Research Article
Patient Satisfaction with the Healthcare Service Quality: An Empirical Investigation at
Malaysian Public Hospitals by Utilizing SERVQUAL-Gap Analysis
Wan Salmuni Wan Mustaffa*1, Rafiduraida Abdul Rahman2, Nurul Fadly Habidin3, Noor Al-HudaAbdul Karim4, Aidi Ahmi5
1,2,3,4Faculty of Management and Economics, Universiti Pendidikan Sultan Idris, Malaysia 5TunkuPuteriIntanSafinaz School of Accountancy, Universiti Utara Malaysia, Malaysia 1
*Corresponding author: wan.salmuni@fpe.upsi.edu.my
Article History:Received: 10 November 2020; Revised: 12 January 2021; Accepted: 27 January 2021;
Published online: 05 April 2021
Abstract: The healthcare industry is among the most rapidly growing service industries in the world economy.In recent
years, the government of Malaysia has takenvariousinitiative to increase funding for the healthcare sector to improve the quality of life amongst citizens.However, the continuing complaints regarding patients’ dissatisfaction towards the quality of healthcare services lead to a huge challenge to the service providers. Thus, the main objective of this research is to measure patient satisfaction withhealthcare service quality. The selected Malaysian public hospitals were involved in this research. A questionnaire was used as a research instrument distributed to the patient's experienced service deliveryat Malaysian public hospitals. The convenience sampling technique was employed to gather the data. Data collected were analyzed using SERVQUAL-gap analysis. The descriptive results revealed that the patients wereonly moderately satisfied with healthcare service quality rendered byMalaysian public hospitals. Based on the SERVQUAL-gap analysis results, the empathy dimension showed the lowest mean value. This indicates that service quality offered by Malaysian public hospitals still needs improvement in terms of the level of caring and needs as well as individualized attention that the hospital needs to provide to their patients. This research benefits the managerial in the healthcare industry to deliver excellent service experience to the patients by considering the relevant indicators of service evaluation.
Keywords: Patient Satisfaction, Service Quality, Healthcare Industry, SERVQUAL-Gap Analysis.
1. Introduction
The growth of the healthcare service industry in Malaysia is proven by the increasing number of public and private hospitals. In 2019, statistics revealed by Ministry of Health Malaysia (MOH) indicated that there were 144 registered public hospitals and 216 registered private hospitals in Malaysia (MOH, 2019). The public hospitals are accessible to all legal Malaysian residents, funded by the government, and provide low-cost and comprehensive services. Whereas, private hospitals run based on a profitable basis (Brandt & Lim, 2011).Government of Malaysia is always committed to strengthening its healthcare organizations to ensure high quality and safe services delivery to the customers (Jaafar et al., 2013). For instance, MOH has spent 4.8 percent of gross domestic product (GDP)on improving the services rendered by public hospitals (Economic Transform Program, 2016). Under the framework of the New Malaysia Economic Model, the healthcare service industry has been targeted to serve as the engine of growth to propel and sustain the economy. This scenario creates a massive challenge among Malaysian healthcare service providers, especially public hospitals, to deliver a world-class service experience to customers.
In recent years, the government has taken various initiatives to increase funding for the healthcare sector to improve the quality of life and compensate for a broad ageing demographic in Malaysia. Nevertheless, the issue regarding patient satisfaction towards the quality of services rendered by Malaysian public hospitals is still being debated among practitioners and academicians (Ting et al., 2019; Abd Manaf et al., 2017;Hasyimah et al. 2014). Moreover, the role of “patients” as “customers” has forced healthcare organizations to deliver a higher level of satisfaction with overall healthcare service experience (Mohamed, 2015). Patient satisfaction is defined as a judgment that a healthcare service gives a satisfying level with a service experience (Hafiz et al., 2011). The measurement of patient satisfaction is becoming a valuable instrument for the optimum evaluation of healthcare service providers.
Although the previous studies had examined the patient satisfaction towards healthcare service experience, there is still lack of studies focusing on which service indicators contribute the most dissatisfied evaluated by thepatients (Islam, Ahmed &Tarique, 2016;Abd Manaf, 2012; Ali&Wan Mohamad, 2009).Thus, this research aimed to inspect patient satisfactionwith the healthcare service qualityat the selected Malaysian public hospitals. Twenty-two SERVQUAL indicators covered five service dimensions, namely Tangibles, Reliability, Responsiveness, Assurance and Empathy, were utilized to measure the patient satisfaction rendered by a
Patient Satisfaction with the Healthcare Service Quality: An Empirical Investigation at Malaysian Public Hospitals by Utilizing SERVQUAL-Gap Analysis
Malaysian public hospital. Interestingly, this research also measured the patient satisfaction insights of each service quality indicators by using SERVQUAL-gap analysis. The information gathered from gap-analysis can assist the healthcare service providers in diagnosing, which service indicator needs to give extra attention (Shahin, 2006).
2. Literature Review
Overview of Patient Satisfaction Research in Healthcare Service
Recently, the literature revealed that the researchers are showing their interest in investigating the issue of patient satisfaction in the healthcare service industry. For instance, Abd Manaf (2012) discovered three factors of inpatient satisfaction towards public healthcare service delivery in Malaysia, namely the clinical dimension of service, the physical dimension of service, and additional facilities. This study revealed that the patients weredissatisfied with the physical aspects of service. As suggested by the quality management practices, healthcare service industry should focus on improving and maintaining the quality of care to the customers even though it is costly (Abd Manaf, 2005).Hihnala et al. (2017) investigated environmental healthcare by utilizing Lean principles. The research output revealed that the environmental factors increased the correlation between customer satisfaction and quality of service offered. A study by Mohsin and De Run (2010) utilized the SERVQUAL scale to measure Malaysian healthcare service quality. This study assists healthcare service providers in identifying the gaps between service delivered and patients’ expectations.
The challenges of the Malaysian Government are to strengthen its healthcare organizations, public and private in order to ensure high quality and safe services are provided to the customers (Jaafar et al., 2013).Ali and Wan Mohamad (2009) conducted a study in a public hospital in Malaysia to assess five key elements in the delivery of the quality of healthcare services. The five key elements were plans and procedures, leadership, policies, orientation and training, monitoring and supervision, and service performance. A study conducted by Kashif et al. (2015) introduced and validated the customer experience quality (EXQ) scale in Malaysian private healthcare. EXQ scale links the customer experiences to the marketing outcomes such as satisfaction, loyalty, behavioural intentions and word of mouth.
Theoretical Perceptive of Customer Satisfaction and Service Quality
Expectancy-Disconfirmation Paradigm (EDP) is the most extensively applied theory to evaluate consumer satisfaction and dissatisfaction within the service context (Mustaffa et al., 2019; Archambault, 2008; Liao, Chen & Yen, 2007; Arambewela, Hall & Zuhair, 2005; McKinney, Yoon & Zahedi, 2002). The customer satisfaction based upon EDP is judged in relation to a comparison standard between the expectations and perceptions towards service indicators. The expectations are viewed as customer desirefor services, whereas customers’ perceptions are a subjective assessment of actual service experience. Drawing on EDP theory, SERVQUAL (service quality) scale was developed and extensively used to measure quality indicators cross-services settings (Parasuraman et al., 1985, 1988, 1991). SERVQUAL consists of twenty-two indicators representingfive dimensions as follows:
1. Tangible refers to the customers’ perceptions of the appearance of physical facilities, equipment, personnel, and communications materials.
2. Responsiveness refers to the employees’ willingness to help customers and the ability to provide prompt service.
3. Reliability refers to the ability of service provider to deliver the service accurately and dependably.
4. Assurance refers to the knowledge and courtesy of employees and their ability to convey trust and confidence.
5. Empathy refers to the caring, individualized attention provided to the customers.
Service quality is inspected based on a gap analysis (mean perceptions (P) – mean expectations (E)). Thus, if customers’ perceptions exceed their expectations (P>E), service quality is very satisfactory. When customers’ perceptions equal their expectations (P=E), service quality is satisfactory.However, when customers’ expectations exceed their perceptions (E>P), service quality is poor.
3. Methodology
This research was conducted at the selected Malaysian public hospitals. The patients who experienced healthcare service delivery at Malaysian public hospitals were selected as research respondents.According to the data released by the United Nations in 2018, the total population of Malaysian residents is 32,042,458.Thus, referring to Krejcie and Morgan (1970), 384 respondents is the best sample size to generalize a vast number of populations. The population of this research wasdivided into three regions (east coast region, central region, and southern region) in Peninsular Malaysia. As illustrated in Figure 1, a leading public hospital at each region was selectedas a research setting, which wasHospital Kuala Lumpur (central region), Hospital TengkuAmpuanAfzan (east coast region), and Hospital Melaka (southern region). These hospitals were selected based on the large number visited and admitted patients (MOH, 2019). Next, the convenience sampling technique was employed in order to select the respondents.This sampling technique was preferred because it is fast, inexpensive, easy and subjects are readily available. Moreover, it was unable to gather the complete list of the patients who have used the public hospital's services due to the confidentiality of information.
Figure 1. Research Setting Instrumentation
The questionnaire was utilized as a research instrument which comprised of three sections. Section I intended to assess the patients’ perceptionsof service quality rendered by Malaysian public hospitals. Section II intended to measure the patients’ expectations of service quality offered by public hospitals.SERVQUAL model was operationalized to measure service quality (Parasuraman et al., 1985, 1988, 1991). Twenty-two items extracted from the SERVQUAL scale were used to measure different dimensions of healthcare service delivery. These items were categorized into five main service dimensions as follows:
1. Tangibles -Tangibles dimension was operationalized based on four indicators: i) modern equipment, ii)
visually appealing facilities, iii) professional appearance of the staff, and iv) cleanliness of the hospital.
2. Assurance – Assurance dimension was operationalized based on four indicators: i) hospital is capable of
handling patients’ medical problems effectively, ii) hospital takes sufficient measure for the safety of their patients, iii) doctors are well-mannered, and iv) doctors and nurses are knowledgeable and professional to answer patients’ questions.
3. Empathy– Empathy dimension was operationalized based on five indicators i) individual attention with a
friendly manner, ii) hospital has the best interest in mind for their patients, iii) understand patients’ specific needs, iv) convenient consultation hours, and v) staff are never too busy to respond to their patients,
4. Responsiveness - Responsiveness dimension was operationalized based on four indicators: i) minimal
waiting time to get the service (prompt services), ii) willingness to help the patients, iii) ease of obtaining information from the hospital pertaining to patients’ queries, and iv) response to the patients’ complaints.
5. Reliability - Reliability dimension was operationalized based on five indicators: i) perform the services at the
right time as promised, ii) sincerity to solve patient’s problems, iii) providing the service right the first time, iv) maintain error-free records,and v) availability of the doctors.
Patient Satisfaction with the Healthcare Service Quality: An Empirical Investigation at Malaysian Public Hospitals by Utilizing SERVQUAL-Gap Analysis
Modifications were made as the items were generated and validated within the healthcare context (Islam, Ahmed &Tarique, 2016). All indicators were inspected using a 7-point Likert scale.Section III contained the questions to gather information concerningthe respondents’ demographic profile including gender, age, marital status and education level. The respondents were also guaranteed that their participation in this research was confidential and would not affect their medical treatment.
Data Analysis
In this research, data gathered were analyzed by utilizing gap analysis (mean perceptions (P) – mean expectations (E)) to measure patient satisfaction with healthcare service quality at Malaysian public hospitals. Thus, if mean patients’ perceptions exceed their mean expectations (P>E), service quality is very satisfactory. When mean patients’ perceptions equal their mean expectations (P=E), service quality is satisfactory.However, when mean patients’ expectations exceed their mean perceptions (E>P), service quality is poor.
4. Results and Discussion
Demographic Profile of Respondents
After conducting the Exploratory Data Analysis (EDA) and removing the incomplete questionnaires, about 215 completed questionnaires were proceeded to data analysis. This contributes to 56% of response rate. Table 1 presents the descriptive results of respondents’ demographic information.The table shows that the female respondents(59.5%) were more than male respondents (40.5%). Most of the patients who participated in this research were in the 31-40 years age group. 59.5% of respondents were married. The descriptive demographic results also revealed that 77.6% of respondents who participated in this research had completed their education at the higher education level. Besides, 66% of patients who participated in this research were government servants, whereas only 1.4% of patients involved in this research were retiree.
Table 1. Respondents’ Demographic Information
Demographics Frequency Percentage (%)
Gender Male 87 40.5 Female 128 59.5 Age 20-30years 33 15.3 31-40 years 102 47.4 41-50 years 65 30.2 51-60 15 7.1 >60 years 0 0 Marital status Single 87 40.5 Married 128 59.5 Education Level No Education 3 1.4 Primary education 10 4.7 Secondary Education 35 16.3 Higher Education 167 77.6 Occupation Government 142 66 Private 35 16.3 Self-employed 20 9.3 Retiree/Pensioner 3 1.4 Students 15 7
In this research, the SERVQUAL model was utilized to measure patient satisfaction with healthcare service quality at Malaysian public hospitals. Twenty-two indicators extracted from the SERVQUAL scale were used to measure five dimensions of healthcare service quality, namely Tangibles,Reliability, Responsiveness, Assurance, and Empathy. The descriptive analysis of patients’ actual perceptions covers calculating the mean based on a 7-point Likert (1=very dissatisfied, 2= moderately satisfied, 3=slightly dissatisfied, 4= neutral, 5=slightly satisfied, 6=moderately satisfied, 7=very satisfied). The descriptive analysis of an overall SERVQUALpatients’ actual perceptions revealed that the mean patient satisfaction with healthcare service quality was 5.18.This result indicates that the mean of the overall patients’ actual perceptions wasmoderately satisfied with healthcare service quality rendered by Malaysian public hospitals.
Gap Analysis Results
A gap analysis was performed to measure the discrepancy between patients’ perceptions of service received and their expectations towards service quality rendered by Malaysian public hospitals. The patients’ perceptions are viewed as a subjective assessment of the actual service experience. On the other hand, the patients’ expectations refer to patients’ desires for services. Figure 2 indicates the gap analysis results of SERVQUAL dimensions. On average, the Empathy dimension showed the highest service gap value with mean-1.94, followed by Tangible (-1.80), Assurance (-1.79), Responsiveness (-1.78), and Reliability (-1.75). This indicates that the quality of service offered by Malaysian public hospitals still needs improvement in terms of the level of caring and needs as well as individualized attention that the hospital needs to deliver to their patients.
Figure 2. Gap Mean of SERVQUAL Dimensions
Next, the gap analysis for twenty-twoSERVQUAL scale was performed to inspect which service quality indicator contributes to the most critical gap.Table 2 shows the specific results of the gap analysis of SERVQUAL indicators. The results revealed that the indicators; 17 and 20 had the highest (critical) gap values with -2.21 and -2.07, respectively. This indicates that the patients are still dissatisfied with the staff, including doctors and nurses, respond to their questions.
Table 2. Gap Analysis Results of SERVQUAL Indicators
Dimension Indicator P E (P-E)
Tangibles 1) Modern equipment. 5.14 7 -1.86
2) Visually appealing facilities. 5.25 7 -1.75
3) Professional appearance of the staff. 5.24 7 -1.76
4) Cleanliness of the hospital. 5.19 7 -1.81
Reliability 5) Perform the services at the right time as promised. 5.16 7 -1.84
6)Sincerity to solve patient’s problems. 5.23 7 -1.77
7) Providing the service right the first time. 5.35 7 -1.65
8) Availability of the doctors. 5.38 7 -1.72
9) Maintain error-free records. 5.22 7 -1.78
Responsivenes s
10) Ease of obtaining information from the hospital pertaining to patients’ queries.
5.21 7 -1.79
11) Minimal waiting time to get the service (prompt services). 5.19 7 -1.81
12) Willingness to help the patients. 5.25 7 -1.75
13) Response to the patients’ complaints. 5.16 7 -1.84
Assurance 14) Hospital is capable to handle patients’ medical problems effectively. 5.30 7 -1.70 -2.00 -1.95 -1.90 -1.85 -1.80 -1.75 -1.70 -1.65 Mean Gap
Patient Satisfaction with the Healthcare Service Quality: An Empirical Investigation at Malaysian Public Hospitals by Utilizing SERVQUAL-Gap Analysis
15) Hospital takes sufficient measure for the safety of their patients.
5.35 7 -1.65
16) Doctors are well-mannered. 5.38 7 -1.62
17) Doctors and nurses are knowledgeable and professional to answer patients’ questions.
4.79 7 -2.21
Empathy 18) Individual attention with friendly manner. 5.06 7 -1.94
19) Convenient consultation hours. 5.03 7 -1.97
20) Staff are never too busy to respond to their patients. 4.93 7 -2.07 21) Hospital has the best interest in mind for their patients. 5.14 7 -1.86
22) Understand patients’ specific needs. 5.15 7 -1.85
P = Patients’ Perceptions E= Patients’ Expectations
5. Conclusion
This research was conducted to measure patient satisfaction with the healthcare service quality at the selected Malaysian public hospitals. Twenty-two SERVQUAL indicators via five dimensions, namely tangible, responsiveness, reliability, assurance, and empathy, were applied to achieve the research purpose. The descriptive result of patients’actual perceptions indicated that the patients were only moderately satisfied with service quality rendered by Malaysian public hospitals. Interestingly, this research was able to measure the concept of patient satisfaction in the healthcare service context in more detail using the SERVQUAL-gap analysis. As stated by Shahin (2006), the information gathered from gap-analysis can assist the service providers in diagnosing,which service indicator needs to give extra attention. The gap analysis demonstrated that the empathy dimension showed the lowest service gap value. This indicates that service quality rendered by Malaysian public hospitals still needs improvement in terms of the level of caring and individualized attention that the hospital needs to deliver to their patients. For specific results of the gap analysis for service quality indicators revealed that indicators 17 and 20 had the highest gap values. This indicates that the service providers at Malaysian public hospitals should assign the staff, including doctors and nurses who are knowledgeable and professional, to answer patients’ queries.
The research findings provide practical implications for service providers in the healthcare industry. This research will assist the healthcare service providers in developing a specific strategic marketing tool to retain customers with their companies by understanding the patients’ needs towards service quality aspects. This research has a limitation that could possibly suggest directions for future research. In this research, the patients who experienced service delivery at Malaysian public hospitals were selected as the sample. However, past literature has claimed that different groups of respondents may experience the service in different ways (Mavondo, Tsarenko, &Gabbot, 2008; Ramsay, Barker, & Jones, 1999). Therefore, it is recommended to conduct a comparative study between the patient experience at public hospitals and private hospitals to highlight similarities and differences between customer groups.
6. Acknowledgement
This research is funded by Universiti Pendidikan Sultan Idris Research Grant (2017-0198-106-01).
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