. (McAlexander et al., 1994 p.34). The clinical

procedures and outcomes are the shared aims of the patient and physician and are

seen as an implicit rather than explicit element of services which patients feel theyare not qualified to evaluate (Rashid & Jusoff, 2009; Conway & Huffcutt, 2003).

They, therefore, depend on being able to have a trust in the expertise of the

professional. They seek other prompts such as the soft elements, which although

subjective are easier to assess. Much literature has been based on these peripheral

(functional) items (Lytle & Mokwa, 1992), but debate continues around how they are

defined (table 5) and their subjectivity compared with technical processes and

outcomes which are reported through performance indicators and used for

accountability, regulation and accreditation (Rubin et al., 2001).


14/32


14

Margaret Hyde

Table 5 Dimensions in health care

Author Dimensions

(Angelopoulou et al., 1998) Physicians mannerQuality of information sourcesPhysicians professional/technical competenceInterpersonal relations/skills

(Pajinkihar, 2008) AutonomyInformationCommunications

EmpathyRespectDignity

(Dagger et al., 2007) TechnicalInterpersonal

Amenities

(Gostin et al., 2003) Responsiveness:Dignity, autonomy, confidentiality, information,prompt attention, access to social support,quality of amenities, choice

(Jabnoun & Chaker, 2003) TangiblesAccessibilityUnderstandingCourtesyReliability

SecurityCredibilityResponsivenessCommunicationCompetence

(Hasin et al., 2001) CommunicationResponsivenessCourtesy

CostCleanliness

(Murray et al., 2001) Respect for People:Dignity, autonomy, confidentiality, information

Client OrientationPrompt attention, provision of basic amenities,social support networks, choice

(Walters & Jones, 2001) SecurityPerformanceAesthetics

ConvenienceEconomyReliability

(Zineldin, 2000) Object (Technical)Processes (Functional)Infrastructure

InteractionAtmosphere

(Camilleri & O'Callaghan, 1998) Technical careService personalisationPriceEnvironment

Patient amenitiesAccessibilityCatering

(Andaleeb, 1995) CommunicationCostFacility

CompetenceDemeanour

(Tomes & Ng, 1995) EmpathyUnderstanding illnessMutual respectDignity

FoodPhysical environmentReligious needs

(Lytle & Mokwa, 1992) Core BenefitCondition/treatment/outcome

IntangiblesReliability, empathy, assurance, responsiveness

TangibleAppearance of personnel, decor of facilities,location of facilities, appearance of facilities

(Smith et al., 1986) Expressive aspects the art of careInstrumental aspects quality of care, efficacy oftreatment, continuity of careAccess /cost aspects e.g. cost and convenience


15/32


15

Margaret Hyde

6. Methodology

The research uses multiple methods to exploit the advantages of both qualitative and

quantitative techniques (Johnson & Onwuegbuzie, 2007). It is the approach

favoured by pragmatists where all that matters is whether a strategy works

satisfactorily. There is no distinction between theory and practice. This

epistemology is gaining increasing amounts of attention in social sciences which is

becoming more complex and dynamic with an increasing need for a more pluralistic

approach. It uses the most appropriate means to understand the question and solve

the problem and is ideally suited to the health care sector where structures,

processes and patterns are complex (Lowe et al., 2005).

Qualitative techniques were used to generate in-depth data about the meaning of

quality to both service users and providers. This data was then be used as the basis

of a questionnaire distributed across a wide demographic sample.

6.1. Qualitative Process

6.1.1. Interviews

A literature review was followed by a series of interviews to understand how quality

is currently measured and what issues staff believe are important to patients/carers.

These were carried out with representatives from stakeholders, managers and

clinicians including:

the chair of large teaching hospital trust

director of facilities of a large teaching hospital trust

the regional director of the Care Quality Commission

a local MP

a local authority representative

medical director of a district general hospital

matron of a hospice

accident and emergency receptionist

a senior nurse with responsibility for cancer patients

a director of nursing

a physiotherapist

Each interview was semi-structured and lasted approximately one hour in length.

The aim was to understand what priorities organisations place on service quality

elements and to understand measures taken to evaluate these qualities

6.1.2. Focus groups

A series of eight focus groups comprising patients, carers and general members of

the public was held. These included groups comprising people with multiple needs,

young mothers, elderly, a user group at a local surgery and general members of the


16/32


16

Margaret Hyde

public and represented a wide age range from early 20s upwards. Members were

selected from personal contacts and recommendations from organisations

comprising the health economy in Greater Manchester. The objective was to

discuss participants own ideas about the priorities they would apply to elements of

quality (Cohen & Mallon, 2001).

6.1.3. Analysis

The interviews and group discussions were digitally recorded and later transcribed.

Copies were sent to the interviewees and to at least one member of each focus

group to ensure that they were an accurate reflection of what had taken place. In the

case of the groups which comprised participants with multiple and complex needs

and the elderly, escorts who were present were asked to check for reliability on

behalf of the group members. The transcripts were then coded via open coding and

against SERVQUAL to draw out themes and items which were then used in the

design of a questionnaire. This was an iterative process as the complexity of data

required revisits in order to ensure reliability and effectiveness in the coding. Thiswas especially the case when transcribing groups comprising participants who had

complex needs and for whom communication was difficult.

An earlier career in the NHS equipped the researcher with experience in

communicating with staff at all levels and in dealing with sensitive issues among a

wide cross-section patients and carers.

6.2. Quantitative Process

6.2.1. Distribution of Questionnaires

A self-administered questionnaire was designed comprising seven themes with atotal of 104 items derived from the qualitative data. Respondents were asked to rate

the importance they placed on each item on a seven point Likert scale ranging from

not so important to very important.

The questionnaire was designed with the support of two senior academics and then

piloted twice among personal contacts.

As health care is relevant to everyone it was important the sample for distribution

comprised a wide demographic. Anyone over the age of 18 was deemed relevant.

This age was chosen as a cut off as approaching anyone under 18 would create

ethical issues.

Distribution was via a number of channels:

Snowballing techniques through personal contacts

Convenience sampling using personal contacts of the researcher

A database 950 from the voluntary sector based in the north east of

Manchester


17/32


17

Margaret Hyde

A national database of 5,500 taken from mail order customers and

representing all socio-economic groups and demographics

More than 1,100 responses were received.

6.2.2. Analysis

At the time of writing analysis of the quantitative work had not been completed.

SPSS will be used to complete a factor analysis and produce regression tables. The

data will ultimately confirm or falsify dimensions currently used in the evaluation of

service quality in health care and will lead to the development of an instrument which

can be adapted for use in clinics, local doctors surgeries or hospitals.

7. Results

The results discussed here are interim since only data from the qualitative work are

available.

The dimension that featured most prominently was aligned with SERVQUALs

empathy. When deconstructed into items to reflect comments made by participants,

the open coding suggested the factor was far more complex than suggested by

either SERVQUALs original model of ten elements, or the later model of five. The

open coding broke the dimension down into five distinct items: attitude, reception,

empathy, respect and privacy. The last two of these reflect the importance literature

places on each as dimensions important to professional services. Neither is made

distinct in the SERVQUAL model.

Assurance also received high scores and was easier to assimilate with both

SERVQUAL versions, although the inclusion of polite staff and staff getting supportin the refined model of five dimensions did not fit with the open coding which focused

mainly on trust and safety.

The most apparent omission within either SERVQUAL model was communications.

This appeared as a factor in its own right within open coding, featuring third in

priority. It proved to be a complex factor breaking down into 15 individual items.

See Appendix 2.

Access to services was yet another factor which didnt easily fit within the refined

SERVQUAL model where it was represented as simply convenient hours are in

place within the empathy factor, although it did appear independently in the originalmodel. Yet again, open coding revealed it to be a dimension high on respondents

agendas and one which comprised several individual items (appendix 2).

There was some synergy with tangibles, although health care raises an extra item

with the provision of food. Responsiveness and reliability were also aligned fairly

closely with SERVQUAL.


18/32


18

Margaret Hyde

Table 6 compares the dimensionality of each model. Appendix 2 sets out the

breakdown of each dimension into items.

Table 6 SERVQUAL vs OPEN CODING

SERVQUAL 10 SERVQUAL 5 Open Coding

Tangibles Tangibles EnvironmentFood

Reliability Reliability Ease of access and reliability ofservicesAccess

Responsiveness Responsiveness Responding to needs

Understanding the customer Empathy Caring approach

Courtesy

Security Assurance Having trust in my care

Competence

Credibility

Communications Communications/involvement inmy own care

These interim results suggest a degree of synergy between the original SERVQUAL

model with 10 dimensions. They do not, however, reflect the complexity of each

with reference to health care.

8. Limitations

It is likely that everyone has contact with health services at some part of their lives

which means that it is not viable to reach every potential user group. Some groups

were over represented, while others lacked representation. In the qualitative work,

focus groups were, in the main, from north east Manchester and despite the high

levels of black and minority ethnic (BME) groups in the area, these were not

included, largely due to potential language difficulties and access problems where

community members are less likely to participate in mainstream projects.

Surprisingly few were included in the national database or the local voluntary sector

for the quantitative work.

9. Ethics

The nature of the work was very sensitive where a number of respondents were

reflecting on the circumstances of serious illness, or even death. Ethical approval

was obtained from the National Research Ethics Committee North West for generic

coverage across all sites. Focus group participants were asked to sign a form

setting out the purpose of the study and where it is likely to be published. A similar

explanation was included with the questionnaire the completion of which signified

permission for inclusion in the study. All data has been treated confidentially and in

the case of the qualitative work, anonymously.


19/32


19

Margaret Hyde

10. Contribution to Knowledge

There has been little work done in developing new concepts for the measurement of

service quality since the development of SERVQUAL 25 years ago. Evidence

supports the view that the model is not ideal for general cross-sector usage and a

gap exists, particularly in the provision of a service specific framework bespoke to

health care. This is an area of immense topical relevance of which every member of

the population is a stakeholder. The aim of the study is to overcome this anomaly by

contextualising service quality in a health care setting, thus adding to the theoretical

debate. It marries local strategic decision making with contemporary Government

policy which clearly sets out a direction where patients are central to service delivery,

focus is placed on quality and competition is likely to become a feature. The aim of

the project is to tackle the miscellany of methods currently used in the sector by

developing a fresh diagnostic framework to evaluate quality and tailored to local

needs. In achieving this, it will help health care providers to identify failings and set

strategy in accordance with Government policy aspirations to improve patient

experience and in so doing establish themselves as a place of patient choice.

11. Conclusion

The evaluation of quality in health care is extremely complex and over recent years,

has become high on the Government agenda in the UK. Despite this, there remain

concerns about the overall issue of quality in this sector. While there is an

abundance of work carried out nationally, much of it is performance which, although

important, leaves room for more priority to be placed on the human elements of

quality.

As the most widely used operational model, SERVQUAL claims to be suitable forcross sector application, although further investigation suggests otherwise. It omits

some key dimensions and items which contribute towards overall patient experience

within health care, especially around professional relationships and communications

both of which are multifaceted with a number of second level items. It also ignores

basic constructs such as privacy, dignity and respect, each of which can be seen as

human rights (Gostin et al., 2003).

While recognising the effectiveness of using dimensionality in evaluating health care,

findings from the qualitative part of this project support the need for service specific

models to reflect the unique needs of the health care sector.

12. Future Research

More extensive research over if or how dimensions vary according to different user

groups would create an opportunity to develop evaluation instruments for individual

specialities. The principles of this research can also be extended to other sectors in

order to create sector specific tools for service evaluation.


20/32


20

Margaret Hyde

There are also openings for further research into the relevance of customer service

versus service quality in a sector where patients (especially older ones) often

experience services in the long term giving them more experience allowing them to

judge long term quality more effectively rather than transactional and short term

customer service.

BIBLIOGRAPHY

Dr. Foster Unit. Imperial College. [Online] [Accessed on 23rd November 2012]

www1.imperial.ac.uk/.../pcph/research/drfosters

Abbott, A. (1991) 'The order of professionalization: an empirical analysis.' Work and Occupation,

18(355-384)

Andaleeb, S. S. (1995) 'Determinants of customer satisfaction with hospitals: a managerial model.'

International Journal of Health Care Quality Assurance, 8(2) pp. 181-187.

Angelopoulou, P., Kangis, P. and Babis, G. (1998) 'Private and public medicine: a comparison of

quality perceptions.' International Journal of Health Care Quality Assurance, 11(1) pp. 14-20.

Babakus, E. and Boller, G. W. (1992) 'An empirical assessment of the SERVQUAL scale.' Journal of

Business Research, 24 pp. 253-268.

Bellou, V. (2007) 'Achieving long-term customer satisfaction through organizational culture -

Evidence from the health care sector.' Managing Service Quality, 17(5) pp. 510-522.

Berry, L. L., Parasuraman, A. and Zeithaml, V. A. (1988) 'The Service-Quality Puzzle.' Business

Horizons, pp. 35-43.

Brady, M. K. and Cronin, J. J. (2001) 'Some new thoughts on conceputalizing perceived service

quality: a hierarchical approach.'Journal of Marketing, 65 pp. 34-49.

Buttle, F. (1996) 'SERVQUAL: review, critique, research agenda,"service quality measurement andmanagement technology".' European Journal of Marketing, 13(1) pp. 8-25.

Camilleri, D. and O'Callaghan, M. (1998) 'Comparing public and private hospital care service quality.'

International Journal of Health Care Quality Assurance, 11(4) pp. 127-133.


21/32


21

Margaret Hyde

Care Quality Commission. (2011a): Care Quality Commission. [Online] [Accessed on 25 June]

www.cqc.org.uk/aboutcqc.cfm

Care Quality Commission. (2011b) What standards to expect from the regulation of your NHS

hospital.London:

Carman, J. M. (1990) 'Consumer Perceptions of Service Quality: An Assessment of the SERVQUAL

Dimensions.'Journal of Retailing, 66(1) pp. 35-55.

Carrillat, F. A., Jaramillo, F. and Mulki, J. P. (2007) 'The validity of the SERVQUAL and SERVPERF

scales.' International Journal of Service Industry Management, 18(5) pp. 472-490.

Cohen, L. and Mallon, M. (2001) 'My Brilliant Career? Using Stories as a Methodological Tool in

Careers Research.' International Studies of Management and Organisation, 31(3) pp. 48-68.

Conway, J. M. and Huffcutt, A. I. (2003) 'A Review and Evaluation of Exploratory Factor Analysis

Practices in Organizational Research.' Organizational Research Methods, 6(2) pp. 147-168.

Coulter, A., Fitzpatrick, R. and Cornwell, J. (2009) The Point of Care: Measures of patients' experience

in hospital: purpose, methods and uses.London: King's Fund.

Cronin, J. J. and Taylor, S. A. (1994) 'SERVPERF versus SERVQUAL: Reconciling Performance-Based

and Perceptions-Minus-Expectations, Measurement of Service Quality.' Journal of Marketing, 58(1)

pp. 125-131.

Dagger, T. S., Sweeney, J. C. and Johnson, L. W. (2007) 'A Hierarchical Model of Health Service

Quality: Scale Development and Investigation of an Integrated Model.' Journal of Service Research,

10 pp. 123-142.

Daley, J. (2001) '"A 58 year old woman dissatisfied with her care".' The Journal of the American

Medical Association, 285(20) pp. 2629-2635.

Department of Health. (2010) London: Department of Health. [Online] [Accessed on 25 June]

http://www.dh.gov.uk/en/Aboutus/Features/DH_120689

Desombre, T. and Eccles, G. (1998) 'Improving service quality in NHS Trust hospitals: lessons from

the hotel sector.' International Journal of Health Care Quality Assurance, 11(1) pp. 21-26.

Dougall, A., Russell, A., Rubin, G. and Ling, J. (1999) 'Rethinking patient satisfaction: patient

experiences of an open access flexible sigmoidoscopy service.' [Online]. [Accessed


22/32


22

Margaret Hyde

Dr. Foster. (2009) Hospital Guide. [Online] [Accessed

http://www.drfosterhealth.co.uk/newsPublications/publications/reports/index

Eiriz, V. and Figueiredo, J. A. (2005) 'Quality evaluation in health care services based on customer-

provider relationships.' International Journal of Health Care Quality Assurance, 18(6) p. 2005.

Goodrich, J. and Cornwell, J. (2008) Seeing the Person in the Patient: The Point of Care review paper.

London: King's Fund.

Gostin, L., Hodge, G. H., Valentine, N. B. and Nygren-Krug, H. (2003) The Domains of Health

Responsiveness.World Health Organisation.

Gremler, D. D. and Gwinner, K. P. (2000) 'Customer-Employee Rapport in Service Relationships.'

Journal of Service Research, 3 pp. 82-104.

Gronroos, C. (1990) Service Management and Marketing: Managing the Moment of Truth in Service

Competition.Mass.: Lexington Books.

Gummesson, E. (2001) 'Are you looking forward to your surgery? .' Measuring Business Excellence,

5(2) pp. 7-9.

Hasin, M. A. A., Seeluangsawat, R. and Shareef, M. A. (2001) 'Statistical measures of customer

satisfaction for health-care quality assurance: a case study.' International Journal of Health Care

Quality Assurance, 14(1) pp. 6-14.

Howden, C. and Pressey, A. D. (2008) 'Customer value creation in professional service relationships:

the case of credence goods.' The Service Industries Journal, 28(6) pp. 789-812.

Jabnoun, N. and Chaker, M. (2003) 'Comparing the quality of private and public hospitals.' Managing

Service Quality, 13(4) pp. 290-299.

Jain, S. K. and Gupta, G. (2004) 'Measuring Service Qualty: SERVQUAL vs SERVPERF Scales.' Vikalpa,

29(2) pp. 25-37.

Johnson, R. B. and Onwuegbuzie, A. J. (2007) 'Mixed Methods Research: A Research ParadigmWhose Time Has Come.'Journal of Mixed Methods Research, 1(112) pp. 14-25.

Kang, G.-D. (2006) 'The hierarchical structure of servcie quality: integration of technical and

functional quality.' Managing Service Quality, 16(1) pp. 37-50.

Kilbourne, W.E., D., J.A., D., M. and Giarchi, G. (2004) 'The applicability of SERVQUAL in cross-

national measurements of healthcare quality.'Journal of Services Marketing, 18(7) pp. 524-533.


23/32


23

Margaret Hyde

Ladhari, R. (2009) 'A review of twenty years of SERVQUAL research.' International Journal of Quality

and Service Sciences, 1(2) pp. 172-198.

Lehtinen, U., Lehtinen, J.R. (1991) 'Two Approaches to Service Quality Dimensions.' The Service

Industries Journal, 11(3) pp. 287-303.

Lloyd, A. E. a. L., S.T.K. (2009) 'Interaction behaviors leading to comfort in the service encountere.'

Journal of Services Marketing, 25(3) pp. 176-189.

Lowe, S., Carr, A. N., Thomas, M. and Watkins-Mathys, L. (2005) 'The fourth hermeneutic in

marketing theory.' Marketing Theory, 5 pp. 185-203.

Lytle, R. S. and Mokwa, M. P. (1992) 'Evaluating Health Care Qualty: The Moderating Role of

Outcomes.'Journal of Health Care Management, 12(1) pp. 4-14.

Macintosh, G. (2009) 'Examining the antecedents of trust and rapport in services: Discovering new

interrelationships.'Journal of Retailing and Consumer Services, 16 pp. 298-305.

Mangin, D. and Toop, L. (2007) 'The Quality Outcomes Framework: what have you done to

yourselves?' British Journal of General Practice, 57(539) pp. 435-437.

McAlexander, J. H., Kaldenberg, D. O. and Koeng, H. F. (1994) 'Service Quality Measurement.'Journal

of Health Care Marketing, 14(3) pp. 34-40.

Mels, G., Boshoff, C. and Nel, D. (1997) 'The Dimensions of Service Quality: The Original European

Perspective Revisited.' The Service Industries Journal, 17(1) pp. 173-189.

Murray, C. J. L., Kawabata, K. and Valentine, N. (2001) 'People's Experience Versus People's

Expectations.' Health Affairs, 20(3) pp. 21-24.

O'Connor, S. J., Powers, T. L. and Bowers, M. R. (1988) 'Improving service quality in the health care

setting.'Journal of Health Care Marketing, 8(4) pp. 63-66.

Office for National Statistics. (2011) London: [Online] [Accessed on 9 August]http://www.statistics.gov.uk

Pajinkihar, M. (2008) 'Nurses' (Un)Parnter-Like Relationships With Clients.' Nursing Ethics, 16(43) pp.

43-56.

Parasuraman, A., Zeithaml, V. A. and Berry, L. L. (1985) 'A Conceptual Model of Service Quality and

its Implications for Future Research.'Journal of Marketing, 49 pp. 41-50.


24/32


24

Margaret Hyde

Parasuraman, A., Zeithaml, V. A. and Berry, L. L. (1988) 'SERVQUA: A Multiple-Item Scale for

Measruing Consumer Perceptions of Service Quality.'Journal of Retailing, 64(1) pp. 12-40.

Rashid, W. E. W. and Jusoff, H. K. (2009) 'Service quality in health care setting.' International Journal

of Health Care Quality Assurance, 22(5) pp. 471-482.

Rhee, S.-K. and Rha, J.-Y. (2009) 'Public service quality and customer satisfaction: exploring the

attributes of service quality in the public sector.' The Service Industries Journal, 29(11) pp. 1491-

1512.

Richards, N. and Coulter, A. (2007) Is the NHS Becoming more patient-centered?: Picker Institute.

Robinson, S. (1999) 'Measuring service quality: current thinking and future requirements.' Marketing

Intelligence and Plannning, 17(1) pp. 419-445.

Rosen, L. D., Karwan, D. R. and Scribner, L. L. (2003) 'Service quality measurement and the

disconfirmation model: taking care in interpretation.' Total Quality Management, 14(1) pp. 3-14.

Rubin, H. A., Pronovost, P. and Iette, G. B. (2001) 'The advantages and disadvantages of process-

based measures of health care quality.' International Journal for Quality in Health Care, 13(6) pp.

469-474.

Rust, R. T. and Oliver, R. L. (1994) Service Quality: New Directions in Theory and Practice.Thousand

Oaks, CA: Sage Publications.

Sanchez-Hernandez, R. M., Martinez-Tur, V., Peiro, J. M. and Ramos, J. (2009) 'Testing a hierarchical

and integrated model of quality in the service sector: functional, relational and tangible dimensions.'

Total Quality Management, 20(11) pp. 1173-1188.

Scrivener, R. (2011) RCN's Definition of Dignity. [Online] [Accessed on 16th July 2012]

www.rcn.org.uk

Smith, R., Bloom, P. and Davis, K. (1986) 'Research on Patient Satisfaction: Potential Directions.'

Advances in Consumer Research, 13 pp. 321-326.

Sureshchandar, G. S., Rajendran, C. and Anantharaman, R. N. (2002) 'The relationship between

management's perception of total quality service and customer perceptions of service quality.' Total

Quality Management, 13(1) pp. 69-88.


25/32


25

Margaret Hyde

Sureshchandar, G. S., Rajendran, C. and Anantharaman, R. N. (2002a) 'The relationship between

service quality and customer satisfaction - a factor specific approach.' Journal of Services Marketing,

16(4) pp. 363-379.

Sureshchandar, G. S., Rajendran, C. and Anantharaman, R. N. (2002b) 'Determinants of customer-

perceived service quality: a confirmatory factor analysis approach.' Journal of Services Marketing,

16(1) pp. 9-34.

Tabak, N. and Ozon, M. (2004) 'The influence of nurses' attitudes, subjective norms and perceived

behavioral control on maintaining patients' privacy in a hospital setting.' Nursing Ethics, 11(4) pp.

366-377.

Tomes, A. and Ng, S. C. P. (1995) 'Service quality in hospital care: the develoopment of in-patient

questionnaire.' International Journal of Health Care Quality Assurance, 8(3) pp. 25-33.

Triggle, N. (2012) Why can't the NHS get basic care right. London: BBC. [Online] [Accessed on 23rdNovember 2012] http://www.bbc.co.uk/news/health-20427441

Vargo, S. L. and Lusch, R. F. (2004) 'Evolving to a New Dominant Logic for Marketing.' Journal of

Marketing, 68 pp. 1-17.

Vukmir, R. B. (2006) 'Customer Satisfacction.' International Journal of Health Care Quality Assurance,

19(1) pp. 8-31.

Walters, D. and Jones, P. (2001) 'Value and value-chains in health-care: a quality management

perspective.' TheTQM Magazine, 13(5) pp. 7-15.

Winsted, K. F. (2000) 'Service behaviours that lead to satisfied customers.' European Journal of

Marketing, 34(3/4) pp. 399-417.

Woodall, T. (2001) 'Six Sigma and Service Quality: Christian Gronroos Revisited.'Journal of Marketing

Management, 17 pp. 595-607.

Wright, G., Hines, A. a. and Hyde, S. M. (2011) 'Measuring Quality in Public Services'. In 10th

International Research Conference on Quality, Innovation and Knowledge Management. Malaysia:

Zineldin, M. (2000) 'Total relationship management (TRM) and total quality management (TQM).'

Managerial Auditing Journal, 15(1/2) pp. 20-28.

Zineldin, M. (2006) 'The quality of health care and patient satisfaction: An exploratory investigation

of the 5Qs model at some Egyptian and Jordanian medical clinics.' International Journal of Health

Care Quality Assurance, 19(1) pp. 60-92.


26/32


26

Margaret Hyde

Appendix 1

QUESTIONNAIRE

There is currently much interest in the quality of health care and we are trying tounderstand more about what are the most important elements for patients, their

family/friends or carers. We would appreciate your time in completing this questionnaire.

It should take approximately 15 minutes to complete. Please place a cross in the most

appropriate boxes that reflect your own opinionabout the priorities you give to different

elements of care. Your answers should reflect the type of care you would like to receive

rather than the level of care you feel you do receive. Please return completed forms to

[email protected].

Your replies are totally confidential. The information we gather from this questionnaire may

be shared with appropriate health and associated professionals to help improve the services

offered at NHS surgeries, clinics and hospitals.A version in larger print is available on request to [email protected]

07847557672

All completed forms will be entered into a draw for 25 gift token for Marks and

Spencer or Argos, depending on the choice of the winner.

If you wish to enter the draw please give your contact details here. This may be

an e-mail address, phone number or mailing address. These will be kept

confidential.

Name

Contact details

THE ENVIRONMENT IN WHICH I AM CARED FOR

I want ...

Not so Very

Important Important

1 2 3 4 5 6 7

staff to be smart

hospital signposting to be clear

hospital waiting areas to have things to do

staff to wear badges providing their name and job role

decor in a hospital ward to be bright, cheerful and welcoming

staff to wear uniforms which help identify their position and seniority

local clinics/doctors surgeries to be bright and well decoratedequipment to appear to be modern

staff not to wear uniforms

efforts to be made to make hospital environments as relaxing as possible

good bedside entertainment such as TV/radio to be available if confined to

hospital

equipment to be undamaged and works first time

there to be sufficient comfortable seating in waiting rooms


27/32


27

Margaret Hyde

A CARING APPROACH

I want ...

Not so Very

Important Important

1 2 3 4 5 6 7

the receptionist to be friendly and courteous

not to be asked for medical information by the receptionist

to be asked what name I should be addressed by

the professional to show interest in me as a person, not a set of symptomsthe professional to show respect towards me

the professional to help me to relax during a consultation

the professional to be friendly and informal

the doctor to understand me as a person and my needs

all wards/departments to offer similar standards of service

staff to have people skills

COMMUNICATIONS/INVOLVEMENT IN MY OWN CARE knowing whats going on

I want ...

Not so Very

Important Important

1 2 3 4 5 6 7

to feel comfortable in asking questions

to choose where I am treatedprofessionals to have all the relevant information about me to hand

information to always be given in simple, jargon-free terms

to be given appropriate information at all times during my care

to choose who treats me

to receive important information face to face rather than by letter

my records to be made available to me on request

not to have to repeat information to different professionals

professionals to ask if I understand what they have said in case of accents or

terminology

to feel my doctor or other health care professional listens to what I say

to feel assured information is passed to other departments/agencies if necessary

staff to refer to notes about concerns I have, my dislikes/likes etc

information given by different staff/departments to be consistent

to be given my options and involved in deciding the appropriate treatment to feel that I am an equal partner with the health care professional is important

equipment to be available so I can take my own cholesterol and blood pressure

staff to be aware of patients who are hard of hearing and speak accordingly

staff not to speak to me in a patronising manner

RESPONDING TO MY NEEDS

I want...

Not so Very

Important Important

1 2 3 4 5 6 7

not to feel a nuisance if I ask for help when in hospital

nurses/assistants in hospital to answer calls for assistance in a timely manner

complaints to be handled in a timely manner

not to be moved from a ward with no noticesomeone to reassure me during uncomfortable/painful procedures

any complaint I may make to be addressed appropriately

staff to show a willingness to be helpful

to know who to speak to if I have concerns

to not be transferred between wards during the night or at meal times

my needs to be assessed and appropriate action is taken if I have a problem

nurses to be aware of my personal needs/concerns/fears

not to feel uncomfortable if I have to make a complaint

staff to have time to cater for my needs and to make me feel comfortable


28/32


28

Margaret Hyde

HAVING TRUST IN MY CARE

I want ...

Not so Very

Important Important

1 2 3 4 5 6 7

to see the environment at the local doctor/clinic is clean

to feel that the doctor trusts what I tell him/her

the doctor to refer to a book/website if unsure about something the professional to take time to conduct an examination, treatment and/or tests

to have trust in the clinical ability of the person treating me

information about the professional history of my specialist to be available to me

not to be asked for personal/medical information in a public area/waiting room

where possible, to see the same professional

the hospital to look clean

the doctor to be sufficiently competent to not have to refer to a book/website

the hospital I attend to have a good reputation/be free from public criticism

to feel the professional knows me well enough to understand my needs

there to be co-ordination between staff/departments providing my care In

hospital

to know my doctor

the doctor to have my full medical history to handthe doctor to take into account my medical history where diagnosis is difficult

to be sure my personal/medical history will not be passed on in error

access to wards to be controlled

there to be general agreement between professionals about my treatment

to feel there is no danger of accidents when in hospital

to know the doctor is competent even if he/she is not friendly

strong leadership to be apparent and reflected in the level of care

to see the hospitals record on cleanliness, e-coli and MRSA clearly displayed

EASE OF ACCESS TO AND RELIABILITY OF SERVICES

I want...

Not so Very

Important Important

1 2 3 4 5 6 7

it to be easy to get timely appointments with my local doctor/clinic

appointments not to run late

to be able to easily get through on the phone to the local surgery or hospitals

opening hours of local surgeries/clinics to extend beyond normal office hours

the location of services to be convenient

an explanation if appointment times are not kept to

to have the option to see a GP who specialises in my needs

not to have to spend lengthy periods in waiting rooms

not to have to pay to get a faster or more convenient appointment

physical access to premises to take account of people with disabilities

home visits to be easily available when needed especially for children/elderly

it to be easy to speak to the right person

it to be easy to speak to a member of the ward staff if I am in hospital

to feel unrushed when I see a doctor or other professionalto have plenty of notice and reasons given if my appointment is cancelled

to be able to discuss more than one problem at one appointment

staff to do what they say they will when they say they will do it

plenty of car parking to be available

be able to get timely appointments for specialist services

a choice of dates in the case of needing inpatient treatment

car parking to be free of charge


29/32


29

Margaret Hyde

FOOD

I want...

Not so Very

Important Important

1 2 3 4 5 6 7

volunteers to be on duty to help patients eat

light snacks such as toast, teacakes, fruit, ice cream to be readily available

no activities (except emergencies) to take place during meal time to allow staff to

help patientsnot to have to decide the day before what I want to eat the following day

food to be appetising and tasty

ABOUT ME

Please place a cross by the appropriate category

I am: (a) Retired

(b) A homemaker

(c) Not employed

(d) In full time employment

(e) In part time employment

If (a) please state what your occupation was

If (d) or (e), please state your occupation

Do you have qualifications? Yes No If so to what level?

GCSE A level NVQ HND/HNC Degree Post Graduate Professional

(or equivalent)

Other (please state)

Please place a cross by your age group

I am aged: 18-35 36-50 51-65 66-75 76+

Please return your completed form to [email protected].

THANK YOU VERY MUCH FOR YOUR TIME


30/32


30

Margaret Hyde


31/32


Margaret Hyde

Appendix 2

SERVQUAL vs OPEN CODING BREAKDOWN OF ITEMS

SERVQUAL 10 SERVQUAL 5 OPEN CODING

Tangibles

Appearance ofphysical facilities,equipment personneland communicationmaterials

Tangibles

up-to-dateequipment physicalfacilities visuallyappealing

staff well dressedand

neat polite

appearance offacilities in keepingwith the service

Environment

Modern looking equipment Light spacious environment

Smart staff with ID badges

Appealing waiting areas withseating

Good signage

Bedside entertainment

Food

Help with eating if needed

Light snacks available

Appetising food

ReliabilityAbility to perform thepromised service

dependably andaccurately

Reliability

staff should besympathetic if

customerexperiences

problems

when firm promisessomething by acertain time it isachieved

dependability

provide service attime they promise

records keptaccurately

Ease of access and reliability of services

Timely appointments available, notto run late

Get through easily on the phone Convenient opening hours

Convenient locations

Specialist GPs

Home visits

Physical access for people withdisabilities

Easy to speak to right person

Feel unrushed

Staff do what they say when theysay

Car parking

Flexibility on appointments

AccessApproachability andease of contact

ResponsivenessWillingness to helpcustomers and provide

prompt service

Responsiveness provide prompt

service

tell customers whento expect service

willing to helpcustomers

staff not too busy toprovide promptservice

Responding to needs In hospital to be able to get help

when needed

Not to be moved without notice

Willing staff

To know right person to speak to

Nurses to be aware of my personalneeds/concerns/fears

Staff to have time to cater for myneeds

Complaints dealt with in timelymanner

Understanding thecustomer

Making the effort toknow customers andtheir needs

Empathy

staff know the

needs of customer staff have

customers bestinterests at heart

staff give personalattention

staff give individualattention

convenient openinghours

Caring approach

Friendly receptionists

Privacy To be seen as a person, not set of

symptoms

Staff to have people skillsCourtesyPoliteness, respect,consideration andfriendliness of contact

personnel


32/32


SecurityFreedom from danger,risk or doubt

Assurance

customers can truststaff

customers feel safe

polite staff

staff get supportfrom firm

Having trust in my care

Clean environment

Doctor trusts what I tell him/her

Professional takes time

Trust in the professional

Information about professional isavailable

Seeing the same person each time Co-ordination between

departments and agencies

CompetencePossession of therequired skills andknowledge to perform

the serviceCredibilityTrustworthiness,believability, honestyof the service provider

CommunicationsKeeping customersinformed in languagethey can understandand listening to them

Communications/involvement in my owncare

Feel comfortable asking questions

Professional to have all relevantinformation about me to hand

To be given appropriate informationabout my care

My records made available onrequest

Not to have to repeat informationconstantly

Accents and terminology do notimpede my understanding

Professional listens to me

Information passed on wherenecessary

Staff dont patronise me

Staff refer to notes about myconcerns/preferences

Consistent information given

To choose where I am treated andby whom

To feel an equal partner

The items within the open coding will be refined following a process of factor

analysis.

Hyde Margaret - Understanding Dimensionality in Health Care

Documents

Transcript of Hyde Margaret - Understanding Dimensionality in Health Care