Dissetation Service Quality

Development of a Model for Healthcare Service
Quality:
An Application to the Private Healthcare Sector
in Egypt
Dissertation
To obtain the degree of Doctor of Business Administration

at the Maastricht School of Management, under authority of
the Director Dean Prof. R.S.J. Tuninga,
by
Dr Ingy Mohamed Fikry Farid
MD, MPhil, MBA, MSc

Published by:
Maastricht School of Management

P.O. Box 1203
6201 BE Maastricht
The Netherlands
I.M.F. Farid, Development of a Model for Healthcare Service Quality: An

Application to the Private Healthcare Sector in Obstetrics in Egypt. DBA
Dissertation, Maastricht School of Management, Maastricht 2008. – With
references. – With summary in English.
Key words: Service Quality/Healthcare Marketing/Developing Countries/ Egypt/

Gap Analysis/ SERVQUAL/ SERVPERF/ Patient Satisfaction/
Cover: Ingy Mohamed Fikry Farid

Printing: Egypt
© 2008 by I.M.F. Farid, Maastricht School of Management. All rights reserved. No

part of this publication may be reproduced, stored in a retrieval system or
transmitted in any form or by any means, electronic, mechanical, photocopying,
recording or otherwise, without prior written permission of the publisher.
This dissertation is approved of by the Doctoral Supervisors:
Prof. Dr. Jan Walburg

President/CEO of Trimbos Institute (Netherlands Institute of Mental Health and
Addiction)
Maastricht School of Management (MSM)
The Netherlands
Prof. Dr. Ahmed Taher

Assistant Professor of Marketing
American University in Egypt
Arab Republic of Egypt
Reader:
Quang Truong, Ph.D
Associate Professor
External Reviewers:
Prof. Dr. J. Chr. Van Dalen
Prof. Dr. L. Tigchelaar
ACKNOWLEDGEMENTS
My parents are the people who have helped make it possible. Their
guidance and support has formed me into the person that I am today and the
lessons they have taught me are going to stay with me forever. Without their
help and direction, I would never have achieved what I have done and their
continuous love and devotion have pushed me to make all my achievements
possible. All my love and thanks to my husband Alaa, who has pushed me to
excel and given me the motivation to pursue my dreams to wherever they lead
me and reach my goals however far they are. I also have to express my thanks
and appreciation to my sisters, whose help, support and patience have made me
achieve my goals.
A special thanks to my supervisors, Dr Ahmed Taher, who has taught
me a great deal and whose advice, insights and contributions have been
significant in the completion of this work and Dr Jan Walburg, whose insights
and efforts have helped make this work complete. Their motivation and
guidance were influential its accomplishment. A special thanks to my
colleague, Dina El Kayali, whose help has been invaluable in the success of
this work. And finally, a special thanks to all the professors and teachers of
Maastricht School of Management, who have provided me with a wealth of
knowledge that will remain with me and enrich me forever.
i
TABLE OF CONTENTS
Page
Acknowledgment i
List of Tables v
List of Figures vii
List of Abbreviations x
Executive Summary xi
Chapters
1 Introduction and Problem Definition 1
1.1 Significance of the problem and Choice of Topic 1
1.2 Problem Definition 2
1.3 Research Question 3
1.3.1 Major Research Questions 3
1.3.2 Minor Research Questions 3
1.4 Objectives of the study 3
1.5 Research Methodology 4
1.6 Scope of the Research 5
1.7 Expected Contributions 6
1.8 Limitations 6
1.9 Organization of the Research 7
2 Literature Review 8
2.1 Healthcare Sector Worldwide 10
2.2 Consumer Satisfaction Literature 10
2.2.1 Confirmation/disconfirmation concept 10
2.2.2 Equity theory 11
2.2.3 Attribution Theory 11
2.3 Consumer Satisfaction and Service Quality Literature 11
2.3.1 The Nordic School 12
2.3.2 The Gap Analysis School 12
2.3.3 Critique of the Gap School 13
2.4 Consumer Satisfaction Studies in Healthcare 17
2.5 Outcome of Healthcare and Satisfaction 20
2.6 Linking Service Quality, Patient Satisfaction and Behavioural Intentions 21
to Return
2.7 Effect of Consumer Demographics on Service Quality Expectations and 22
Perceptions
2.8 Egyptian Healthcare System 22
2.8.1 Structure of Egyptian Healthcare System 23
2.8.2 Stakeholders in Healthcare System in Egypt 25
2.8.3 Healthcare finances in Egypt 28
2.8.4 Healthcare services positive indicators 28
2.8.5 Healthcare services in Egypt reform for public and private sector 29
2.8.6 Healthcare sector national reform program 29
2.9 Linking between Service Quality, Outcome, and Financial Performance 31
2.10 Service Quality: Implementation of a Consumer-Focused Culture 34
ii
3 Model and Hypothesis 54
3.1 Introduction 54
3.2 Conceptual Framework 55
3.2.1 Constructs and Sub-constructs 55
3.2.2 Theoretical framework 61
3.3 Limitations & Assumptions 66
3.4 Research Questions 66
3.4.1 Major research questions 66
3.4.2 Minor research questions 67
3.5 Research Hypothesis 70
3.6 Research Methodology 72
3.6.1 Research Purpose 72
3.6.2 Sample size/selection 73
3.6.3 Development of questionnaire 73
4 Research Methodology 76
4.1 Research Design 76
4.1.1 Purpose 76
4.1.2 Process 77
4.2 Sample Selection 77
4.2.1 Population 77
4.2.2 Sampling Method for In-depth Interviews 78
4.2.3 Sampling Stratification variables 79
4.2.4 Sampling criteria 79
4.2.5 Sample size 80
4.2.6 Sampling error 81
4.2.7 Non-sampling error 81
4.3 Data Analysis Methods 81
4.3.1 Qualitative data analysis 82
4.3.2 Quantitative data analysis 84
4.3.3 Research design strategy Chart 88
5 Qualitative Research and Pilot Study 91
5.1 Results if In-depth Interviews 91
5.2 Pilot Study Results 99
6. Quantitative Research Results 102
6.1 Descriptive Analysis Techniques 102
6.1.1 Perceptions and Expectations of hospital service provided 103
6.1.2 Importance of hospital service provided 114
6.1.3 Overall Assessment of hospital service provided 115
6.2 Quantitative Data Analysis 116
6.2.1 Measurement of Error 118
6.2.2 Determining the Best Method for Healthcare Service Quality Measures 118
among the tested methods
6.2.3 Identifying constructs underlying healthcare service quality 126
6.2.4 Identifying sub-constructs of healthcare service quality and testing the 127
effect of each of the identified sub-constructs on patient's overall
perception of service quality
6.2.5 Identifying the relationship between overall customer satisfaction and 131
iii
behavioural intentions to return and recommend, value for money and
outcome
6.2.6 Demographic Factors and their Relationship with Variables of the 132
Research
6.3 Challenges confronted by the researcher 139
7 Discussion 140
7.1 Establishment of the Model 142
7.2 Effect of Certain Sub-Constructs on Overall Perceived Service Quality 149
7.3 Link between Satisfaction and Service Quality 155
7.4 Relationship between demographics and service quality 159
8. Conclusion, Implications and Directions for Future Research 159
References 164
Appendices
A Egypt: Socioeconomic Classification I
B Questionnaire III
C Results of Pilot Study XI
D Results of Quantitative Survey XIV
iv
LIST OF TABLES
Table Page
2.1 Demonstrating Dimensions Identified by Hulka et al., 1975, Ware et 37
al, 1977, Wolf et al., 1978, Bertakis, 1977, Ley, 1983, Kiam-Caudle
and Marsh, 1975, Wooley et al., 1978 and Feletti et al., 1986
2.2 Demonstrating Dimensions Identified by Zeithaml et al., 1990 38
2.3 Demonstrating Dimensions identified by Brown and Swartz, 1989 39
2.4 Demonstrating Dimensions Identified by Joby, 1992 and by 41
Walbridge and Delene, 1993
2.5 Demonstrating Dimensions Identified by Woodside Arch G, Lisa L 43
Frey and Robert Timothy Daly, 1989 and Carmen, 1990
2.6 Health Expenditure Indicators (1990-2005) 44
2.7 Sources of finance, by percent (1990-2004) 45
2.8 Demonstrating Health Service Providers Indicators 45
3.1 Demonstrating the Constructs and Sub-constructs to be Used in the 57
Present Research
3.2 Demonstrating Dependent and Independent Variables to be used in the 67
study and their Corresponding Research Questions
3.3 Demonstrating Main Areas of Ideas and Questionnaire design 75
4.1 Demonstrating the Scales to be Tested 85
4.2 Demonstrating the Variables, research questions and analytical 89
methods used for data analysis
5.1 Demonstrates the Means and Variances for the Two Methodologies 101
5.2 Demonstrates the Independent t-test Results 101
6.1 Demonstrating percentage of average and summary of perceptions for 103
premises and employees
6.2 Demonstrating percentage of average and summary of expectations 104
for premises and employees
doctors services
for doctors services
diagnostic services
for diagnostic services
nursing services
for nursing services
admission services
for admission services
meals
v
for meals
rooms and housekeeping services
discharge services
for discharge services
6.17 Demonstrating percentage of average of importance for each of 114
hospital services provided
6.18 Demonstrating percentages for overall assessment of hospital services 115
provided
6.19 Summarizing the steps undertaken in the research 116
6.20 Demonstrating Cronbach Alpha for the Variables in the Research 118
6.21 Demonstrating KMO and Bartlett's Test for WEIGHTED SERVPERF 119
Method
6.22 Demonstrating Total Variance Explained for WEIGHTED 120
SERVPERF Method
6.23 Demonstrating Rotated Component Matrix and Constructs of the 121
Research
6.24 Logistic Regression for Constructs and Overall Perceived Service 124
Quality
6.25 Demonstrating Goodness-of-Fit Tests for construct logistic regression 125
analysis
6.26 Demonstrating Measures of Association: (Between the Response 125
Variable and Predicted Probabilities) for construct logistic regression
analysis
6.27 Demonstrates the levels of the model of the research 127
6.28 Demonstrating sub-constructs used in the current research with the 128
questions corresponding to each sub-construct
6.29 Demonstrating Results of Ordinal Logistic Regression for Sub- 129
constructs and demonstrates Across-Construct Relationships
6.30 Demonstrating Goodness-of-Fit Tests for Sub-constructs and Across- 129
Construct Relationships
6.31 Measures of Association: (Between the Response Variable and 130
Predicted Probabilities) for Sub-constructs and Across-Construct
Relationships
6.32 Demonstrates Correlation Between Overall customer satisfaction and 131
Behavioural intentions to return and recommend, Value for money
and Outcome
6.33 Demonstrating Tests of Equality of Group Means for the variable 132
―Age‖
6.34 Demonstrating Eigenvalues for the variable ―Age‖ 133
6.35 Demonstrating Wilk‘s Lambda for the variable ―Age‖ 133
vi
―Education‖
6.37 Demonstrating Eigenvalues for the variable ―Education‖ 134
6.38 Demonstrating Wilk‘s Lambda for the variable ―Education‖ 134
6.39 Demonstrating Eigenvalues for the variable ―Income Level‖ 135
6.40 Demonstrating Wilk‘s Lambda for the variable ―Income Level‖ 135
―Income Level‖
6.42 Demonstrating Standardized Canonical Discriminant Function 136
Coefficients for the variable ―Income Level‖
6.43 Demonstrating Structure Matrix for the variable ―Income Level‖ 137
6.44 Demonstrating Functions at Group Centroids for the variable ―Income 138
Level‖
6.45 Demonstrating Classification Results for the variable ―Income Level‖ 138
7.1 Summarizing the layout undertaken in the research discussion 141
7.2 Demonstrates the Use of Constructs and Sub-Constructs 153
A.1 Demonstrates Frequency of Responses of the Results for the Construct XII
"Premises and Employees" in the Pilot Study
A.2 Demonstrates Frequency of Responses of the Results for the Construct XII
"Doctors Service" in the Pilot Study
A.3 Demonstrates Frequency of Responses of the Results for the Construct XIII
"Diagnostic Service" in the Pilot Study
"Nursing Service" in the Pilot Study
"Admission Service" in the Pilot Study
"Meals" in the Pilot Study
A.7 Demonstrates Frequency of Responses of the Results for the Construct XIV
"Rooms and Housekeeping" in the Pilot Study
A.8 Demonstrates Frequency of Responses of the Results for the Construct XIV
"Discharge Service" in the Pilot Study
A.9 KMO and Bartlett's Test for SERVQUAL Method XV
A.10 Demonstrating Total Variance Explained for SERVQUAL Method XV
A.11 Demonstrating Rotated Component Matrix for SERVQUAL Method XVI
A.12 KMO and Bartlett's Test for WEIGHTED SERVQUAL Method XVII
A.13 Demonstrating Total Variance Explained for WEIGHTED XVII
SERVQUAL Method
A.14 Demonstrating Rotated Component Matrix for WEIGHTED XVIII
SERVQUAL Method
A.15 KMO and Bartlett's Test for SERVPERF Method XIX
A.16 Demonstrating Total Variance Explained for SERVPERF Method XIX
A.17 Demonstrating Rotated Component Matrix for SERVPERF Method XX
vii
LIST OF FIGURES
Figure Page
2.1 Conceptual Model of Disconfirmation-of-Expectations Process 46
2.2 Gronroos Service Quality Model 47
2.3 Parasuraman, Zeithaml & Berry Conceptual Model of Service Quality 48
2.4 Parasuraman, Zeithaml & Berry Extended Gap Model 49
2.5 Structural Model to Demonstrate the Relationships between 50
SERVQUAL and SERVPERF and Consumer Satisfaction, Overall
Service Quality and Purchase Intentions
2.6 Application of A General Framework to Customer (Patient) 51
Satisfaction with received Hospital Care
2.7 Demonstrating the Feedback Cycle in Healthcare 52
2.8 Demonstrating the Outcome Quadrants in Healthcare 52
2.9 Demonstrating Levels of Outcome in Healthcare 53
3.1 Scale Development Modules 61
3.5 Demonstrating Demographic Criteria as a Discriminating Variable 63
3.6 Demonstrating a General Framework of the Constructs to Overall 64
Perceived Service Quality with Received Hospital Care
3.7 Demonstrating the Constructs and Sub-constructs to be tested in the 65
Present Research
4.1 Demonstrating classification of hospitals by Ministry of Health in 80
Egypt
6.1 Demonstrating the stages of the research 102
6.2 Demonstrating percentage of average perceptions and average 104
expectations for premises and employees
expectations for doctors services
expectations for diagnostic service
expectations for nursing services
expectations for admission services
expectations for meals
expectations for rooms and housekeeping services
expectations for discharge services
6.10 Demonstrating percentage of average of importance for each of 115
hospital services provided
6.11 Demonstrating percentages for overall assessment of hospital services 115
provided
6.12 Demonstrating the Steps of the Research Analysis Process 116
viii
7.1 Demonstrates the Model of the Research on the Construct Level 146
7.2 Demonstrates the Model of the Research on the Construct and Sub- 154
Construct Level
8.1 Demonstrates the Model of the Research on the Construct and Sub- 160
Construct Level
ix
LIST OF ABBREVIATIONS
CS/D Confirmation Satisfaction/Disconfirmation

E Expectations
GDP Gross Domestic Product
IMS Indicator Measurement System
MEMRB Middle East Market Research Bureau
MENA Middle East and North Africa
MHA Maryland Hospital and health System
P Perceptions
PZB Parasuraman, Zeithaml and Berry
QIP Quality Indicator Project
SIR Sickness Impact Profile
t Time
UK United Kingdom
US United States
x
ABSTRACT
While quality in tangible goods has been thoroughly described and measured by
marketers, quality of services has yet a lot to be done. Accurate measurement of service quality
as perceived by patients has yet to reach a consensus for healthcare organizations. To this day
for the healthcare service market in Egypt and the Arab world, there is a need for a healthcare
service quality model that takes into consideration a complete coverage of the dimensions that
consumers use in evaluating healthcare service quality. The research to be conducted will focus
on service quality, patient satisfaction and intentions to return, and the consumer role in the
medical service encounter.
The main objective of this research was to formulate and empirically investigate a
fully tested and applicable healthcare service quality model that encompasses the criteria
consumers use in evaluating healthcare in Egypt for private sector hospitals. Also, research
aims to provide a valid and reliable scale with which healthcare providers can use for
measurement of the service quality in their organizations.
The current research was composed of two phases. The first phase aimed to develop
the model and questionnaire through a secondary data gathering process, qualitative interviews
with experts and Egyptian patients and a pilot study. The second phase was a full-fledged
quantitative survey to test and verify the model and the scale developed for the Egyptian
market.
The first phase has enabled the researcher to achieve several goals. The in-depth
interviews with patients enabled gathering their insight on what are the factors that they as
Egyptian patients expected and perceived in their recent hospital experience and the secondary
data gathering process identified the dimensions uncovered by previous researchers for
healthcare service quality. A tentative questionnaire was constructed based on this and was
further refined through the pilot study and the in-depth interviews with healthcare and business
expert. This further developed the previous preliminary questionnaire and model constructs
and final modification were done on the questionnaire format preparing it for the next phase of
quantitative data collection.
The second phase enabled the researcher to establish a healthcare service quality
model for private hospitals in Egypt in the field of Obstetrics and Gynaecology. The researcher
was able to determine the underlying constructs and sub-constructs of healthcare service
quality as well as determining which of the sub-constructs have greater impact on the patients‘
overall perception of service quality in the hospital. The researcher also determined the best
method for healthcare service quality measures among the eight alternative methods of service
quality measurement scales (SERVQUAL weighted and un-weighted versus SERVPERF
weighted and un-weighted) as well as establishing whether an additive or interactive
methodology was preferable in the current research setting. Several relationships were also
uncovered between the variables of the research consumer satisfaction, intention to return and
recommend, value for money and finally outcome. Finally, the role of demographics as a
discriminating variable was also established.
Marketers can use the model and the scale to evaluate consumer perceptions from
their healthcare service providers and thus be used as a valuable tool to identify and elevate the
level of services in areas that need to be addressed. This will ensure a higher level of patient
satisfaction and thus ensuring loyalty, repeat patronage and positive recommendation
behaviour, which is the ultimate goal of healthcare service providers. Thus the current research
could prove invaluable for improving the level of services in areas deemed defective by the
consumers of the service. This will be the first application of its kind in the healthcare sector in
Egypt and the Arab World.
xi
1. INTRODUCTION
While quality in tangible goods has been thoroughly described and measured
by marketers, quality of services has yet a lot to be done. Accurate measurement of
service quality as perceived by patients has yet to reach a consensus for healthcare
organizations. Many industries have been extensively researched as regards
measurement of service quality with the healthcare industry proving to be one of the
most difficult to put down to the multi-service type of operations existing in hospitals.
The research to be conducted will focus on service quality, patient satisfaction
and intentions to return, and the consumer role in the medical service encounter. A brief
overview on the existing literature for the relevant issues will be tackled. This will be
followed by a description of the problem at hand, the objective of the present research,
an outline for the theoretical framework, the research design, the research questions, the
research hypothesis, and the data analysis methods to be used. Finally, the results of the
research, conclusion and managerial implications will be done.
1.1 Significance of the Problem and Choice of topic

Services have been classified as consumer services (e.g. retail services) and
professional services (e.g. healthcare, law etc). Professional services such as those
offered by doctors or lawyers come the closest to be considered as pure services with
the service being produced and consumed simultaneously for both the consumer and the
provider and the consumer is an integral part of the service process. Because of
increasing competition and service providers and more demanding patients, service
quality has become a watchword for healthcare service providers but as yet has proven
difficult to measure. Service quality has been directly linked to repeat sales, positive
word-of-mouth and recommendation. Consumer satisfaction is directly linked to service
quality thus perceived quality, patient satisfaction and behavioral intentions are concepts
of foremost importance to healthcare marketers (Ross et al., 1987, John Joby, 1992,
Paul, 2003).
To this day for the healthcare service market, there is a need for a healthcare
service quality model that takes into consideration a complete coverage of the
dimensions that consumers use in evaluating healthcare service quality. It has been
researched extensively for many industries and briefly for the healthcare industry and
there is substantial proof that in the multi-service healthcare industry the dimensions
identified are quite different than those used for other industries and are yet to be
uncovered. The methodology of measurement of service quality also needs to clarified
where some authors used simple questionnaires fitted for their departments, others used
the widely tried and tested SERVQUAL, other yet accepted the critique of the gap
school and opted for performance- based measurement.
Healthcare service quality has to be addressed in a comprehensive model that
incorporates all dimensions of value to patients. This will work towards developing a
measurable scale that marketers can use to evaluate consumer expectations and
perceptions from the healthcare service providers and thus be used as a valuable tool to
identify and elevate the level of services in areas that need to be addressed. This will
ensure a higher level of patient satisfaction and thus ensuring repeat patronage and
positive recommendation behaviour, which is the ultimate goal of healthcare service
providers. The proposed model could be the first comprehensive formalization of the
healthcare service quality constructs and a scale applied in the Arab world for the
healthcare industry.
-1-
Health systems are undergoing rapid change and the requirements for
conforming to the new challenges of changing demographics, disease patterns, emerging
and re-emerging diseases coupled with rising costs of health care delivery have forced a
comprehensive review of health systems and their functioning. As the countries examine
their health systems in greater depth to adjust to new demands, the number and
complexities of problems identified increases. Some health systems fail to provide the
essential services and some are creaking under the strain of inefficient provision of
services. A number of issues including governance in health, financing of health care,
human resource imbalances, access and quality of health services, along with the
impacts of reforms in other areas of the economies significantly affect the ability of
health systems to deliver (EMRO, 2006).
Numerous researchers have stressed the importance of improving the level of
healthcare service quality in the private sector in Egypt. The hospital industry faces
challenges, including an increase in patients who don't pay their bills, competition from
independent entrepreneurial doctors who are doing more diagnostic and treatment
services in their offices or establishing their own surgical centres and hospitals. Many
hospitals have reported that the rate of admissions has already slowed, partly because
patients are seeking services elsewhere (Berman et al, 1997, Bakr, 2008, Appleby,
2006).
The topic under investigation is concerned with developing a model for
healthcare service quality for the Egyptian private sector hospitals. Egypt is undergoing
a drastic transformation on all industry levels in the past era. Geographically and
culturally, it lies in the heart of the Middle East and is considered the gate to Africa and
one of the most influential centres of the Arab world.
Recently, Egypt has made substantial progress in improving the health status of
its population during recent decades. Despite these gains, wide disparities in health
conditions persist. New health challenges are also emerging, which will increase the
need for treatment of disease and for behaviour change (Berman et al, 1997).
Currently, there is a drastic need for improvement of the quality of healthcare
services provided in both the private and the public hospitals in Egypt. The market is
divided into subsidized public and out-of-pocket private healthcare sectors. The
government‘s subsidized health-care plan introduced in the 1950s has become
synonymous with long lines, surly nurses and overworked doctors who examine an
average of 17 patients an hour. Over 36 million Egyptians receive state health care,
while 21 million have opted for private health care and 15 million – about 20 percent of
the population – have no health coverage at all (Bakr, 2008).
Due to the vastly different segments frequenting the two sectors thus making a
single study encompassing both sectors not feasible as well as the limitations of the
study mentioned later, the researcher has opted to focus the study on the private
healthcare sector with recommendations for focusing on the public sector in future
research.
1.2 Statement of the Problem

The Egyptian private healthcare sector is in need of elevation of the level of
service quality. In order to achieve this goal, there is a need for a model for healthcare
service quality applied and tested on the Egyptian healthcare market as well as a scale to
enable researchers to measure healthcare service quality in the hospitals aiming to pin-
point areas of service quality short-falls for short and long-term improvement strategies.
-2-
Currently, there is lack of existing knowledge about a healthcare service
quality model that takes into consideration a complete coverage of all the constructs and
sub-constructs that consumers use in evaluating healthcare service quality in Egypt that
is probably quite different than those used for other industries and in other countries. In
addition, there is insufficient knowledge about the most appropriate methodology for
measurement of healthcare service quality for healthcare in Egypt (performance-based
(weighted/un-weighted) versus gap-based (weighted/un-weighted) measurement for
healthcare service quality measurements, interactive versus additive). Moreover, there is
lack of existing knowledge about the effect of demographics in the Egyptian healthcare
service market.
1.3 Objective(s) of the Study

The main objectives of this research is:
1. To define the constructs and sub-constructs used by Egyptian consumers in the
evaluation of healthcare service quality in private sector hospitals in Egypt.
2. To analyse the best method for measurement of service quality among the tested
measures.
3. To determine relationships between variables of the study (overall consumer
satisfaction on one hand and return behaviour, outcome and value for money on the
other hand).
4. To determine relationships between consumer demographics characteristics and
their effects on the variables in the research.
5. To recommend a healthcare service quality model for the private healthcare sector
in Egypt.
1.4: Research Questions

1.4.1: Major Research Questions
Q1: What are the constructs and sub-constructs underlying healthcare service quality?
Q2: What is the best measure of healthcare service quality among the eight tested
models?
Q3: Do consumer demographic (Age, Education, Socioeconomic Standard) have an
effect on variables of the research?
Q4: Does the service quality of certain dimensions have greater impact on the overall
perception than others?
Q5: What is the relationship between overall customer satisfaction on one hand with
behavioural intentions to return and recommend, value for money, outcome to mother
and outcome to baby on the other?
1.4.2: Minor Research Questions
Q1: Are the sub-constructs Physician Reliability, Physician Assurance (Security),
Physician Interaction (Empathy/Responsiveness), Physician's Competence (Assurance) ;
Nursing Reliability, Nursing Assurance (Security), Nursing Interaction (Empathy),
Nursing Responsiveness ; Diagnostic Service Competence, Diagnostic Service
Reliability ; Hospital Premises and employees Tangibles ; Admission Responsiveness,
Admission Knowledge and Courtesy (Assurance) ; Meals Tangibles ; Rooms Tangibles
and Housekeeping Courtesy (Assurance) ; Discharge and Courtesy (Assurance)
underlying factors for healthcare service quality?
Q2: Is an un-weighted performance based measurement of service quality (un-weighted
SERVPERF) is a more appropriate measure for service quality than SERVQUAL,
weighted SERVQUAL and weighted SERVPERF?
-3-
Q3: Is an interactive methodology a more appropriate measure for service quality than
an additive methodology?
Q4: Does the consumer demographic characteristic (Age) have a significant effect on
variables of the research?
Q4: Does consumer demographic characteristics (Education) have a significant effect on
variables of the research?
Q4: Does consumer demographic characteristics (Socioeconomic Standard) have a
significant effect on variables of the research?
Q5: Does the service quality of certain service quality dimensions have significantly
greater impact on the overall perception of service quality than others?
Q6: Is there a correlation between overall customer satisfaction and the patients'
intention to return and recommend the hospital?
Q7: Is there a correlation between overall customer satisfaction and the value for
money?
Q8: Is there a correlation between overall customer satisfaction and the outcome to
mother?
Q9: Is there a correlation between overall customer satisfaction and outcome to baby?
1.5 Research Methodology

The current research is composed of two phases. The first phase aims to develop the
model and questionnaire through a secondary data gathering process, qualitative
interviews with experts and Egyptian patients and a pilot study. The second phase will
be a full-fledged quantitative survey to test and verify the model and the scale developed
for the Egyptian market.
The First Phase
1. Qualitative exploration of the characteristics of the healthcare services in Egypt
upon which consumer build their perceptions about the quality of the healthcare
service. This will be performed through:
a. A series of in-depth interviews with patients frequenting the private
healthcare sector in Cairo to gather their insight on what are the factors
that they as Egyptian patients expected and perceived in their recent
hospital experience.
b. Secondary data gathering process through a thorough literature review to
identify the dimensions uncovered by previous researchers for healthcare
service quality
2. From the above step, a tentative questionnaire will be constructed based on the
work of previous researchers and the experiences of Egyptian healthcare patients.
The questionnaire will be containing both the international standards for healthcare
service quality measurements and in-depth insight for the Egyptian market. This
questionnaire was to be further refined through the next sections:
a. A pilot study to test the questionnaire and the reliability of data as well as
to test all aspects of the questionnaire aiming to eliminate any potential
problems in the questionnaire and refine it for final use.
b. In-depth interviews with healthcare and business experts to further develop
the previous preliminary questionnaire and model constructs.
3. Final modification on the questionnaire format will be done, prior to the
quantitative data collection procedure.
-4-
The Second Phase
1. Themes and information from previous phase will then be developed into a valid
and reliable instrument for measurement of health care service quality. A modified
conceptual model of service quality will be constructed that will be based on the
work of previous authors in the field as well as data gathered from the qualitative
section of the study.
2. A quantitative survey for a sample of patients frequenting the private healthcare
sector in Greater Cairo, Egypt will be performed to test the model:
a. The population under study will be individuals frequenting private
hospitals in the Greater Cairo governorate. Sampling Methods will include
the simple random sampling technique.
b. The questionnaire will include items extracted from the literature review
and further subject to modifications following the preliminary qualitative
part of the research. A final questionnaire will be developed and
administered via a full-fledged field survey.
c. The final questionnaire is composed of several sections. They include
sections covering perceptions, expectations, importance of healthcare
services in their most recent encounter with one of the private healthcare
providers in Egypt. Also a section containing a direct assessment of the
overall service quality of the hospital and finally a section gathering
information about the demographic characteristics of the respondent
1.6 Scope of the Research

The present research lies on the continuum of research processes, starting with
exploratory to descriptive and ending on the analytical continuum. It will start with
exploratory research to explore and identify the characteristics of healthcare service
quality that consumers base their perceptions of the service quality upon in the private
sector in Cairo, Egypt. Then the research will move beyond the descriptive towards the
analytical continuum and will go beyond identifying these characteristics, to analyzing
them an understanding and measuring the relationships between them.
The research will constitute of a two-phase study. First a qualitative phase then
a quantitative phase will be done. The qualitative phase of the research identifying and
describing healthcare characteristics will be performed through an extensive literature
review and a series of in-depth interviews. The quantitative phase of the research will be
performed through of a survey questionnaire. A sample of patients will be drawn from
the population and studied to make inferences about the population. A representative
sample will be taken and the use of statistical techniques will enable the researcher to
generalize these findings to the population.
The population under study is the individuals frequenting private hospitals in
the greater Cairo governorate. This population features members of the A & B class in
Egypt who can afford to pay for the prices of privatized healthcare in Egypt and random
sampling will be done. The individuals selected for the study will include females who
have frequented a private hospital in the past five years months for performing a
successful childbirth (normal and interventional), had at least a one overnight stay in the
hospital and are residing in Greater Cairo. Since the population exceeded 75,000
individuals, thus the sample size of 384 was chosen to represent the population at hand
and the results of the present research sample can be safely generalized to the
population.
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1.7 Expected Contribution
This study hopes to establish a base for healthcare service quality models
applied on Egyptian private healthcare sector. A deeper understanding of the sub-
constructs used to evaluate healthcare and a scale for measuring service quality in
healthcare will be achieved. The relationship with several factors as demographics,
overall perceptions, satisfaction and future purchase and recommendation behavior will
be highlighted. This research implies a more comprehensive model for healthcare
service quality than those present in the field, especially for the Arab world. One of the
major obstacles to this comprehensive study would be lack of a guiding empirical
research in the Arab World.
To summarize, the expected contributions of this dissertation will include a
fully tested and applicable model for healthcare service quality highlighting all the
constructs and sub-constructs that patient's use for evaluation of healthcare service
quality for private sector hospitals. The provision of a valid and reliable scale with
which healthcare marketers can deploy for measurement of the service quality in their
organizations will be also be done and this tool will prove invaluable for improving the
level of services in areas deemed defective by the consumers of the service. This will be
the first application in the healthcare sector in Egypt and the Arab World.
1.7.1: Theoretical significance and contribution
Healthcare managers and marketers would be able to identify all dimensions
that patients use for evaluation of the level of service provided in their
organizations.
Healthcare managers and marketers would have a valid and reliable scale by
which they could measure the service quality in their organizations.
Healthcare managers and marketers would be able to determine what leads to
customer satisfaction and return and recommendation behaviour.
Healthcare managers and marketers would be able to recognize the factors that
could lower customer dissatisfaction and disloyalty and bad word-of-mouth
behaviour.
Healthcare managers and marketers would be able to understand the right
actions and attitudes required from their staff including doctors, nurses,
admission and discharge personnel, housekeeping and kitchen staff that is
needed to satisfy and retain customers
Healthcare managers and marketers would be able to learn to promote
interactions that are likely to yield positive impact upon customers‘ decision.
1.7.2: Practical implementations and managerial implications
Hospitals would be able to tailor their strategies thus offer the best services that
match their client‘s expectations.
Hospitals will be able to judiciously allocate their resources to achieve their
goals of customer satisfaction and retention.
Implementing this study will lead to a higher level of healthcare service quality
provision in Egypt.
Hospitals will own a valid and reliable scale to measure their clients
satisfaction through a tailored sophisticated measurement tool.
1.8: Limitations
Several limitations will be faced by the researcher in the current research.
Limitation 1: Difficulty in generalizing the results: This research has limitations
in terms of scope and external validity. The findings and implications will be
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particularly relevant to healthcare providers only in Egypt and only for the
private sector hospitals. General hospitals, rural populations and low
socioeconomic classes were not studied. These sampling criteria were adopted
for ease and time limitations of research as well as the belief that the needs and
perceptions of each of these strata would differ greatly and this could be
considered for future research.
Limitation 2: Limitation in Variables under Study: A limitation in the research
is that it has limited itself to relating satisfaction and perceived service quality
to the factors studied (service quality expected and perceived, knowledge and
demographics). Several other moderating or mediating factors as insurance
and accessibility could be considered and tested in future research
Limitation 3: Practical Limitations: The sample size should be big enough to
enable use of multivariate analysis techniques, but there are limitations in the
extra finance, effort and organization would be essential to perform a larger
size for this research.
Limitation 4: Limitation in the sample under study: A limitation in terms of
scope due to applying the study only on obstetrics patients exists. Patients
frequenting other specialities were not studied. Other specialities could be
considered in future research.
1.9 Organization of the Research

This research is organized into seven chapters. The first chapter (the current
one) is the introductory chapter and will include a highlight of the problem, the research
questions, the significance and the contribution of the current research. The next chapter
includes a through literature review on healthcare sector, consumer satisfaction, service
quality, healthcare service quality and satisfaction studies, literature linking service
quality, patient satisfaction and behavioural intentions to return and finally literature on
the effect on consumer demographics on service quality expectations and perceptions.
The third chapter introduces the model to be tested in the present research and the
development of the research hypothesis. The fourth chapter discusses the methods used
to analyze the data. The fifth chapter outlines the pilot data collection procedures, the
reliability and validity assessments, and the results of the quantitative phase. The sixth
chapter demonstrates the results of the quantitative phase of the research. The seventh
chapter is a discussion on the current research findings. The final chapter eight is a
conclusion, implication for future research and directions for future research.
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2. LITERATURE REVIEW
The success of a service organization lies centrally within the boundaries of

satisfied and repeated customers. In the tangible goods sector, quality has been clearly
defined and measured by marketers. Quality of services however remains less clearly
defined and measured. Many researchers have described measures for service quality.
Although consumer satisfaction and service quality literature is extensive and some
authors even argue that research in this topic has finally reached a maturity stage, a
focus combining service quality measures, expectations antecedents and consumer role,
and linking service quality with satisfaction and intentions to return in healthcare has
been less studied and each issue was treated in isolation of the others.
The following literature review aims to give a comprehensive overview on the
issues around the subject to be discussed in the present research. Several topics will be
reviewed in this section. First, an overview of the worldwide healthcare industry will be
made. Second, consumer satisfaction literature will be briefly reviewed. Third, service
quality literature will be discussed highlighting the work of the most prominent authors
in that field with specific emphasis on healthcare service quality research. Fourth,
consumer role in the form of knowledge brought to the encounter and its role as an
antecedent to service quality perceptions will be made. Finally the role of consumer
demographics on service quality perceptions will be reviewed.
2.1: Healthcare Sector Worldwide

The ecosystem spending of hospitals, physicians, pharmaceutical companies,
and insurance providers was in excess of $2 trillion (Advertising Industry Newswire,
2006). For the better part of the 1990s, healthcare costs rose at a slower rate than they
had throughout the 1980s. Between 1960 and 1997, the percentage of GDP spent on
healthcare by 29 members of the organization for Economic Cooperation and
Development (OECD) nearly doubled from 3.9% to 7.6% (PricewaterhouseCoopers,
1999).
The percentage of GDP spent on healthcare by the United States was among
the most among the OECD members, about 13.6% in 1997. According to the US
government, this percentage is expected to increase to more than 16% by 2010. Another
study conducted by the Commonwealth fund revealed that the UK spent at least 6.7%
on healthcare (PricewaterhouseCoopers, 1999). The healthcare landscape has once again
changed. PricewaterHouseCoopers's latest estimate is that premiums rose by 8.8 percent
from 2004 to 2005 (PriceWaterhouseCoopers, 2006).
As for the per capita spending, healthcare spending has gown significantly
across the world. From 1960's to 1999, it has increased from less than $500 per captia to
$1800 in Japan, $2100 in Australia and Europe, and $2,400 in Canada. In the U.S., per
capita spending has increased from $144 per capita in 1960 to almost $4,400 by 1999
(Altera Corporation, 2006).
Private health spending increases per capita were the lowest in several decades
during the period 1994-1998. Industry observers generally attributed this slower growth
in healthcare costs to the success managed care health plans had with network-based
healthcare. Yet in the late 1990s, per capita healthcare spending costs began to increase
again, peaking around 2002, when PwC estimated that premiums were increasing 13.7
percent (PricewaterhouseCoopers, 1999).
Healthcare spending in the US has reached mammoth proportions with the
nation spending about $1.65 trillion a year on healthcare. While healthcare costs have
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sky rocketed on one hand – healthcare represents 15% of gross domestic product and
consumes one-fourth of the federal budget, more than defense (Cranberry Corporations).
During the period 2000-2003, the average annual increase in personal health care
expenditures was 8.2 percent. This equates to $4,866 per capita in 2003 as compared to
$2,398 in 1990 (Silverstein, 2006). The U.S. per capita spending is projected to grow to
$7,500 by 2008. Equipment suppliers understand that in order to be successful in the
medical market they have to be focused and successful in the U.S. (Altera Corporation,
2006)
Healthcare is on an upward track where there is about a ½% increase in
healthcare cost for each percentage increase in wealth. There are downward cost
pressures through increasing automation and technology but these are offset by the
upward pressures of an aging society, consumerism, biotechnology and medical
breakthroughs. The result is an increase in the costs of healthcare of between 2 ½ to 3 ½
per year (PricewaterhouseCoopers, 1999).
The medical marketplace has become increasingly competitive and aggressive.
Due to the high costs associated with running a successful organization, the importance
of retaining current patients and attracting new ones is the ultimate means of survival in
this new medical marketplace. Patient loyalty and new patients inflow mainly results
from achieving patient satisfaction with the medical services they receive in the
hospital. Loyalty will directly stem from the patients satisfaction or dissatisfaction with
the hospital. Also satisfied and dissatisfied customers through word-of-mouth generate
information about the care provided in a certain hospital that may attract or deter
potential patients to that place. Patient satisfaction may also influence successful
medical outcomes (Ross et al., 1987). A satisfied patient is one who is more likely to
partake and conform with treatment and rehabilitation (Roger et al., 1982, Macgregor,
1981, Burton and Wright, 1980, Liang and Cullen, 1984).
Patient satisfaction is considered the in the last stage of the buyer decision
process which is constituted of need recognition, information search, evaluation of
alternatives, purchase decision and the post-purchase behaviour (Kotler and Armstrong,
1999). Satisfaction is important since a company's revenue comes from two basic
groups, new customers and retained customers. It costs much more to attract new
customers than it does to retain older ones thus it makes sense for marketers to strive to
retain their customers through achieving patient satisfaction since satisfied customers re-
purchase, talk favourably to others about the brand, pay less attention to competing
brands and advertising thus are less likely to switch and but products and alternatives
from other companies (Kotler and Armstrong, 1999). Some marketers go beyond merely
meeting the customers' expectations to aiming to delight the customer thus ensuring that
they are more likely to re-purchase, talk favourably of the product and pay premium
prices (Kotler and Armstrong, 1999)..
The past few years have witnessed increased concern regarding the quality of
primary healthcare. Policymakers have been anxious to investigate and develop the
efficiency of healthcare delivery. Recently, the medical profession has been increasingly
focusing on the development of workable measures to capture the outcome of medical
care (Fitzpatrick, 1989, Frater and Costain, 1992) and quality (Fargmer, 1991).
The hospital marketer is now concerned in how to build an increase in demand
for his organization versus other organizations. Building customer loyalty through
satisfaction with the offered services as well as attracting new customers is one of the
main targets of a hospital. To ensure patient satisfaction, hospital marketers used patient
surveys to ask patients to rate their satisfaction with the services offered. Surveys are a
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useful and simple management tool that give a direct reflection of patient satisfaction
with hospital services (Swan et al., 1985).
It is believed that increases in patient satisfaction can be achieved with
improving the services that rated low in the satisfaction surveys or in services that
patient relate strongly with future intentions to revisit the hospital thus enters the
importance of measuring consumer satisfaction with the service quality (Anderson,
1981).
Another important aspect of the healthcare industry is a hospital is composed
of both a technical (medical service) and functional (hospitality service) aspect. Steven
D Wood, PhD, Executive Director of JD Power and Associates Healthcare Division
states that ―we believe patients can separate their personal medical outcome from their
service experience during their hospital stay. With that in mind, hospitals can definitely
differentiate themselves on the basis of the service aspects of the patient experience.
Patients enter the hospital in a heightened state of anxiety, making empathy and relevant
information both welcome and highly valued. Patients also place a high value on the
service aspects of their hospital experience – such as food, comfort of the bed, room
amenities, and the responsiveness of the staff-just as a hotel guest would do‖ (Managed
Care Weekly Digest, 2003). A hospital marketer should focus on improving both
aspects of the hospital service and not just one or the other.
2.2: Consumer Satisfaction Literature

The study of consumer satisfaction has always been one of the central issues in
marketing in today‘s competitive marketplace, where companies needs to satisfy its
customers to ensure its profitability. Briefly, the work of the foremost authors in the
subject will be highlighted in the following section.
2.2.1: Confirmation/disconfirmation Concept
One of the earliest concepts of consumer satisfaction literature is the
confirmation/disconfirmation concept. The majority of studies in consumer satisfaction
are based on this paradigm. This is traced back to the early consumer behavior models
(Nicosia, 1966, Engel et al, 1968, Howard and Sheth, 1969). These theories incorporate
post-purchase evaluation as an integral part in mapping the consumer decision process.
The confirmation/disconfirmation paradigm is widely accepted as ‗a view of the
process by which consumers develop feelings of satisfaction/dissatisfaction (CS/D)
(Cadotte et al., 1987). A choice is made for a particular brand at a certain time, t. This
choice is based on the usual process involving expectations or brand attribute beliefs,
attitudes and intentions (Oliver, 1980). At some subsequent time, this focal brand is
used, t+1. Here, a perception of the brand‘s performance is triggered and the consumer
evaluates the experience of using the brand. Evaluation usually implies comparison of
the actual performance of the brand with some standard in the consumer‘s mind. Thus
there are three outcomes to this experience:
Confirmation: Occurs when performance matches the standard. The patient
experiences a neutral feeling
Positive Disconfirmation: Occurs when performance is better than the standard and
this leads to satisfaction
Negative Disconfirmation: Occurs when performance is worse than the standard
and this leads to dissatisfaction
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2.2.2: Equity Theory
Also prominent in consumer satisfaction literature is the equity theory that states
that consumers will analyze the purchase process to determine the extent to which it is
fair. Dissatisfaction is the result of a perceived unfavourable ratio of outcomes to inputs
in an exchange process in relation to the other party in the exchange (Fisk and Young,
1985, Cadotte et al., 1987, Murfin et al., 1995).
2.2.3: Attribution Theory
Furthermore, there is also the ‗Attribution Theory‘ that focuses on the way
people identify causes of actions (Folkes et al, 1984). In addition, the Attribution-Based
Affective Feelings (Westbrook, 1987) deals with the affective feelings associated with
the product or service after purchase that can influence the level of satisfaction and
states that both positive and negative feelings can exist simultaneously about a purchase.
An example of this is on purchase of a new product there is excitement about the
purchase while there might be irritation during the purchase process stemming from
unfriendly sales personnel (Murfin et al., 1995).
2.3: Consumer Satisfaction and Service Quality Literature

Many researchers have researched service quality and considerable findings
and progress has been achieved in the measurement of service quality (Zeithaml et al,
1988, Gronroos, 1984) strong findings as well as opposing critique against the
usefulness of the existing satisfaction measures (Peterson and Wilson, 1992, Carman,
1990, Cronin and Taylor, 1992, 1994) has emerged. A brief overview on the relevant
literature will be tackled in the following section.
Services have been defined as either consumer services (e.g. department stores)
and professional services (legal, medical etc) (Fitzsimmons and Sullivan, 1982, Sasser
et al., 1978). Professional services, which are those provided by professional as doctors
or lawyers such as healthcare services, legal services etc, have been classified as close to
pure services. No tangible good is exchanged between the provider and the consumer
and the service is usually produced and consumed simultaneously for each customer
(Woodside et al., 1989).
Service literature has left confusion as to the relationship between consumer
satisfaction and service quality. This is important because service providers have a need
to know and distinct between having customers who are ‗satisfied‘ with their
performance or to deliver the maximum level of ‗perceived service quality‘. Several
researchers have tried to clarify this relationship. Parasuraman et al., 1985, 1988
proposed that higher levels of perceived service quality resulted in increased consumer
satisfaction. Other researchers conclude that satisfaction is an antecedent of service
quality. Bitner, 1990 demonstrated a causal pathway between satisfaction and service
quality. Bolton and Drew, 1991 assuming that service quality is an attitude suggested
that satisfaction is an antecedent of service quality. They posed that ATTITUDEt
(perceived service quality) is a function of consumer‘s residual perception of the service
quality from a prior period (ATTITUDEt-1) and the consumer‘s level of
(dis)satisfaction with the current level of service (CS/Dt).
Consumers have become more quality-conscious in the past era and the benefits
of quality in contributing to market shares and the return-on-investment of firms has
been clearly demonstrated (Philips et al., 1983). The definition of quality is essential
before any developments in service quality strategy. The definitions in goods literature
are not applicable of services mainly due to the three unique service characteristics,
intangibility, inseparability and heterogeneity (Leichty and Churchill, 1979). Whereas
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the goods marketing literature stresses the four P‘s (Price, Promotion, Place and
Product), in services the most important construct of services is performance, which
creates true and loyal consumers (Parasuraman et al., 1990). Service quality researchers
have defined service quality as the ability of the organization to meet or exceed
consumer expectations. Zeithaml et al., 1990 have defined it as ‗the extent of
discrepancy between customer expectations/ desires and perceptions‘.
Service quality has recently received major attention from researchers and
noTable contributions have been made in service quality models namely by Lehtinen
and Lehtinen, 1982, Gronroos, 1983, 1984, Lewis and Booms 1983, Parasuraman et al.,
1985, 1988, Zeithaml et al., 1988, 1993, Berry at al., 1988, Le Balnc and Nyugen, 1988,
Brown and Swartz, 1989, Carman, 1990 and Cronin and Taylor, 1992. Two main bodies
of research prominently appear relevant in lieterature and on which numerous other
researchers built their work. These include the Nordic School (Gronroos, 1983, 1984)
and the ‗Gap Analysis School‘ (Parasuraman, Zeithaml and Berry, 1985).
2.3.1. The Nordic School
The Nordic School (Gronroos, 1980, 1982, 1983, 1984) primarily defined
perceived service quality as being primarily dependent on two variables, expected and
perceived service. The latter is in turn influenced by a technical and a functional
dimension.
Technical quality answers the question of what the consumer gets and the
functional quality answers to how the consumer gets. Technical quality dimensions are
namely technical solutions, know-how, computerized systems and machines. Functional
service qualities comprise accessibility, appearance, long-run customer contacts,
internal relations in the hospitals, attitudes, behaviors and service mindedness of the
service personnel (Gronroos, 1983). Finally, image was also introduced as an
intervening variable between quality (technical and functional) and consumer perception
of service quality (Gronroos, 1983).
Gronroos, 1984 concludes that functional quality is considered to be more
important at least as long as the technical quality is on a satisfactory level. The findings
also indicate that a high level of functional quality may compensate for temporary
problems with technical quality.
2.3.2. The Gap Analysis School
This school recognized that a key set of discrepancies or gaps exist regarding
executive perceptions of service quality and the tasks associated with service delivery to
consumers; these gaps can be major hurdles in attempting to deliver a service which
consumers would perceive as being of high quality. Research was conducted with
executives and clients of four types of service industries (retail banking, credit card,
securities brokerage and product repair and maintenance). (Parasuraman et at. 1985).
Since the industries under investigation represented a cross section of
industries, which vary along key dimensions used to classify services (Lovelock
1981a,b, 1983), many researchers concluded that the findings are also likely to be of
relevance to medical services.
The gaps can be subdivided into gaps on the marketer and consumer sides:
Gap 1 is the difference between consumer expectations and
management perceptions of consumer expectations.
Gap 2 is the difference between management perceptions of consumer
expectations and service quality specifications.
Gap 3 is the difference between service quality specifications and the
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service actually delivered.
Gap 4 is the difference between service delivery and what is
communicated about the service to consumers.
Gap 5 is on the consumer side, and it shows the difference between a
consumer‘s actual and perceived quality of service
With regard to gap 5, service quality determinants used by consumers do not
tend to vary substantially across service industries and were classified into 10 key
categories: reliability, responsiveness, competence, access, courtesy, communication,
credibility, security, understanding/knowing the customer and tangibles then later
summarized to five (Parasuraman et al., 1985).
Then the SERVQUAL, a 22-item instrument for assessing customer
perceptions of service quality in service and retailing organizations was developed. The
reliabilities and factor structures indicate that the final 22-item scale and its five
dimensions have sound and sTable psychometric properties. There was also strong
support for SERVQUAL validity (Parasuraman et al., 1988).
The original scale consisted of a 97-item instrument, which was further divided
into 10 dimensions and 54 items using item-to-item correlations and coefficient alpha
computations. This was followed by factor analysis reducing the items further to 34
items and five of the original 10 dimensions. These included tangibles, reliability,
understanding/knowing the consumer, responsiveness and access, which remained
distinct. The remaining five dimensions, communications, credibility, security,
competence and courtesy collapsed into 2 distinct dimensions, each consisting of items
from the original five dimensions. This 37-item scale was following another step of
purification was reduced into the final 22-item scale, divided into five dimensions,
tangibles, reliability, responsiveness, assurance and empathy. The last two dimensions
containing items representing the seven original dimensions: communications,
credibility, security, competence, courtesy, understanding/knowing the consumer and
access (Parasuraman, et al., 1988, 1991). Of all these dimensions, reliability has
emerged as the most important one from the customers‘ viewpoint regardless of the
service being studied (Berry 1988).
The remaining five dimensions include:
Tangibles are the appearance of the physical facilities, equipment and
appearance of personnel.
Reliability is the ability to perform the promised service dependently arid
accurately.
Responsiveness is the willingness to help customers and provide prompt
service.
Assurance is the knowledge and courtesy of employees and their ability to
inspire trust and confidence.
Empathy is the caring, individualized attention the firm provides its customers.
2.3.3. Critique of the Gap School
Several authors suggested several critiques and modifications for the
SERVQUAL. Some authors question the stability of the dimensions. Others propose a
performance-based rather than a gap-based measurement due to the strong effect of
prior experience. Several other authors question the importance of weights in the scale
measurements.
Several issues have been raised with regard to use of (P-E) gap scores, i.e.,
disconfirmation model. Most studies have found a poor fit between service quality as
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measured through Parasuraman, Zeithaml and Berry‘s (1988) scale and the overall
service quality measured directly through a single-item scale (e.g., Babakus and Boller,
1992; Babakus and Mangold, 1989; Carman, 1990; Finn and Lamb, 1991; Spreng and
Singh, 1993). Though the use of gap scores is intuitively appealing and conceptually
sensible, the ability of these scores to provide additional information beyond that
already contained in the perception component of service quality scale is under doubt
(Babakus and Boller, 1992; Iacobucci, Grayson and Ostrom, 1994). Pointing to
conceptual, theoretical, and measurement problems associated with the disconfirmation
model, Teas (1993, 1994) observed that a (P-E) gap of magnitude ‗-1‘ can be produced
in six ways: P=1, E=2; P=2, E=3; P=3, E=4; P=4, E=5; P=5,E=6 and P=6, E=7 and
these tied gaps cannot be construed as implying equal perceived service quality
shortfalls. In a similar vein, the empirical study by Peter, Churchill and Brown (1993)
found difference scores being beset with psychometric problems and, therefore,
cautioned against the use of (P-E) scores.
Validity of (P-E) measurement framework has also come under attack due to
problems with the conceptualization and measurement of expectation component of
the SERVQUAL scale. While perception (P) is definable and measurable in a
straightforward manner as the consumer‘s belief about service is experienced,
expectation (E) is subject to multiple interpretations and as such has been
operationalized differently by different authors/researchers (e.g., Babakus and Inhofe,
1991; Brown and Swartz, 1989; Dabholkar et al., 2000; Gronroos, 1990; Teas, 1993,
1994). Initially, Parasuraman, Zeithaml and Berry (1985, 1988) defined expectation
close on the lines of Miller (1977) as ‗desires or wants of consumers,‘ i.e., what they
feel a service provider should offer rather than would offer. This conceptualization was
based on the reasoning that the term ‗expectation‘ has been used differently in service
quality literature than in the customer satisfaction literature where it is defined as a
prediction of future events, i.e., what customers feel a service provider would offer.
Parasuraman, Berry and Zeithaml (1990) labelled this ‗should be‘ expectation as
‗normative expectation,‘ and posited it as being similar to ‗ideal expectation‘. Later,
realizing the problem with this interpretation, they themselves proposed a revised
expectation (E*) measure, i.e., what the customer would expect from ‗excellent‘ service
(Parasuraman, Zeithaml and Berry, 1994).
It is because of the vagueness of the expectation concept that some researchers
like Babakus and Boller (1992), Bolton and Drew (1991a), Brown, Churchill and Peter
(1993), and Carman (1990) stressed the need for developing a methodologically more
precise scale. The SERVPERF scale — developed by Cronin and Taylor (1992) — is
one of the important variants of the SERVQUAL scale. For, being based on the
perception component alone, it has been conceptually and methodologically posited as a
better scale than the SERVQUAL scale which has its origin in disconfirmation
paradigm.
Methodologically, the SERVPERF scale represents marked improvement over
the SERVQUAL scale. Not only is the scale more efficient in reducing the number of
items to be measured by 50 per cent, it has also been empirically found superior to the
SERVQUAL scale for being able to explain greater variance in the overall service
quality measured through the use of single-item scale. This explains the considerable
support that has emerged over time in favour of the SERVPERF scale (Babakus and
Boller, 1992; Bolton and Drew, 1991b; Churchill and Surprenant, 1982; Gotlieb,
Grewal and Brown, 1994; Hartline and Ferrell, 1996; Mazis, Antola and Klippel, 1975;
Woodruff, Cadotte and Jenkins, 1983). Also when applied in conjunction with the
- 14 -
SERVQUAL scale, the SERVPERF measure has outperformed the SERVQUAL scale
(Babakus and Boller, 1992; Brady, Cronin and Brand, 2002; Cronin and Taylor, 1992;
Dabholkar et al., 2000). Seeing its superiority, even Zeithaml (one of the founders of the
SERVQUAL scale) in a recent study observed that ―…Our results are incompatible with
both the one-dimensional view of expectations and the gap formation for service
quality. Instead, we find that perceived quality is directly influenced only by perceptions
(of performance)‖ (Boulding et al., 1993). This admittance cogently lends a testimony
to the superiority of the SERVPERF scale.
As for the use of weighted scales (weighted SERVQUAL and weighted
PERVPERF), the significance of various quality attributes used in the service quality
scales can considerably differ across different types of services and service customers.
Security, for instance, might be a prime determinant of quality for bank customers but
may not mean much to customers of a beauty parlour. Since service quality attributes
are not expected to be equally important across service industries, it has been suggested
to include importance weights in the service quality measurement scales (Cronin and
Taylor, 1992; Parasuraman, Zeithaml and Berry, 1995, 1998; Parasuraman, Berry and
Zeithaml, 1991; Zeithaml, Parasuraman and Berry, 1990).
Bolton and Drew, 1991a and previous satisfaction and attitude literature
demonstrated that the addition of importance weights is not expected to improve either
performance or gap-based measurements of service quality.
Cronin and Taylor (1992, 1994) also criticized SERVQUAL and suggested a
modified operationalization of the service quality model. Their results indicate that a
performance-based measure of service quality improves the means of measuring the
SERVQUAL construct. Several authors defend the performance-based measurement
including Mazis et al., 1975, Churchill and Suprenant, 1982 and Woodruff et al., 1983.
Applications/ modification of SERVQUAL in a medical setting can be found in the
studies by Mowen et al, (1993) Joby (1992) and Walbridge and Delene (1983).
Oliver (1980) suggests that in absence of prior experience with a service
provider, expectations initially define the level of perceived service quality. Then upon
the first experience with the service provider, the disconfirmation process leads to a
revision of the initial level of perceived service quality. Subsequent experiences with the
service provider will lead to further disconfirmation, which again modifies the level of
perceived service quality. Finally, the redefined level of perceived service quality
similarly modifies a consumer‘s purchase intensions towards that service provider. Thus
experience (a subset of knowledge) has a great role in the formulation of expected and
perceived service quality. Measurement of service quality based on gap analysis could
be severely affected by this factor, thus arose the debate on measurement through (E-P)
versus Performance-based scales.
Many dimensions were identified for use in evaluation of service quality by
consumers. The most prominent work was performed by Parasuraman, et al., (1988) and
(1991) was however tested for the four industries mentioned above. Basically, PZB have
developed an instrument for measuring service quality that they propose to be used as a
basic skeleton for use across a broad spectrum of services Carman (1990).
Carman (1990) replicated and tested a slightly modified SERVQUAL battery and
found the overall stability of dimensions impressive. However, he suggested that items
on seven or eight rather than five dimensions should be retained and that the wording
and subject of some items should be adapted to the specific service context at hand.
Carman, 1990 also proposed that in settings where it is obvious to consumers that
several service functions are being performed, the instrument be administered for each
- 15 -
function separately as well as the scales being refined by factor analysis and reliability
tests before commercial applications. They also suggested major shortcomings in the
treatment of expectations. They suggest that expectations can be collected in terms of
perception-expectation difference rather than directly ask each question separately or
even to gather "mean expectations" and get the difference between perceptions and
'mean expectations' thus collecting expectations as infrequently as once every third year
in the absence of major change in the service delivery. As for importance, the author
also recommended that mean rather than individual importance weights might be
satisfactory.
A survey of the consumers of the fast food restaurants in the Delhi, India was
carried out to gather the necessary information concerning comparison of unweighted
as well as the weighted versions of the SERVQUAL and the SERVPERF scales. They
were comparatively assessed in terms of their convergent and discriminant validity,
ability to explain variation in the overall service quality, ease in data collection, capacity
to distinguish restaurants on quality dimension, and diagnostic capability of providing
directions for managerial interventions in the event of service quality shortfalls (Sanjay
and Gupta, 2004).
The results indicated that SERVPERF scale was a more convergent and
discriminant valid explanation of the service construct, possesses greater power to
explain variations in the overall service quality scores, and is also a more parsimonious
data collection instrument. On the other hand, it is the SERVQUAL scale which entails
superior diagnostic power to pinpoint areas for managerial intervention. The obvious
managerial implication emanating from the study findings is that when one is interested
simply in assessing the overall service
quality of a firm or making quality comparisons across service industries, one can
employ the SERVPERF scale because of its psychometric soundness and instrument
parsimoniousness. However, when one is interested in identifying the areas of a firm‘s
service quality shortfalls for managerial interventions, one should prefer the
SERVQUAL scale because of its superior diagnostic power (Sanjay and Gupta, 2004).
No doubt, the use of the weighted SERVQUAL scale is the most appropriate
alternative from the point of view of the diagnostic ability of various scales, yet a final
decision in this respect needs to be weighed against the gigantic task of information
collection. Following Cronin and Taylor‘s (1992) approach, one requires collecting
information on importance weights for all the 22 scale items thus considerably
increasing the length of the survey instrument. However, alternative approaches do exist
that can be employed to overcome this problem. One possible alternative is to collect
information about the importance weights at the service dimension rather than the
individual service level. Addition of one more question seeking importance information
will only slightly increase the questionnaire size. The importance information so
gathered can then be used for prioritizing the quality deficient service areas for
managerial intervention. Alternatively, one can employ the approach adopted by
Parasuraman, Zeithaml and Berry (1988). Instead of directly collecting information
from the respondents, they derived importance weights by regressing overall quality
perception scores on the SERVQUAL scores for each of the dimensions identified
through the use of factor analysis on the data collected vide 44 scale items (Sanjay and
Gupta, 2004).
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2.4: Consumer Satisfaction Studies in Healthcare
Because of increasing competition and more demanding consumers, service
quality has become a watchword for virtually all businesses and in the medical field in
particular due to the high importance of excellent service quality in a field where poor
service quality could ultimately lead to morbidity. However, quality is difficult to
measure for service providers in the medical field.
Healthcare service quality has been regarded as a multi-dimensional construct.
It has been envisioned to be composed of two main parts: quality as perceived by the
consumer and quality in fact. Although many researchers argue the point that the 'real'
quality of a service cannot be accurately portrayed in patient's perceptions, however
patients will always continue to draw their own conclusions about the quality of the
service. In healthcare especially, perception for the patient is the reality and it is the
perceived quality as opposed to the actual or absolute quality that is important for
healthcare professionals to manage. This is the basis on which consumers make
purchase, repurchase and recommendation decisions (Paul, 2003).
Donabedien (1992) states that the research concluded that health care is
conceived as consisting mainly of two parts, a technical task and an interpersonal
exchange and envisaged an ideal whereby practitioner and patient together engage in a
search for the most appropriate solution (thus jointly engaging in the production of
care). Another research was not in favour of medical services being driven by market
forces and suggests that a cost-effective practice should view patients not as consumers
in episodic relationships but as co-producers in continuing relationships (Hart 1992,
Murfin et al., 1995).
Cartwight (1967, 1986) and Cartwright & Anderson (1981) found that men and
women were equally satisfied with their doctors, younger people were more critical than
older people as well as the existence of an inverse relationship between social class and
satisfaction.
Jowell and Airey (1990) studied surveys performed on the National Health
Service (NHS). They showed that surveys performed showed no grounds for
complacency. While in 1983, only 26% of the public expressed dissatisfaction with
NHS systems, by 1986, this portion was 39% and increased to 46% by 1989.
Morrel et al., (1986) and Howie et al., (1991) found that patients report greater
satisfaction with increase in the length of time in their surgical consultations. Savage
and Armstrong, 1990 reported that satisfaction is influenced by consultation style.
Several authors also investigated the issue using meta-analytical approaches.
These include Ware et al., 1978 (analysis of 81 healthcare services, where only 11
showed reliability estimates for patient satisfaction measures), Lebow, 1982
(consolidated 26 studies on patient satisfaction with mental health treatments), Hall and
Doran, 1988 (meta-analysis of 221 medical care studies, and pointed out the unclear
domain of satisfaction measures where different studies measured different aspects of
satisfaction). Most studies showed a uniform skewness towards satisfaction from the
majority of respondents. Peterson and Wilson, 1992 revealed that satisfaction studies
from many different aspects of healthcare showed skewed distribution towards
satisfaction and concluded that ―measurements of consumer satisfaction are not
especially informative or diagnostic‖ and that ―it is unclear what customer satisfaction
ratings are measuring‖. Thus new and different approaches for measuring satisfaction in
healthcare are called for (Murfin et al., 1995).
Carman (1990) had conducted extensive research on several industries including
an acute care hospital. In the hospital setting where multiple encounters were present in
- 17 -
one stay, factor analysis results were different from those in other settings. The factors
that resulted are summarized in Table 2.3. In the hospital setting for example, the
communications separated from assurance. Explanation broke out as a factor and cut
across several lines in some cases. Obviously, patients felt an acute need for information
when concerned with curing disease.
Several others researchers conducted research in this field, using the above the
PZB model as a baseline and elaborating on it while others used it as is for testing in
different industries. The current research is concerned with the healthcare industries and
several researchers have contributed to this body of research considerably in the past.
Before the emergence of the PZB model, many authors have produced significant work
in the field of healthcare service quality and after the emergence of the model many
have used it as basis. Some have stuck to the original broad lines dictated by
Parasuraman, et al., (1988) and (1991) while others have added to this research
incorporating more dimensions relevant to multi-service settings in general and the
healthcare service in specific. Much research has been done to develop satisfaction
measurement instruments mostly in the form of attitude scales of the Likert variety.
Before PZB, perhaps the most prominent authors in the field include Hulka et al., 1970
and 1971, Zyzanski, et al, 1974, Ware et al, 1977, Hulka et al., 1975, Wolf et al., 1978,
Bertakis, 1977, Ley, 1983, Kiam-Caudle and Marsh, 1975, Wooley et al., 1978 and
Feletti et al., 1986. Other prominent researchers who have used added to this research in
terms of dimensions using the original framework described by Parasuraman, et al.,
(1988) and (1991) include Brown SW and Swartz TA, 1989, Joby J. 1992, Woodside et
al., 1989 and Walbridge SW and Delene LM, 199 and Carmen, 1990. Their
contribution is examined in detail in Tables 2.1, 2.2, 2.3, 2.4 and 2.5.
Many researches have been conducted to measure service quality at different
hospitals using different methodologies. Some have stuck to the original model
described by Parasuraman et al., 1988 (SERVQUAL) and Cronin and Taylor, 1992
(SERVPERF) while others have adapted different models according to their healthcare
setting and needs.
Brown SW and Swartz TA, 1989 measured 3 gaps in their research. The first gap
measured was between patients' expectations and experiences (E-P). The second gap
measured was between patients' expectations and physician perception of their
expectation. The third gap measured the difference between patient's experience and the
physician's perceptions of their experience. They uncovered several dimensions
demonstrated in Table 3.2.
Woodside, Frey and Daly, 1989 identified several major acts in the hospital and
drew a ‗blueprint‘ for mapping the service encounter in hospital services requiring an
overnight stay. It is mainly concerned with the hospitality aspect of the service
encounter.
Paul, 2003 compared the two predominant service quality measures SERVQUAL
and SERVPERF and applied the study on Periodontists. He concluded that SERVPERF
without importance weights appears to be the better model for measurement of service
quality in periodontists.
Hill and McCrory., 1998 measured service quality conceptualized as (perceptions
minus importance) at Belfast maternity hospitals. They tested perceptions and
importance of clinical and non-clinical service factors from both the patient‘s and the
staff‘s sides. They concluded that perceptions of previous patients were significantly
more positive than first-time patients. Hygiene/cleanliness ranked as one of the top most
important issues in the hospital while patients were disinclined to be judgmental about
- 18 -
clinical staff since they often felt unqualified to judge clinical expertise. The authors
identified several critical areas in the hospital that required improvement and suggested
to improve service quality through attempting to reduce the discrepancy between the
respondent‘s importance ratings and their perceptions and to begin with factors with the
highest importance ratings and the largest discrepancies.
Schlegelmitch et al., 1992 compared the relative importance of choice criteria and
satisfaction with primary care providers across two different healthcare organized health
system which included the state-employed general practitioner in the United Kingdom
and the self-employed primary care giver in the United States. Few differences appeared
to exist between the patient‘s evaluations of the service encounter in both countries with
greater dissatisfaction existing in the US market due to the unrealistic expectations
created there. The identified dimensions included treatment-related information,
professionalism, communication skills, technical competence, emotional problems and
perceived unfriendliness amd they underlined the importance of non-technical aspects of
the medical encounter.
De Man et al., 2002 analyzed patients‘ and personnel‘s perception of service
quality in nuclear medicine organizations and compared the perceptions of patients‘ and
personnel. They also examined the importance of the different service quality
dimensions by studying their relationship to patient satisfaction. Their results showed
that the original five dimensions of SERVQUAL were not confirmed. Patients
considered tangibles and assurance as one dimension while empathy was divided into
empathy and convenience. Personnel perceived service quality as less good than patients
except for empathy. Patient‘s perceptions of service quality correlated strongly with
satisfaction especially for reliability and tangibles-assurance.
Gazibarich, 1996 developed a five-step customer benefit framework for ensuring
the quality of dietetic services from the customer perspective. The five steps include
identifying customers, identifying needs, translating needs to benefits, measurement of
quality and taking action. They proposed that the two instruments SERVQUAL and
SERVPERF might be used as instruments for measuring dietetic service quality.
Baxter, 2004 tested the SERVQUAL model on occupational health hospital in
Nottingham and concluded that it is possible to adapt the standard SERVQUAL tool and
apply it within the occupational health setting. They concluded that what the customers
perceived and expected were not dissimilar but that the service provided was below
their expectations. The service quality areas of reliability and assurance were thought to
be most important with responsiveness and empathy a joint second and finally
tangibility the least important factor for patients.
Hiidenhovi et al., 2001 and 2002 studied healthcare service quality from the
perspective of patients in hospital outpatient departments. Hiidenhovi et al., 2001
developed a reliable and valid service quality instrument for receiving feedback from
patients to improve outpatient departments. They started with a 47-question version of
the questionnaire that was tested on 314 patients. This was gradually reduced to 43 and
then reduced to a 12 item questionnaire on a 7 point scale from very poor to excellent
with tested reliability and validity. Hiidenhovi et al., 2002 further applied this tool to
test service quality over a three-week period in a Finnish University hospital involving
19 outpatient departments. The questionnaire proved to be a good tool enabling
systematic access to patient feedback on service quality in outpatient departments.
The Tables 2.1,2.2, 2.3, 2.4 and 2.5 demonstrate the dimensions identified for use
in evaluation of service quality for healthcare. They summarize the work of the most
prominent authors on the subject.
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2.5: Outcome of Healthcare and Satisfaction
Two main dimensions of healthcare service quality come into focus and they
are technical (or outcome) quality and functional (or process) quality. Technical quality
is described as the technical accuracy of the medical diagnosis and procedures or
conformity with professional specifications. The functional quality is described as the
way in which healthcare services are delivered to patients. For the technical (outcome)
quality of the service, there are objective measurement instruments while there are few
objective measures for the functional (or process) part of the service thus mainly
subjective evaluation is used in judgment of this section (De Man et al., 2002).
Consumers find difficulty in the evaluation of healthcare services and they
rarely know on which feature of the health service to base their judgments on or how
best to evaluate those feature they chose to evaluate since healthcare by nature in a
multi-service opeions that involves many encounters and facets. This is especially true
when patients try to evaluate the more technical features of the healthcare service such
as the qualifications of the medical staff or the outcome or improvement of the patient's
condition. Typically, patient's can usually assess the attentiveness, the responsiveness,
the comfort provided by the service provider, the length of the wait before treatment and
patients do not actually have the technical knowledge to evaluate the technical (medical)
aspects of healthcare in an effective manner (Paul, 2003).
Since the 1980‘s, the outcome management concept has been put in use for
healthcare organizations. outcome management is the ―Use of interrelated strategies to
improve the performance of individuals, teams and organizations. It enables
organizational leaders to monitor and respond to how the organization delivers its goals.
It involves measuring progress against a series of performance indicators‖ (Walburg et
al., 2006).
The elements of outcome management include the patient, the care team, the
care process and the outcomes. All the elements are linked to form a micro-system and
the relationship between the elements is demonstrated in Figure 2.7.
Other factors are also relevant in evaluation of the results of the care process
and include patient assessment, patient satisfaction, outcomes (seen as clinical and
functional outcomes) as well as the costs of the healthcare services provided. Walburg et
al., 2006 combines all these variables in a model demonstrating ―Outcome Quadrants"
and is demonstrated in Figure 2.8. The outcomes feedback to the team and are compared
to a previously formulated norm of goals aiming to maintain a continuous process of
monitoring, management and improvement (Walburg et al., 2006). Nelson et al., 1998
referred to the above categories as the ―Clinical Value Compass‖. They encompass the
four main constructs described below:
1. Clinical Outcome: These are disease-specific outcomes associated with the
diagnosis. It can be measured as the difference between the initial assessment
of the patient‘s clinical condition and the assessment after the treatment
process. Different care providers measure clinical outcomes through different
methodologies but perhaps the most widely used is the IMS system (Indicator
Measurement System) developed by the Joint Commission of the USA in 1994
and the QIP (Quality Indicator Project) developed by the Maryland Hospitals
and Health Systems (MHA).
2. Functional Outcome (Quality of Health): Although medical treatment is
mainly aimed at cure and prevention of illness, treatment also has a profound
impact on the physical, psychological and social functioning of the patient
(Walburg et al., 2006). Benson, 1992 divided outcome into several layers
- 20 -
demonstrated in Figure 2.9. The first two layers (Biochemistry, Physiology,
Microbiology) and (Symptoms) are focused upon typically by care providers
while for the patient it is quite different. The quality of life as depicted by the
last two levels (Capacity to Function) and (Well-being) should be the desired
outcome of treatment for both the healthcare provider and the patient. Many
systems exist for measuring quality of life and these include the ―Medical
Outcome Study‖ produced by the Rand Corporation, the Nottingham Health
Profile developed in the UK, the Sickness Impact Profile (SIR) and the EuroQol
developed in Europe (Walburg et al., 2006).
3. Patients Opinions: Since treatment is offered for the patient, the information
on patient‘s opinions regarding their treatment is needed to improve the
treatment process and customize it to suite patient‘s expectations. Measurement
is typically performed through administering questionnaires and sometimes
through observation, focus groups and exit interviews. Perhaps the most
important aspect of measuring patients‘ opinions is how to make use of them
for outcome management. Walburg et al., 2006 identified a seven-step process
that may lead to operationalization of patients opinions which are
operationalization of vision, inventory of patients desires and expectations,
development of standards, selection of measurement instrument, data
collection, analysis and feedback and finally improvement.
4. Cost of Treatment: Treatment costs are a noteworthy issue in the healthcare
process and healthcare services cost a significant amount of money. If better
treatment is linked to higher costs and ultimately better outcomes and vice
versa then cost-effectiveness analysis is definitely called for. Payoff between
the cost and benefits has to be reached.
Patient satisfaction reigns supreme in healthcare marketing, and satisfaction

hinges upon receiving quality service from providers. But other factors play a role in
building satisfaction levels. Healthcare providers are evaluated on an additional set of
standards based on the trust level of the patients. Patients with high trust levels place
significant weight on how service providers perform on the core benefits. However,
those who are low in trust rely more on peripheral cues. The implication is that
healthcare providers must focus on both core benefits and peripheral cues if they want to
satisfy the full range of clients they service. As competition in healthcare increases,
hospital and clinician providers are becoming more concerned about patient satisfaction
as the long-term harm of dissatisfaction can be devastating. After all, satisfied clients
are more likely to become loyal ones. They return when they need further care and share
positive word of mouth with their friends and family Dissatisfied clients, however,
change providers or just quit seeking medical care altogether. Dissatisfied clients are
also a source of negative word of mouth. Patient satisfaction is so important that
accrediting bodies such as the Joint Commission on Accreditation of Healthcare
Organizations are now viewing it as an outcome measure (Rajesh and Muncy, 2002).
2.6: Linking Service Quality, Patient Satisfaction and Behavioural Intentions to

Return
Consumer satisfaction is of great importance to marketers because it is
assumed to be of significant determination to repeat sales, positive word-of-mouth and
consumer loyalty (Woodside et al., 1989). A significant number of authors have
succeeded in proving that customer satisfaction influences behavioural intentions to
- 21 -
repurchase from the same provider as well as linking service quality with consumer
satisfaction (Smith and Houston, 1983, Kotler, 1988).
Patient evaluations of the healthcare service provided is manifested as
perceived quality of the service, patient satisfaction with the service and behavioural
intentions to return to the same provider (John J, 1992). Success in retaining current
patients and attracting new ones is the ultimate means for survival in the medical
marketplace. The success of retaining or attracting patients may result from patient
satisfaction with the medical service they receive. The satisfaction or dissatisfaction of
the patient (healthcare consumer) with the hospital experience is directly related to the
patient‘s willingness to remain within the same service provider or any individual
physician (repurchase behaviour). Similarly, dissatisfied or satisfied patients report the
adequacy of the service they received which may attract or deter potential patrons to the
same hospital (recommendation behaviour) (Ross et al., 1987).
Hospital marketers are interested in increasing the demand for the services of
the organization and the current patients are prime prospects for return behaviour when
patients are satisfied with the hospital service provided thus comes the importance of
measuring satisfaction. It is believed that improvement of services that receive low
satisfaction ratings or services that are strongly correlated with the patient‘s future
intentions to utilize the hospital would improve patient satisfaction (Swan et al, 1985).
Woodside et al., 1989 have proved that consumer judgments of specific service events
within service acts influences their overall patient satisfaction with the service act and
that satisfaction with the service acts influences overall consumer satisfaction with the
service encounter. They also supported the position advocated by Churchill and
Surprenant, 1982 that satisfaction is a major outcome of the marketing activity that links
service quality with post-purchase phenomenon such as behavioural intentions to return
to the same provider.
2.7 Effect of Consumer Demographics on Service Quality Expectations and

Perceptions
Several researchers studied market segmentation on the basis of consumer service
quality expectations and perceptions. Webster et al., 1989 found that consumer
demographic characteristics have a significant effect on their quality expectations for
professional services and not for non-professional services. For non-professional
services, the consumer educational level was the only factor that had a significant effect
on service quality expectations. They studied age, gender, marital status, ethnicity,
occupation, education, and income. Katherine & Hathcote (1994) also studied this issue
and findings indicated that only 3 characteristics, race, marital status and income yielded
significant differences. This was not tested for the healthcare service at all and a gap in
the knowledge about the effect of demographics for healthcare services exists.
2.8 Egyptian Healthcare Systems

Egypt has made substantial progress in improving the health status of its
population and in reducing unwanted fertility during recent decades. Over the past
several years, health system authorities in Egypt have been considering the prospect of
significant reform to the health sector. Despite these gains, wide disparities in health
conditions persist. New health challenges are also emerging, which will increase the
need for treatment of disease and for behaviour change. Health and health care are
issues of high concern for Egypt's population and political leaders (EMRO, 2006).
- 22 -
Like many countries, Egypt faces difficult choices in trying to meet the rising
demands and expectations of its population. Egypt is going through a demographic and
epidemiological transition that is affecting both the size and health status of the
population. The population growth rate has fluctuated from a low of 1.92% a year
during 1966–1967, to 2.75% annually during 1976–1986, later declining to 2% a year
during 1980–1993 and 2.1% annually in 2001. Changes in fertility and mortality rates
have been the major source of population growth in Egypt (EMRO, 2006).
Health conditions in Egypt have been changing. This transition, along with
economic growth, will increase the demand for health care services, especially for the
treatment of illness. Emerging adult and chronic health problems require more extended
and costly treatments. New priorities and an increasing role for health promotion and
prevention are also becoming important. Primary care has a critical role to play both in
meeting this demand as well as in helping to reduce the financial burden of future needs
and demands (EMRO, 2006).
While Egypt's government-financed, government-provided primary care
services have done well in providing many of the mass public health services, they do
not perform so well in the areas that are likely to be future priorities. Most primary
illness care is obtained in the private sector, even by lower-income populations, despite
the official offer of free, publicly provided services. Even those entitled to the free
services of the Public Organization for Health Insurance (also known as the Health
Insurance Organization [HIO]) often use private services. Government primary care
services are inefficient and widely perceived as lacking in quality. (Berman et al., 1997).
Recently, the Egyptian healthcare industry is amidst a period of considerable
change, centring around a growing trend towards privatization. Prior to the 1990s, the
sector was predominantly state-controlled, with the private sector playing only a
minimal role in healthcare provision. While the government still retains a great degree
of control, the private sector is now playing an increasingly important role, emerging
largely as a result of the declining standard of public sector care. There are around 200
private hospitals in Egypt, operating nearly 15% of all beds (Epsicom Business
Intelligence, 2007).
The coverage of the Egyptian population with the National Health Insurance
scheme is increasing through the addition of new population groups under the umbrella
of social health insurance, for example school children and newborn children. In the
year 1980, the coverage was 4% of the total population, and it doubled in 1990. In the
year 1995, it reached 36% and increased over the last ten years to 45%. Out of pocket
spending has been rising over past decade and currently stands at 62% (EMRO, 2006).
2.8.1 Structure of the Egyptian Healthcare System

The health delivery system in Egypt consists of the government sector
providers, which are financed primarily through Ministry of Finance budget transfers,
and public sector providers, which receive some transfers from MOF (but have other
independent sources of revenues), and also the private sector providers.
2.8.1.1 Public Health Care System
The Ministry of Health and Population (MOHP) is the major provider of
primary, preventive and curative care throughout Egypt, utilizing 4,506health facilities
and 152.172 beds nationwide. The MOHP operates through a functional structure,
through an administrative and a technical workforce across four levels namely, Central,
Health Directorates (at governorate level), Health Districts, and Health care Providers
(EMRO, 2006).
- 23 -
The MOHP central organizational structure is an extensive structure headed by
the Minister. It employs almost 5,000 personnel, including professional and supporting
staff, who are in charge of main central functions such as planning, supervision,
program management and maintenance (EMRO, 2006).
At the central level, the MOHP is divided into broad functional divisions
including the Minister‘s Office Affairs Sector, the Training and Research Sector, the
Health Care and Nursing Sector, the Preventive Affairs and Endemic Diseases Sector,
the Curative Health Sector, the Health Regions Sector. In addition to the above six
sectors, the central organizational structure of the MOHP includes a central department
directly accounTable to the Minister the Central Department for General Secretariat and
the Sector for Technical Support and Projects (EMRO, 2006).
The MOHP overall structure is therefore made up of seven functional divisions
embracing 23 central departments and 73 general departments at the central level. Each
of departments is in charge of various functions. The seven sectoral heads, however,
report directly to the Minister. In addition to this, several of the central departmental
heads also report directly to the Minister. These include the heads of Preventive Care,
Laboratories, Primary Health Care, Endemic Diseases, Technical Support and Projects,
Curative Care, Research and Development, Pharmaceuticals, Dentistry, Family Planning
and Nursing.
The above central organizational structure is replicated at each governorate
level. The governorate level health directorates are responsible to the MOHP for
technical functions, but report to the Governorate Executive Council (headed by the
Governor) for day-to-day management of activities (EMRO, 2006).
Egypt is formed of 26 governorates. There are, however, 27 health directorates
in operation because Luxor City has a separate health directorate, despite being
administratively part of Qena Governorate. An Undersecretary or a Director General,
the ―Director of Health Affairs‖, whose functional grade differs according to the
governorate size, heads each governorate health directorate. The Director of Health
Affairs supervises the Health District Directors. The district health organizational
structure is simply a replication of the governorate structure, where the basic functions
are implemented on a smaller scale (EMRO, 2006).
Reporting to the governorate health directorates are 255 health districts. Each
district has a director who is sometimes also the District Hospital Director (seconded to
take over both jobs). The health districts (and to some extent the health directorate)
work, in theory, according to the organizational structure and staffing patterns
authorized by the CAOA. However, in reality, there is a great degree of variability in
these structures and patterns (EMRO, 2006).
2.8.1.2 Private Health Care System
A) Structure of Private Healthcare System
At present there is very little organized financing of the private health services.
Most of the transactions occur as household out of pocket payments to the provider on a
fee for service basis for both ambulatory and inpatient care. There is no formal
mechanism in place to monitor and evaluate the rates being charged and the quality of
the health care service offered by different categories of private providers, although the
Medical Syndicate may have some information on medical fees charged by the member
physicians. On a very limited scale, private firms and private insurance companies enter
into contractual arrangements with private providers. The number of health service
providers joined the NGO sector within the few past years, increase dramatically due to
different socioeconomic reasons (EMRO, 2006).
- 24 -
On the side of the health care providers, there are no strict rules and regulations
are governing this sector, the NGOs are tax-exempted and it is considered an attractive
sector for physicians, who are not capable of practicing health services privately, to
practice medicine through the NGOs facilities (EMRO, 2006).
The Private Sector delivery structure tends to be unorganized and fragmented,
but amounts to a significant proportion of both inpatient and outpatient services. The
quality of its services varies widely and is largely unregulated. There is also more
emphasis on curative services rather than preventive and health promotion services. So
far, the private sector has not been involved in the health policy dialogue nor has it
demonstrated significant interest in doing so. Private sector provision of services covers
everything from traditional healers and midwives, private pharmacies, private doctors,
and private hospitals of all sizes. Also, in this sector are a large number of NGOs
providing services, including religiously affiliated clinics and other chariTable
organizations, all of which are registered with the Ministry of Social Affairs.
Physicians represent the most powerful professional group in the health sector.
Doctors are permitted to work simultaneously for the government and in the private
sector. Those who are employed by the government but run a private practice because of
their low salaries, account for a large portion of private providers. Many other
physicians, however, cannot afford to open their own private clinics and work in more
than one nongovernmental religious or private facility, in addition to their morning
government jobs (EMRO, 2006).
B) Problems and challenges facing private health care in Egypt
Several problems are currently facing the private sector in Egypt. They include
inadequate quality of private health care services, presence of some unreachable areas,
insufficient public budget allocated for quality private health care services, deficiencies
in the private health care referral system, in-adequate distribution of health facilities and
services according to community needs as well as providing required number of
qualified family physicians. In addition, private sector faces other problems stemming
from the Egyptian healthcare market structure such as difficulty in implementing health
insurance system covering all community members and providing sufficient resources,
upgrading the quality of undergraduate medical education for physicians and nurses and
developing a strong health system having the ability of accrediting, monitoring, and
evaluating the provided services (EMRO, 2006).
2.8.2 Stakeholders in Healthcare System in Egypt

2.8.2.1Government Stakeholders
The Medical Syndicate
The Medical Syndicate is the country's association of physicians, and by far the
most powerful professional association in the health sector. The Medical Syndicate is
also the founder and administrator of what is perceived as a successful health insurance
model in Egypt, the Medical Union, which includes the four medical syndicates
(physicians, dentists, pharmacists, and veterinarians). The plan, established in 1988,
serves members of the syndicates, spouses, children, retirees and widows/widowers of
deceased members. The program is tightly run, with measures to control utilization and
drug fraud. It also has a number of built-in measures for financial viability such as co-
payments and moderate coverage ceiling. This health insurance model is replicated,
with some differences, by a number of other professional syndicates (EMRO, 2006).
- 25 -
Supreme Council for Health
The prime responsibility of the Supreme Council for Health is to set the
direction for national health policy and overall coordination among major health
organizations. The Council was established by a presidential decree and is chaired by
the Minister of Health and Population. The structure of the Council is very complex
with 18 working groups, each comprising 15–20 members. Each group is designated for
a specific policy area, including primary health care, family planning, maternal child
health, health insurance, private sector, training and human resource development,
health promotion and education, research, legislation, management, pharmaceuticals,
nutrition, foreign affairs, and coordination (EMRO, 2006).
The People’s (National) Assembly
The People‘s (National) Assembly is the legislative body elected by the
Egyptian people to represent them and holds a mandate to protect the rights and the
interests of the public. The Health Committee of the Assembly was developed to be
responsible for overseeing the functioning and accountability of the MOHP, as
representative of the health sector. However, its main preoccupation is with social
protection issues such as universal insurance coverage and primary health care for all.
The Committee must approve any new health sector legislation, bylaws, or decrees, or
the modification of existing ones. It must also approve the endorsement or amendment
of cooperative agreements with bilateral or international organizations in the health
sector. In that sense, the Committee is a powerful legislative body with a strong
likelihood of impacting health policy changes. Though it is a powerful legislative body,
the Committee does not have all the technical expertise needed to adequately analyze,
evaluate and accordingly approve or reject health policy changes (EMRO, 2006).
The Shoura Council
The Shoura Council was developed to be a ‗think-tank‘ for advising the
Government on national public policy matters. The Shoura Council Health Committee
tends to have more health-specific expertise as compared to that of the People's
Assembly. Yet, it has no actual decision- or policy-making authority. The Committee
has in the past generated substantive sectoral analysis reports (EMRO, 2006).
The Steering Committee for Health Sector Reform (SCHSR)
The Steering Committee for Health Sector Reform (SCHSR) was formulated
by ministerial decree no. 256 for the year 1997 to oversee the planning and
implementation of the health sector reform initiative. The Committee is chaired by the
Minister of Health and Population and is comprised of 10–15 members. Members of the
SCHSR include, but are not be limited to, senior representation from the following
stakeholders; Ministry of Health and Population ( including the first undersecretaries),
Ministry of Finance, Ministry of Planning, Ministry of Higher Education, Universities,
Central Agency for Organization and Administration, Social Fund, Parastatal
Organizations, Governorates, Medical Syndicate, Private and non-governmental sector,
the donor community, Ministry of Rural Administration, People‘s Assembly. The
Steering Committee is a fixed body meeting on a regular basis and each member is
appointed for a period of 3–5 years (EMRO, 2006).
2.8.2.2 Medical Stakeholders

A recent Egyptian Health Care Provider Survey done for the Partnerships for
Health Reform (PHR) Project that are being performed to improve people‘s health in
low- and middle-income countries by supporting health sector reforms revealed several
stakeholders in the healthcare field in Egypt (Nanadakumar et al., 1999). They include:
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Individual Physician Practices
In general, physicians in private practice work long hours to see relatively few
patients, probably reflecting Egypt‘s large stock of physicians. More than four-fifths of
privately-practicing physicians have some type of government or public sector job.
Multiple job-holding is the norm. Patient volume reported for the government and
public sector work of privately practicing physicians is much higher than volume
reported in their private practices. Physician‘s earnings in private practice are, on
average, modest, although they are certainly several times larger than their salaries in
government and public service (Nanadakumar et al., 1999).
Health Facilities
The largest inpatient facilities tend to be government, including both MOHP
and university hospitals. Medium-size inpatient facilities are distributed over wider
range of government, public, and private owners. Outpatient facilities are largely found
in the MOHP, HIO, and private non-profit and for-profit sectors. Widespread use of
part-time staffing is supportive of the multiple job-holding pattern common in Egypt.
Egyptian hospitals have a high ratio of physicians to beds. For large inpatient facilities,
this averages about one physician for every two beds. For medium facilities, this
averages almost one physician per bed. It is likely that nominal and real staffing levels
are quite different, especially in government and public sector facilities. Enumerators‘
subjective reports on quality measures at various types of health facilities generally
ranked private and non-MOHP public sector facilities higher than those of the MOHP
(Nanadakumar et al., 1999).
Dayas
A daya (or traditional birth attendant) is usually an older woman who has had
several children herself, lives in the community, and learned her profession by
apprenticeship. The average daya was 55 years old and had 22 years of experience. Only
14 percent reported having some kind of formal training in health care, 70 percent were
illiterate, and none had attended university. Eighty percent of the dayas were in rural
areas. All dayas perform deliveries, and 83 percent provide post-natal care. Other
services rendered include intra-muscular injections, intravenous transfusions, and first
aid. All cases with complications were referred to a physician or hospital. Dayas
reported a high level of knowledge about family planning methods and 81 percent
advise on these methods. While 69 percent reported receiving payment in cash, the
others accept a combination of cash and kind. Fees are dictated by the ability of the
family to pay. Dayas were by and large satisfied with their work and 79 percent felt that
their experience and success were the reasons women came to them for help in
delivering their babies (Nanadakumar et al., 1999).
Dentists
Ninety-one percent of dentist practices were located in urban areas, and 92
percent were males. They had an average experience of 16 years, and 65 percent had
earned higher than a bachelor‘s degree. Multiple employments was common among
dentists. On average dentists worked five hours per day, six days per week in
government jobs and four hours per day, six days a week in their own clinics. Dentists
worked more hours per week in rural areas than urban areas. Dentists saw 14 patients
per week in their private clinics at a rate of 0.6 patients per hour worked. They saw
more patients per week in urban areas. Although there are more dentists in urban areas,
they charge higher fees than those in rural areas. Forty-four percent of dentists were
dissatisfied with the number of patients they were seeing in their private clinics. This
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was significantly higher in rural Lower Egypt. Less than 30 percent of the dentists
reported keeping records for each patient (Nanadakumar et al., 1999).
Pharmacies
There were five times more pharmacies in urban areas than in rural areas.
Pharmacists are likely to be male (81 percent) and have worked an average of 11 years
at the pharmacy where they were interviewed. Overall pharmacies in the sample had
been operating for 18 years. Pharmacists dispensed medicine to those with and without
prescriptions. In addition to selling drugs, pharmacists offer advice to their customers.
The vast majority of pharmacists have only one job. Forty percent of the pharmacies in
the sample reported having contracts with organizations to provide drugs to their
beneficiaries. Ninety seven percent reported they could not provide drugs at some time,
52 percent reported an occasional drug shortage, and 25 percent reported chronic
shortages. The primary reason for this was difficulty in obtaining credit. In only 13
percent of cases was lack of supply mentioned as a reason. Seventy-five percent
suggested increasing the availability of drugs and 44 percent suggested reducing prices
as means to improve the quality of services provided (Nanadakumar et al., 1999).
Other Health Services Providers
This category refers to unlicensed providers, including traditional healers and
other non-physicians. Due to their unofficial status it was very difficult to get these
providers to participate in the survey. Although it is widely accepted that there are more
male than female providers, the majority of traditional health services providers in the
sample were female. Eighty-eight percent of these providers lived in rural areas and
none had attended university. Nearly all providers give injections to patients, 75 percent
dress wounds, and 15 percent set bones. Twenty-four percent furnish patients with drugs
or some kind of medication. On average, they saw 26 patients per week, ranging from 8
per week in urban areas to 85 per week in rural Upper Egypt. Lack of proper training
and health education was cited as the major problem facing improving the quality of
care. Forty-four percent reported that patients come to them first. They felt that their
experience and familiarity with the client were the main reasons why patients came to
them (Nanadakumar et al., 1999).
2.8.3 Healthcare Finances in Egypt

Several indicators for healthcare expenditure have been investigated. Figures
were published in the Egypt Human Development Report in 2003, 2004 and 2005 and
are summarized in the Tables 2.6 and 2.7. They demonstrate health expenditure
indicators, sources of finance by percent and trends in financial sourcing respectively
(EMRO, 2006).
2.8.4 Health Services Positive Indicators

Health services have witnessed a clear improvement. This is shown through
the improvement of the per capita health services as a result of the continuous increase
in the number of public, central and rural hospitals as well as the number of hospital
beds. Moreover, there was a noticeable increase in the number of rural health units,
doctors and nursing categories. In this vein, 10 general and central hospitals were
established, thus bringing the total number to 381 units. A number of 230 rural health
centres were added, thus the total number hit 4500, the number of rural hospitals were
increased from 840 to 931 and the number of beds were increased by about 15,000
(from 170,000 to 185,000) as seen in Table 2.8 (SIS, 2007).
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2.8.5 Healthcare Services in Egypt Reform for Public and Private Sector
Egypt‘s system displays some structural characteristics, such as centralized
control, extensive infrastructure, state responsibility for health care for all individuals,
and extensive state involvement in the pharmaceutical sector. At the same time, the
system has many of the characteristics (e.g. multiple public and private sources of
finance and delivery, limited government oversight of the private sector) of more open-
ended market-based systems. This complex system has significant strengths and
weaknesses resulting from its continuing evolution (EMRO, 2006).
The basic goals of a health care system reform are as follows.
Improving population health status and social well-being.
Ensuring equity and access to care.
Ensuring microeconomic and macroeconomic efficiency in the use of resources.
Enhancing clinical effectiveness.
Improving quality of care and consumer satisfaction.
Assuring the system‘s long-term financial sustainability.
In early 1996, the MOHP initiated a re-assessment of the health sector situation
and recognized a need to explore alternatives for a comprehensive reform. As a result of
these discussions, the Government adopted the HSRP (Health Sector Reform Program)
for Egypt, which lays out a framework for undertaking a comprehensive reform of the
health sector over the medium- and long-term. One of the key objectives of the HSRP is
to achieve universal insurance coverage for all Egyptians (EMRO, 2006).
In addition to the reform and expansion of the social health insurance
functions, the HSRP includes the following elements:
Redefine the role of the MOHP to develop its regulatory functions, notably to
establish quality norms and standards and to establish a mechanism of accreditation
and licensure to enforce those standards, and to consolidate the multiple vertical
public health programs.
Strengthen the program for training and retraining of family health care doctors,
nurses and allied health professionals, with greater emphasis on preventive health
care.
Decentralize management of the government health delivery system to the
governorate and district level, and introduce greater managerial autonomy at the
facilities level.
Rationalization of the public investment in health infrastructure and health
manpower based on Governorate and District Health Plans that identify the actual
needs and availability of resources to sustain the investments (EMRO, 2006).
2.8.6 Health Sector National Reform Program

The Government of Egypt has embarked on a major restructuring of the health
sector. This reform was deemed necessary because the MOHP and its main partners had
identified fragmentation in the delivery of health services, excessive reliance specialist
care and low primary care service quality as the main constraints to achieving universal
coverage (EMRO, 2006).
2.8.6.1 Launch of the Health Sector Reform Program (HSRP)
The Egyptian Health Sector Reform Program (HSRP) was officially launched
in 1997. The World Bank (WB) started its contribution by designing the Master Plan for
Montazah Health District in Alexandria Governorate, in May 1998. By the following
year, in 1999, United States Agency for International Development (USAID) was the
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first donor to begin field-level operations, while the European Commission (EC) joined
the HSRP in November 1999. The African Development Bank (ADB) initiated its work
through designing Master Plans for three health districts in June 2003. The most recent
partner at HSRP is the Austrian Government, which directs its participation to
improving the district hospitals as part of health district approach (EMRO, 2006).
2.8.6.2 Aim of the Health Sector Reform Program (HSRP)
The overall aim of the HSRP is twofold:
Firstly to introduce a quality basic package of primary health care services,
contribute to the establishment of a decentralised (district) service system and
improve the availability and use of health services.
Secondly to introduce institutional structural reform based on the concept of
splitting purchasing/providing and the regulatory functions of the Ministry of
Health and Population. Coverage would be provided by a National Social Insurance
System.
The ultimate goal of health sector reform initiatives is to improve the health status of the
population, including reductions in infant, under-five, maternal mortality rates and
population growth rates and the burden of infectious disease (EMRO, 2006).
2.8.6.3 Preliminary Strategy of Health Sector Reform Program (HSRP)
The HSRP has meanwhile initiated a new primary care strategy in accredited
facilities, known as Family Health Units (FHU‘s). Facilities are being contracted by a
purchasing agency -the Family Health Fund (FHF) - to provide services to the
population. It is envisaged that the HSRP will gradually extend its scope to the
secondary level by establishing District Provider Organizations‖. The FHF will
consequently develop in the direction of a full purchasing agency of services from the
public and private sector. The newly introduced Family Health Model (FHM)
constitutes one of the cornerstones of the reform program. It brings high quality services
to the patient and will integrate most of the vertical programs into the Basic Benefit
Package of services. To date the FHM has been introduced in over 400 health facilities,
which present 10% of the total public primary health care facilities. HSRP has an
ambitious five years plan, by the end of year 2009, to cover the entire public primary
health care facilities with the Family Health Model (EMRO, 2006).
The Health Sector Reform Program is made up of Egyptian experts from
within the Ministry of Health and Population, individuals across the Egyptian health
care system and international advisors. The Egyptian Health Sector Reform Program
went through several stages, including the preparatory stage from 1994 to 1996. During
this stage, several valuable studies were conducted and used later to develop the
―Strategies for Health Sector Change‖ study. This was an analytical report on the
Egyptian health sector. This was followed by designing the health Master Plans stage
for the five pilot governorates. Experimenting stage of the Family Health Model took
place in one of the primary health care facilities, which took about two years to
implement. This was followed by piloting stage of the Model in five governorates and
included activities such as: Building staff pattern, designing the contents of the Basic
Benefits Package and Essential Drug List, and other components of the Family Health
Model. The Program has shifted its strategy in March 2003 from health facility oriented
approach to the district approach, which was called the District Provider Organization.
As of 2005, the HSRP has gradually expanded its operations to ten additional
governorates, pushing the total number of involved governorates to 15, which presents
more than 50% of the country coverage (EMRO, 2006).
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2.8.6.4 Progress with implementation in the Health Sector Reform
On July 6th, 2005 President Mubarak has announced the six dimensions of the
National Plan for Improvement of the Health Sector. The Presidential announcement
reflects the Health Sector Reform Program (HSRP) objectives. The six dimensions of
the National Plan for Improvement of the Health Sector is aiming to universal converge
of the Egyptians with health insurance by the year 2010 through:
1. First dimension: ―Improving the managerial and administrative capacity of Health
Insurance Organization through separation between financing and providing of health
services‖.
2. Second dimension: ―Establishing of Family Health Fund at each Governorate‖.
3. Third dimension: ―Include the uninsured population, with the health insurance
system‖.
4. Fourth dimension: ―Rolling Out of Family Health Model on the nation-wide with
participation from the private and NGO‖.
5. Fifth dimension: ―Improving the health services for the secondary care‖.
6. Sixth dimension: ―Integrating all the current health care providers under one entity to
provide universal health insurance by the year 2010‖.
The Minister of Health and Population has announced, on several occasions,
the MOHP plan for Rolling out the model. The five-year plan was presented to the
Prime Minister. The estimated plan cost is 2.9 billion L.E. for the next five years. Forty
eight percent of this number represents the annual recurrent cost to maintain the quality
of PHC services (EMRO, 2006).
2.9 Linking between Service Quality, Outcome, and Financial Performance

As the health care industry moves toward managed competition and a new
order of health care, information for aligning an entire organization around meeting
customer requirements efficiently will become increasingly important. These customers
are primarily patients, but also include physicians, employees, payers, and other
stakeholders in the managed care environment (Furse et al, 1994).
In this new health care environment, performance in the following areas will be critical:
Financial performance: providing efficient low-cost/high-value services as
measured by financial and operating indicators,
Medical outcome: producing consistently favourable clinical results as measured by
medical records.
Perceived service quality: delivering service experiences that meet customer needs
as measured by customer satisfaction surveys (Furse et al, 1994).
Many studies have shown a strong link between customer satisfaction and firm
profitability. Using 200 of the Fortune 500 firms across 40 industries, Anderson et al.
(2004) show that while market share has no impact on shareholder value, a 1% change
in ACSI (as measured by the American Customer Satisfaction Index on a 0-100 scale) is
associated with a 1,016% change in shareholder value as measured by Tobin's q. This
implies that 1% improvement in satisfaction for these firms will lead to an increase in a
firm's value of approximately $275 million. Ittner and Larcker (1998) also use ACSI
and financial data on 140 firms and find remarkably similar results. Specifically, they
demonstrate that a one point increase in ACSI leads to a $240 million increase in market
value of a firm. Using similar data, Gruca and Rego (2005) find that a one-point
increase in ACSI results in an increase of $55 million in a firm's. Anderson and Mittal
(2000) examine the data from 125 Swedish firms using the Swedish Customer
- 31 -
Satisfaction Barometer (SCSB) and find that a 1% increase in satisfaction leads to a
2.37% increase in ROI. With the SCSB data for 1989-92, Anderson and colleagues
(1997) find that satisfaction elasticity for ROI ranges from 0,14 to 0,27, The Swedish
data lead Anderson et al. (1994) to conclude that a one-point annual increase in SCSB
for five years is worth about $94 million or 11,4% of current ROI, Using data from
12,000 retail banking customers from 59 divisions of a retail bank, Hallowell (1996)
supports results from SCSB data by showing that a one-point improvement in
satisfaction (on a 1-7 scale) increases ROA by 0,59%, With data from 106 firms in 68
industries during the period 1981-91, Nayyar (1995) finds that news reports about
increases in customer service lead to average cumulative abnormal earnings (CAR) of
about 0,46%, or $17 million in market value, Ittner and Larcker (1998) also find that
announcement of ACSI improvement leads to an increase in abnormal returns
approximating 1% in a 10-day period. Rucci et al. (1998), describing the transformation
at Sears during the period 1994-95, develop a model to relate changes in employee
attitude, customer satisfaction, and revenue growth. Results indicate that a five-point
improvement in employee attitude leads to a 1.3 point improvement in customer
satisfaction, which in turn leads to a 0.5% improvement in revenue growth. They further
estimate that a 4% improvement in customer satisfaction translates to more than $200
million in additional 12-month revenues. These extra revenues would increase Sears's
market capitalization by nearly $250 million. Some studies explicitly consider the
impact of service quality on financial performance, while others subsume service quality
as a driver of customer satisfaction and therefore focus on the impact of satisfaction on
financial performance. With profit impact of movicet strategies (PIMS) data, Buzzell
and Gale (1987) find that the short-run elasticity of ROI of quality is 0.25. Anderson et
al. (1994) report this elasticity at about 0.2 from the Swedish data. Nelson et al. (1992),
with data from 51 hospitals, find that selected dimensions of service quality explain
17%-27% of the variation in financial measures such as hospital earnings, net revenue,
and ROA. Using data from almost 8,000 customers of a national hotel chain. Rust et al.
(1995) find that ROI in service quality (e.g., cleanliness) is almost 45%. Aaker and
Jacobson (1994), using data from 34 firms and more than 1,000 customer surveys,
conclude that quality perceptions positively influence stock returns even after
controlling for accounting measures.
Collectively, these studies show a strong and positive impact of customer
satisfaction on firm performance. They further provide a rough benchmark about the
effect size. For example, Anderson et al. (2004) and Ittner and Larcker (1998) show that
a 1% change in ACSI can lead to a $240-$275 million improvement in firm value. In
sum, these results provide a strong guideline to firms about how much they should
spend on improving customer satisfaction.
Health care leaders must also integrate financial, clinical, and service quality
information to achieve the greatest success.
The most traditional method of measuring a health care organization's clinical
success is through medical outcomes. The first level is raw data provided from
medical records, such as morbidity and mortality rates. At the second level, making
these data into information could produce severity-adjusted outcome trends,
profiles, and norms for the organization. Third, a comparison with results from
similar health care organizations provides knowledge for benchmarking and
appropriate clinical practice guidelines (Furse et al, 1994).
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The second component of measuring a health care organization's overall success is
through perceived service quality, or the quality of the customer's total experience with
your organization. The raw data for this factor comes from customer satisfaction
surveys of key stakeholders (patients, physicians, employees, payors, etc.). These
data can be fashioned into information such as satisfaction trends, performance
profiles, and norms for the organization. Industry-wide comparison provides
knowledge for service quality benchmarking and identifying industry best practices
(Furse et al, 1994).
The most fundamental method of measuring an organization's success is through its
financial performance. The first level is raw data from accounting and billing records.
At the next level, financial data such as revenues, return on assets, and earnings can
be integrated with operating data such as length of stay or staffing per patient day to
provide information that helps determine key factors influencing financial
performance. Third, communitywide, network-wide, and industry-wide
comparisons can provide knowledge for financial benchmarking and strategies to
improve financial performance (Furse et al, 1994).
Integrating knowledge of financial performance with perceived service quality
and clinical outcomes creates the wisdom needed to become a world-class quality, low-
cost health care provider (Furse et al, 1994).
A key to the application of total quality management in health care will be the
ability to relate customer satisfaction information to clinical outcomes and financial
performance. The integration of data for all three factors is critical to the success of the
organization as a whole, and there is now empirical support for the linkage between
customer satisfaction with improved medical outcomes and better financial
performance. The results of a study of 15,000 randomly selected patients from 51
hospitals support the relationship between net revenue, earnings, and return on assets
with patient satisfaction on 41 key questions, from admissions to billing. Increasingly,
organizations are beginning to realize that service quality, as measured by customer
satisfaction, is key to success in healthcare and organizational profitability. Historically,
patient satisfaction was one of the last things health care organizations considered to
measure. Today, it is one of the last things they would give up (Furse et al, 1994).
Rajuand and Lonial, (2002) described service quality in terms of the constructs
of quality context and quality outcomes. Quality context (QC) describes the
environment related to quality practices within a hospital which generally encourages
and enhances service quality while quality outcomes (QO) comprises of specific clinical
and patient satisfaction outcomes of the hospital. They also described marketing in
terms of the constructs of marketing orientation and market/product development
outcomes. Market orientation (MO) is a well accepted, albeit complex, construct within
the marketing literature and can be thought of as the process of effectively collecting,
disseminating, and responding to information in order to enhance the marketing function
within the hospital. Such information generally relates to market trends, customers, and
competitors. Market/product development outcomes (MPD) refer to specific outcomes
in relation to product innovation and market segmentation that are general indicators of
the marketing effectiveness of the hospital. Rajuand and Lonial, (2002) succeeded in
linking the above-mentioned constructs to the financial performance (FP) of an
organization. A sequential chain of relationships among the constructs was uncovered
where Market orientation (MO) mediates the effect of Quality context (QC) on Quality
- 33 -
Outcome (QO), and Market/product development outcomes (MPD) mediates the effect
of Quality Outcome (QO) on financial performance (FP).
Gupta and Zeithaml, 2006 have succeeded in integrating the impact of
customer metrics on firms' financial performance. The relationships among customer
metrics and profitability has become quite critical. These relationships are pivotal to
tracking and justifying firms' marketing expenditures, which have come under
increasing pressure. They studied unobservable or perceptual customer metrics and
observable or behavioural metrics.
Observable measures involve behaviours of customers that typically relate to
purchase or consumption of a product or service. From a customer's perspective, these
include decisions of when, what, how much, and where to buy a product. From a firm's
perspective, this translates into decisions about customer acquisition, retention, and
lifetime value. The authors chose to use customer acquisition, customer life-time value,
customer retention and customer equity as metrics for observable measures. As for the
unobservable constructs, the authors chose to include customer perceptions (e.g., service
quality), attitudes (e.g., customer satisfaction), or behavioural intentions (e.g., Loyalty
intention to purchase). In economists' terminology, unobservable constructs are stated
preferences, while observable constructs are revealed preferences (Gupta and Zeithaml,
2006). In this research, authors have come up with several generalizations that include:
Improvement in customer satisfaction has a significant and positive impact on firms'
financial performance.
The strength of the satisfaction, profitability link varies across industries as well as
across firms within an industry.
There is a strong positive relationship between customer satisfaction and customer
retention.
Marketing decisions based on observed customer metrics, such as CLV, improve a
firm's financial performance.
Customer retention is one of the key drivers of CLV and firm profitability
Customer metrics, especially CLV and CE, provide a good basis to assess the
market value of a firm (Gupta and Zeithaml, 2006).
2.10 Service Quality: Implementation of a Consumer-Focused Culture

Many hospitals and medical groups have difficulty adjusting to a marketing-
oriented organization. Embedding the culture of marketing and a customer-focused
culture through the organization is not a simple task. Berkowitz, 2006 stated four
prerequisites for marketing success in organizations. The first is pressure to be
marketing oriented throughout a shared view from top-management. Second, the
capacity to achieve this through allocation of the proper people and resources that are
not only experienced but they have to be adequately trained. Third, a cleared shared
vision of the market concerning all key issues such as customer needs, changes required
to meet them etc that can be obtained through market research. Fourth, development of
an action plan consisting of actionable steps with clear areas of responsibility to achieve
these goals. When reviewed, the human aspect comes clearly into focus and must be
stressed upon in any organizational cultural change.
Changing the mindsets, habits, skills and knowledge of the people who work in
the organization is quite a large challenge. Parasuraman et al., (1990) had developed the
gap model and pinpointed several antecedents to the gaps. These antecedents to efficient
implementation of service quality are many (demonstrated in Figure 2.4). There are
- 34 -
antecedents that affect implementation both from the management and from the
employees‘ side. Antecedents include marketing research orientation of the
organization, levels of upward communication, existing levels of management,
management commitment to service quality, existence of goal setting and task
standardization and the perception of feasibility on the management side. On the
employees such as the contact-personnel side, the presence of teamwork, employee-job
fit, technology-job fit, perceived control, supervisory control systems, role conflict, role
ambiguity, presence of horizontal communications and propensity to overpromise all
contribute to the presence of service quality short-falls in the organization.
Once a decision has been made to focus on improving customer service,
Zeithaml et al (1990) have pin-pointed a six-step model to start getting quality service
improvement off the ground in any organization. The following guidelines are what
Zeithaml et al (1990) state to be ―Guidelines for developing a foundation to change‖.
They include:
First: Get ready for hard work: The organization needs to prepare for what lies ahead:
Senior managers must expect to be directly involved and must get the commitment of
the staff who are responsible, all the way down to sales or contact people. Pin-pointing
all the requirements and striving to make it happen will be hard work for all those
involved.
Second: Collect any relevant data: Data should be collected to enable managements to
base decisions on it. Thus research methodologies have to be discussed and put in place
and the data collected (whether primary or secondary) has to be suiTable for the purpose
for which it is sought. The information obtained from it should be then used for
planning and developing any changes in operations that are required and should be
communicated and shared with all employees so that the ground is prepared for getting
their commitment.
Third: Organize for change: The right personnel in the various levels of management
who will have responsibility to effect the change should be recognized and pinpointed.
The direction of change that the organization will commit to is also to be decided at this
stage. Over and above, the commitment of staff, who are already busy enough with their
previous work loads, should be obtained.
Fourth: Leverage the Freedom Factor: The organization has to start the culture of
empowerment of the employees. Prepare to let employees do what they should be doing
and remove the restrictions of guidelines from their work. The culture should be of
guidance from senior management in their work and not one of control. Thus education
of all levels of management to make them understand what is expected and what their
role is in making the plan succeed.
Fifth: Symbolize service quality: This is management's commitment to quality. They
need to develop symbols that are aimed at showing that the shift in management
thinking is real and they should also form a part of the change in culture towards
improving the quality.
Sixth: Promote the right people: This is a crucial step to the success of any initiative.
Promoting managers to leadership roles is often a decision that does not lead to desired
outcomes because managing and leading are quite different roles.
Following these basic steps allows the development of quality in customer
services. Building a foundation for change has to involve top management to provide
strong internal leadership service. Once top management are willing and able to
implement this culture, then all pieces of the puzzle starts to fall into shape (Zeithaml et
al., 1990).
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Conclusion
This was a brief summary of the most relevant literature for the current research.
The literature review covered a brief description of the healthcare sector, an overview of
consumer satisfaction literature, the link between consumer satisfaction literature and
healthcare service quality literature and healthcare satisfaction and service quality
studies. It also described outcome management and linked between service quality,
consumer satisfaction and behavioural intentions to return and recommend. Finally, the
effect of consumer demographics as a moderating factor was also mentioned. This
research aims to build upon the work of the aforementioned researchers to build a model
that helps in improving the understanding of how service quality plays a role in the
healthcare service industry.
- 36 -
Table 2.1: Demonstrating Dimensions Identified by Hulka et al., 1975, Ware et al, 1977,
Wolf et al., 1978, Bertakis, 1977, Ley, 1983, Kiam-Caudle and Marsh, 1975, Wooley et
al., 1978 and Feletti et al., 1986
Author Dimensions
Hulka et al., 1975 Communication, measurement of patient‘s attitude
towards the system, physician and medical care
received, physician awareness of medical concerns
Ware et al, 1977 Art of care, technical quality of care,
accessibility/convenience, finances, physical
environment, availability, continuity,
efficacy/outcome of care
Wolf et al., 1978 Cognitive/information transfer component of
consultation, affective or caring domain of
consultation, behavioural skilfulness of physicians
Bertakis, 1977 Retention of information conveyed from physician
Ley, 1983 to patient
Kiam-Caudle and Practice premises, receptionists, appointment
Marsh, 1975 system, personnel doctor system, doctor‘s method
of work, use of paramedical staff
Wooley et al., 1978 Satisfaction with outcome, continuity of care,
patient expectations, doctor-patient communication
Feletti et al., 1986 Competence in a physical domain, competence in
the emotional domain, competence-social
awareness, the physician as a model, amount of
time for consultation, perceived amount of
continuity of care by the physician, mutual
understanding in the doctor-patient relationship,
patient‘s perception of their individuality,
information transfer, competence-physical
examination
Source: Hulka et al., 1975, Ware et al, 1977, Wolf et al., 1978, Bertakis, 1977,
Ley, 1983, Kiam-Caudle and Marsh, 1975, Wooley et al., 1978 and Feletti et al., 1986
- 37 -
Table 2.2: Demonstrating Dimensions Identified by Zeithaml et al., 1990
Dimension Questions for Each Dimension
A)Tangibles: The 1. Excellent Companies will have modern-looking
appearance of the Equipment
equipment, 2. The physical facilities at excellent companies will be
physical facilities, visually appealing
personnel, and 3. Employees at excellent companies will be neat-
communication appearing
material used by 4. Materials associated with the service (pamphlets,
the company statements) will be visually appealing at an excellent
company
B)Reliability: The 5. When excellent companies promise to do something by
ability to perform a certain time they will do so
the promised 6. When a customer has a problem excellent companies
service dependably will show a sincere interest in solving it
and accurately 7. Excellent companies will perform the service right the
first time
8. Excellent companies will provide their service at the
time they promise to do so.
9. Excellent companies will insist on error-free records
C)Responsiveness: 10. Employees in excellent companies will tell customers
The willingness to exactly when the service will be performed
help customers and 11. Employees in excellent companies will give prompt
provide prompt service to consumers
service 12. Employees in excellent companies will always be
willing to help consumers
13. Employees in excellent companies will never be too
busy to respond to consumer‘s requests
D)Assurance: the 14. The behaviour of employees in excellent companies
knowledge and will instil confidence in customers
courtesy of the 15. Customers of excellent companies will feel safe in their
employees and transactions
their ability to 16. Employees in excellent companies will be consistently
convey trust and courteous with customers
confidence 17. Employees in excellent companies will have the
knowledge to answer customers questions
E)Empathy: The 18. Employees in excellent companies will give customers
caring individual attention
individualized 19. Employees in excellent companies will have operating
attention that hours convenient to all their customers
employees provide 20. Excellent companies will have employees who give
customers personal attention
21. Excellent companies will have the customers best
interest at heart
22. Employees in excellent companies will understand the
specific needs of their customers
Source: Zeithaml et al., 1990
- 38 -
Table 2.3: Demonstrating Dimensions identified by Brown and Swartz,
1989
Dimension Questions for Each Dimension
A)Professionalism 1. Appointments should be made easily and
quickly
2. I expect the doctor‘s fee to be reasonable for
the professional service rendered
3. I expect my doctor to talk clearly using words I
understand
4. I expect my doctor to be sincerely interested in
me as a person
5. I would prefer that my doctor explain tests &
procedures to me instead of the nurse or
receptionist
B) Auxiliary 6. I would like to have more health-related
Communications information available in the reception area
7. I would like to have brochures available from
my doctor explaining my medical problem and
treatment
8. I would like to receive in the mail a reminder
for my regular check-up
9. I expect the doctor‘s office to be open at times
which are convenient to my schedule
C) Professional 10. Where my medical care is concerned, my
Responsibility doctor should make all the decisions
D)Physician 11. My doctor hears what I have to say
Interaction 12. My doctor usually gives me enough
information about my health
13. My doctor is careful to explain what I am
expected to do
14. My doctor is very thorough
15. My doctor spends enough time with me
16. My doctor examines me carefully before
deciding what is wrong
17. I have complete trust in my doctor
18. My doctor takes real interest in me
19. I have my doctor‘s full attention when I see
him or her
20. My doctor always treats me with respect
21. My doctor thoroughly explains to me the
reasons for the tests and procedures that are
done on me
39
E) Staff 22. My doctor‘s office staff take a warm and
Interaction personal interest in me
23. My doctor‘s office staff know me as an
individual
24. My doctor‘s office staff is friendly and
courteous
25. My doctor‘s office staff is very flexible in
dealing with my individual needs and desires
26. My doctor‘s office staff always act in a
professional manner
27. My doctor‘s office staff is more interested in
serving the doctor than in meeting my needs
F) Diagnostic 28. My doctor prescribes drugs and pills too often
29. My doctor orders too many X-rays and
Laboratory results
30. My doctor‘s main interest is in making as much
money as he/she can
31. My doctor will not admit when he/she do not
know what is wrong with me
32. There are some things about the medical care
that I receive from my doctor that could be
better
33. My doctor rarely ever explains my medical
problem to me
G) Professional 34. My Doctor is better trained than the average
Competence doctor
35. Compared to other doctors, my doctor makes
fewer mistakes
36. My doctor keeps up on the latest medical
discoveries
37. My doctor gives me choices when deciding my
medical care
H) Time 38. My doctor rarely makes me wait and he/she is
Convenience usually on time
39. I am usually kept waiting a long time when I
am at my doctor‘s office
I) Location 40. My doctor‘s office is conveniently located for
Convenience me
41. My doctor is on staff at a hospital which is
convenient for me
Source: Brown and Swartz, 1989
40
Table 2.4 : Demonstrating Dimensions Identified by Joby, 1992, Walbridge
and Delene, 1993and Carman, 1990
Author Dimensions
Joby, 1992 A) Competence: All personnel
The variables were obtained from (doctors, nurses) in excellent
the study of medical questionnaires companies should have the
developed from the works of Hulka knowledge and the skills needed to
et al., 1970, Hulka & Zyzanski, perform the service
1982, Ware and Snyder, 1982, B) Credibility: This is the extent to
Ware, Snyder and Wright, 1976, which the names and reputations of
Ware et al., 1983 and Parasuraman the service provider are demonstrated
et al., 1988) by the service performance
The following variables, in addition C) Security: This is the freedom
to the Five Dimensions measured by from physical risk related to the
the SERVQUAL and stated above, consumer‘s confidence in a
were conducted to test for the successful medical outcome
patient‘s perceptions. D) Courtesy: The respect,
consideration, politeness and
friendliness of the personnel with
whom the patient come in contact
E) Communications: Informing the
patient about various aspects of the
consumption experience and listening
to the patients express themselves
about various aspects of consumer
experience
F) Understanding/Knowing the
Consumer: Providers demonstrating
ability to show an interest in
understanding the needs of the
consumers
G) Access (Availability): The ease of

contact, approachability and quantity
of personnel available in the company
H) Physical Environment
(Tangibles2): The non-medical
services (hospitality services of the
hospital) such as visiting hours,
quality of food, rooms of patients etc
Walbridge and Delene, 1993 Core Medical Services: The central
This study measures physician medical aspects of the service
perceptions of services. The five appropriateness, effectiveness and
dimensions of SERVQUAL were benefits to the patient
tested and two dimensions were
added. One is as above from Brown
41
and Swartz, 1989
(Professionalism/Skill) as well as
from Hayward-Framer and Staurt,
1989 (Core Medical Services).
Carman, 1990 The factors that resulted were
This study uncovers several extra admission service, tangible
factors that realte to the fact that accommodations, tangible food,
there are multiple encounters in one tangible privacy, nursing care,
hospital stay. The study only explanation of treatment, access and
measured perceptions of the service courtesy afforded to visitors,
encounter. discharge planning and patient
accounting (billing).
Source: Joby, 1992, Walbridge and Delene, 1993and Carman, 1990
42
Table 2.5: Demonstrating Dimensions Identified by Woodside et al., 1989
Dimension Variables covering Dimension
A) Admission 1. Admission waiting time
2. Admission personnel courteous and
helpful
B) Nursing Care 3. Overall satisfaction with nursing care
4. Adequate information from nurses
5. Response to requests in a reasonable
length of time
6. Problem with nursing shift
7. Nurse refers to you by name
C) Meals 8. Food served at the right temperature
9. Adequate selection of meals
10. Overall satisfaction with meals served
D) 11. Room ready upon arrival
Housekeeping 12. Room and bath are kept clean
13. Housekeeping staff are courteous
E) Technical 14. Lab testing waiting time
services 15. X-ray personnel courteous
16. Adequate information from doctors
about scheduled treatments and tests
F) Discharge 17. Hospital office personnel explain
coverage and answer billing questions
18. Business office personnel courteous and
helpful upon discharge
Source: Woodside et al., 1989
43
Table 2.6: Health Expenditure Indicators (1990-2005)
Health Expenditure 1990 1995 2000 2004 2005
Indicators
Total health 30 - - 192 -

expenditure/capital, $ (02)
Total health 4.7 3.7 2.4 1.9 3.43
expenditure as % of (94-95) (00-01) (01-02)
GDP
Public sector % of - 44 42 - -
total health (94-95) (00-01)
expenditure
Source: EMRO, 2006
Table 2.7: Sources of finance, by percent (1990-2004)

Source 1990 1995 2000 2004
General
Government
Central 28.98% 35% 29% -

Ministry of
Finance
State/Provincial 2.04% 5% 3% -
Public Firms
Funds
Local
Social Security 8.89% 6% - -
Private
Private Social - - 6% -
Insurance
Other Private - - - -
Insurance
Out of Pocket 55.73% 51% 61% -
Non-profit - - <1% -
Institutions
Private firms - - - -
and
corporations
External 4.35% 3% 1% -
sources
(donors)
Source: EMRO, 2006
44
Table 2.8: Demonstrating Health Service Providers Indicators
Description 1981/82 2006/07
Public and central hospitals (Number) 169 381
Rural hospitals (Number) 39 931
Rural health units (Number) 1880 4500
Beds (in thousand) 84.4 185
Number of doctors (in thousand) 52.3 164
Number of nursing categories (in thousand) 60.3 206
Number of population per bed 499 393
Number of population per doctor 805 440
Number of population per nurse 698 353
Medicine self-sufficiency ratio (%) 73.6 93.3
Source: (SIS, 2007)
45
Figure 2.1 : Conceptual Model of Disconfirmation-of-Expectations Process
Time t Time t + 1
Expectations Use Occasion
Attitudes Perceptions
of Use
Experience
Disconfirmation
Beliefs
Choice Satisfaction/
Dissatisfaction
Source: Cadotte et al., 1987
46
Figure 2.2 : Gronroos Service Quality Model
EXPECTED PERCEIVED
SERVICE Perceived Service SERVICE
Quality
IMAGE
Technical
Quality Functional
Quality
What? How?
Source: Gronroos, 1984
47
Figure 2.3 : Parasuraman, Zeithaml & Berry Conceptual Model of Service
Quality
Word-of-Mouth Personal Past

Communications Needs Experience
Expected Service
Tangibles
Reliability
Gap 5
Responsiveness
Assurance
Empathy
Perceived Service
CUSTOMER
Gap 4 External
PROVIDER
Service Communications
Delivery To
Customers
Gap 3
Service Quality
Gap 1 Specifications
Gap 2
Management Perceptions
Of
Customer Expectations
Source: Parasuraman et al., 1990

48
Figure 2.4 : Parasuraman, Zeithaml & Berry Extended Gap Model
Marketing Research
Orientation
Upward Gap 1
Communications
Levels of
Management
Management
Commitment
to Service Quality
Goal Setting Gap 2
Task
Standardization
Tangibles
Perception of
Feasibility
Reliability
Gap 5
Teamwork
Perceived Responsive
Service
ness
Quality
Employee-Job Fit
Assurance
Technology-Job Fit
Empathy
Perceived Control Gap 3
Supervisory
Control system
Role Conflict
Role Ambiguity
Horizontal
communications Gap 4
Propensity to
Overpromise
Source: Parasuraman et al., 1990
49
Figure 2.5: Structural Model to Demonstrate the Relationships between
SERVQUAL and SERVPERF and Consumer Satisfaction, Overall Service
Quality and Purchase Intentions
έ X1
Path
1
(P1)
Path
2 Path
(P2) 4
(P4)
n1 n2 n 3
Path
3
(P3)
MODEL 1 MODEL 2
έ 1 : SERVQUAL έ 2: SERVPERF
n 1: Overall Consumer Satisfaction n 1: Overall Consumer Satisfaction
n 2: Overall Service Quality n 2: Overall Service Quality
n 3: Purchase Intentions n 3: Purchase Intentions
Path 1: Path linking Satisfaction and purchase intentions

Path 2: Path showing consumer satisfaction as an antecedent of service quality
Path 3: Path showing satisfaction as an outcome of service quality
Path 4: Path linking service quality and purchase intentions
Source: Cronin & Taylor, 1992
50
Figure 2.6: Application of A General Framework to Customer (Patient)
Satisfaction with received Hospital Care
A A A N N N F F F H H H
1 2 i 1 2 i 1 2 i 1 2 i
(A) (N) Nursing (F) Food (H)

Admission Care Events Service Housekeepin
Events Service Events g Events
Service Quality Service Service
Quality Quality Quality
T (T) (D) D
1 1
Technical Discharge
T
Service Events D
2 Events Service 2
Service Quality
T Quality D
i i
Overall Satisfaction with

Hospital Stay
Behavioural Intentions to Receive Care from the

Same Hospital
Source: Woodside, Frey and Daly, 1989
51
Figure 2.7: Demonstrating the Feedback Cycle in Healthcare
Care
Team
Patient Care Outcomes

Process
Source: Walburg et al., 2006
Figure 2.8: Demonstrating the Outcome Quadrants in Healthcare
Clinical Outcome
Life Patient
Quality Satisfaction
Costs
Source: Walburg et al., 2006)
52
Figure 2.9: Demonstrating Levels of Outcome in Healthcare
Well-being 4
Capacity to Function 3
Symptom 2
Biochemistry, Physiology, Microbiology 1
Source: Benson, 1992
53
3. MODEL AND HYPOTHESIS
3.1 Introduction
Following the original SERVQUAL model by Parasuraman et al.,
1988, service quality was measured by detecting the Gap size between the
expectations and perceptions of the consumers for five factors. The original
scale consisted of a 97-item instrument, which was further divided into 10
dimensions and 54 items then further to 34 items and five of the original 10
dimensions and finally reduced into the final 22-item scale, divided into five
dimensions, tangibles, reliability, responsiveness, assurance and empathy.
(Parasuraman, et al., 1991).
However, these purifications were made through data collected for
only four industries: a bank, a credit card company, a firm offering appliance
repair and maintenance services and a long-distance telephone company
(Parasuraman, et al., 1988, 1991). This lengthy refinement and reassessment
was not done for the SERVQUAL scale for healthcare industry by the original
authors. Subsequent researchers tested the final purified scale directly on the
industry and its validity and reliability was tested by several researchers for the
healthcare industry. However, some of the relevant points obtained from their
original focus groups, which were eliminated from the tested four industries
might prove to be relevant to healthcare.
Following an extensive literature review, many other factors were also
identified and tested in Healthcare in addition to the above five mainly from
the works of Brown SW & Swartz TA, 1989, Joby J. 1992, Walbridge SW &
Delene LM, 1993 & Woodside et al., 1989 and Carmen, 1990. These
researchers have gone back a step to include some of the original 10
dimensions that were eliminated from the SERVQUAL after several steps of
refinement and reassessment and others that they thought proved relevant to
healthcare. Also of importance in formulation of the theoretical framework is
research performed by Cronin and Taylor, 1992 in defining and testing service
quality in four different constructs and detecting the most significant construct
of them for the four industries tested.
Thus, in an attempt to formulate a more extensive model for
healthcare service quality, a new model was adapted and tested for healthcare
using dimensions identified for the original SERVQUAL scale, and others
identified for healthcare service quality by other the researchers.
Several steps were undertaken in the current research to achieve this. These
include:
First: Identification of constructs of healthcare service quality was
performed through factor analysis.
Second: The scale for measurement of healthcare service quality was
developed and tested. This was done by using the 4 different inputs
described by Cronin and Taylor, 1992 as well as testing whether additive
or interactive methodology for measurement is best.
o SERVQUAL, Weighted SERVQUAL, SERVPERF, Weighted
SERVPERF testing was performed through factor analysis. The
most appropriate scale for measurement of healthcare service
quality for the current research was chosen and all further testing
was done using this scale.
54
o The most appropriate scale was then be regressed using logistic
regression against the overall perception of service quality to link
the constructs and sub-constructs identified for healthcare service
quality with overall perceived service quality. This also
demonstrated whether and additive or interactive methodology is
a more appropriate method for measurement of healthcare service
quality. The theoretical framework is demonstrating these links;
the variables and the possible modifications to the original
models are shown in Figure 3.1, 3.2, 3,3 and 3.4.
Third: There are factors that are expected to affect the consumer
perceptions of service quality due to their effect on the formulation and the
level of expectations of the consumers. These factors include the
demographic profile of patients (age, education, socioeconomic level). The
effect of Demographics on the variables in the research was also
demonstrated. The links between the variables are demonstrated in Figure
3.5.
Fourth: The relationship between overall consumer satisfaction on one
hand with behavioural intentions to return and recommend, value for
money, outcome to mother and baby was investigated using correlation
tests.
Fifth: An understanding if certain sub-constructs have a greater impact on
the overall perception than others was attempted.
All the constructs and sub-constructs included in the present research are
summarized in Table 3.1. This Table demonstrates the variable, its description,
its reference, its type, the scale, value and range through which it will be
measured in the present research, and finally if it is primary or secondary data.
3.2 Conceptual Framework

3.2.1: Constructs and Sub-constructs
Main Construct: Hospital Medical Services
o Construct: Physician Medical Service
o Definition: Core medical services performed by physicians that
can affect patients' expectations and perceptions of hospital
service provided
o To be measured: Using four sub-constructs: Reliability, Security
(Assurance), Physician Interaction (Empathy/Responsiveness)
and Professional Competence (Assurance)
o Construct: Nursing Service
o Definition: Core medical services performed by nurses that can
affect patients' expectations and perceptions of hospital service
provided
o To be measured: Using five sub-constructs: Tangibles,
Reliability, Security (Assurance), Nursing Interaction (Empathy)
and Responsiveness
o Construct: Diagnostic Service
o Definition: The accuracy and necessity of diagnostic medical
services ordered by physicians and performed by hospital's
laboratories and radiology departments that can affect patients'
expectations and perceptions of hospital service provided
55
o To be measured: Using two sub-constructs: Diagnostic service
competence, diagnostic service reliability.
Main Construct: Hospital Hospitality Service
o Construct: Hospital Premises and Employees
o Definition: Hospital premises and employees are the appearance
of the equipment, physical facilities, personnel, and
communication material used by the hospital that can affect
patients' expectations and perceptions of hospital service
provided.
o To be measured: Using one sub-construct: Hospital Tangibles.
o Construct: Hospital Admission Services
o Definition: Hospitality services provided by the hospital that
involves the appointments, reception, direction, admission and the
courtesy of the personnel involved in admission that can affect
patients' expectations and perceptions of hospital service provided
o To be measured: Using two sub-constructs: Hospital Admission
Responsiveness, Hospital Admission Knowledge and Courtesy
(Assurance)
o Construct: Hospital Meals Services
involves provision of meals of good quality, temperature and
content that can affect patients' expectations and perceptions of
hospital service provided
o To be measured: Using one sub-construct: Hospital Meals
tangibles
o Construct: Hospital Rooms and Housekeeping Services
involves the adequacy and cleanliness of the rooms and the
courtesy of housekeeping service and that can affect the
expectations and perceptions of hospital service provided
o To be measured: Using two sub-constructs: Hospital Rooms
Tangibles and housekeeping personnel courtesy (Assurance)
o Construct: Hospital Discharge Services
involves the courtesy of discharge process personnel and their
knowledge in discharge procedure (billing, insurance etc) that can
affect patients' expectations and perceptions of hospital service
provided
o To be measured: Using two sub-constructs: Hospital Discharge
personnel Knowledge and Courtesy (Assurance).
The following Table 3.1 demonstrates the variables used in the present
research, their definition, type, scale, value/range and finally the source of the
data to be obtained for this variable.
56
Table 3.1: Demonstrating the Constructs and Sub-constructs Used in the Present Research
Sub-construct Description/Definition Type Scale Value/Range Source
1. Physician The ability to perform the promised Quantitative – Discrete (1-5) Primary
Reliability service dependably and accurately Ordinal 1=Least, 5=Most
2. Physician The knowledge and courtesy of the Quantitative – Discrete (1-5) Primary
Assurance physicians and their ability to convey Ordinal 1=Least, 5=Most
(Security) trust and confidence that will ensure
freedom from physical risk and instil
the patient‘s confidence in a successful
A) Physician Medical Service
medical outcome
3. Physician The interest and interaction the Quantitative – Discrete (1-5) Primary
Interaction physician has with his patient and their Ordinal 1=Least, 5=Most
(Empathy/ willingness to help the patient and
Responsiveness) provide prompt service as well as the
caring, individualized display of
professional ability to the patient
4. Physician's The knowledge and the skills that the Quantitative – Discrete (1-5) Primary
Professional physicians need to perform the service Ordinal 1=Least, 5=Most
Competence
(Assurance)
5. Tangibles The appearance and cleanliness of the Quantitative – Discrete (1-5) Primary
nursing personnel used by the hospital Ordinal 1=Least, 5=Most
B) Nursing
Services
Medical
6. Reliability The ability to perform the promised Quantitative – Discrete (1-5) Primary
service dependably and accurately Ordinal 1=Least, 5=Most
57
7. Nursing Security The knowledge and courtesy of the Quantitative – Discrete (1-5) Primary
(Assurance ) nurses and their ability to convey trust Ordinal 1=Least, 5=Most
and confidence that will ensure freedom
from physical risk and instil the
patient‘s confidence in a successful
medical outcome
8. Nursing The interest and interaction the nurses Quantitative – Discrete (1-5) Primary
Interaction have with their patient as well as their Ordinal 1=Least, 5=Most
(Empathy) willingness to help patients and provide
prompt service.
9. Nursing The caring, individualized display of Quantitative – Discrete (1-5) Primary
Responsiveness professional ability to the patient Ordinal 1=Least, 5=Most
10. Diagnostic The necessity and skilfulness of the Quantitative – Discrete (1-5) Primary
C) Diagnostic
Service medical services provided to the patient Ordinal 1=Least, 5=Most

Competence
Services
11. Diagnostic The accuracy of the medical services Quantitative – Discrete (1-5) Primary
Service provided to the patient Ordinal 1=Least, 5=Most
Reliability
12. Hospital The appearance of the equipment, Quantitative – Discrete (1-5) Primary
Premises and physical facilities, personnel, and Ordinal 1=Least, 5=Most
Employees communication material used by the
Tangibles hospital
D) Hospital
Premises&
Employees
58
13. Admission The hospitality services provided by the Quantitative – Discrete (1-5) Primary
Service hospital that involves the appointments, Ordinal 1=Least, 5=Most
Responsiveness reception, direction, and admission
E) Admission
14. Knowledge & The hospitality services provided by the Quantitative – Discrete (1-5) Primary
Courtesy hospital that involves knowledge and Ordinal 1=Least, 5=Most
Events
(Assurance) courtesy of the personnel involved in

admission
15. Meals Tangibles The adequacy of meals served as Quantitative – Discrete (1-5) Primary
regards temperature, quality and Ordinal 1=Least, 5=Most
Events
Meals
content.
F)
16. Rooms The cleanliness of the rooms and Quantitative – Discrete (1-5) Primary
Tangibles bathroom Ordinal 1=Least, 5=Most
Housekeeping Events
G) Rooms and
17. Housekeeping The courtesy of the housekeeping Quantitative – Discrete (1-5) Primary
Courtesy personnel Ordinal 1=Least, 5=Most
(Assurance)
18. Discharge The knowledge of discharge personnel Quantitative – Discrete (1-5) Primary
Discharge
Knowledge & in discharge procedure (billing, Ordinal 1=Least, 5=Most

Courtesy insurance etc)
Events
(assurance)
F)
59
19. Age Dividing the market into different age Quantitative Discrete Groups 1-5 Primary
groups Ordinal 1= 0-25
2= 26-35
3= 36-45
4= more than 46
20. Education Dividing the market into different Quantitative– Discrete Group 1-5 Primary
education groups Ordinal 1 = Diploma /
Some College
2 = Completed
College /
University
3 – PHD or
Masters Degree
21. Socioeconomic Dividing the market into different Quantitative – Discrete Income levels Primary
G) Demographic Profile
income level income groups Ordinal 1 = < 2000 / month

2 = 2000 – 4000 /
month
3 = 4,000 – 9000 /
month
4 = 9,000 – 15,000
/ month
5 = > 15,000 /
month
Source: Author
60
3.2.2: Theoretical Framework
The following section demonstrates the models tested in the current research. Figures 3.1 to 3.4 demonstrate the scales tested. Demographic
criteria as a moderating variables proved relevant to the industry are demonstrated in Figure 3.5. The model for the healthcare industry that
encompasses all the constructs and sub-constructs are demonstrated in Figures 3.6 and 3.7.
Figures 3.1 to 3.4: Scale Development Modules
INDEPENDENT VARIABLE GLOBAL DEPENDENT VARIABLE
SERVQUAL Scale
Figure 3.1` Expected Service

Overall
Perceived
Service Quality
Perceived Service
Weighted SERVQUAL Scale
Weighted Expected Service

Figure 3.2 Overall
Perceived
Service Quality
Weighted Perceived Service
61
INDEPENDENT VARIABLE GLOBAL DEPENDENT
VARIABLE
SERVPERF Scale
Overall
Figure 3.3
Perceived
Perceived Service Service
Quality
Weighted SERVPERF Scale
Figure 3.4 Overall

Weighted Perceived Perceived
Service Service
Quality
Source: Author
62
Figure 3.5: Demonstrating Demographic Criteria as a Discriminating Variable
DISCRIMINATING VARIABLE DEPENDENT VARIABLE
Demographics Overall
Age Perceived
Socioeconomic Income Service Quality
Education
Source: Author
63
Figure 3.6: Demonstrating a General Framework of the Constructs To Overall Perceived Service Quality with the Received Hospital
Care
Ph1 Ph2 Ph N1 N2 N8 PE PE PE A1 A2 A3 F1 F2 F3 RH RH RH
14 1 2 5 1 2 3
(Ph) Physician (N) Nursing Care (H) Hospital (A) Admission (F) Food Service (H) Room and
Medical Service Events Service Employees and Events Service Events Service Housekeeping
Events Service Quality Premises Events Quality Quality Events Service
Quality Service Quality Quality
Dg (T) Diagnostic (D) Discharge

1
Medical Service Events Service Ds
Quality 1
Dg Events Service
2 Quality Ds
2
Dg
5
Overall Perceived Service

Quality
Source: Author
64
Figure 3.7: Demonstrating the Constructs and Sub-constructs to be tested
in the Present Research
Hospital Medical Services
A) Physician Medical Service

1. Reliability
2. Security (Assurance)
3. Physician Interaction
(Empathy/Responsiveness)
4. Professional Competence
(Assurance)
B) Nursing Staff Medical Service

1. Tangibles
2. Reliability
3. Security (Assurance)
4. Nursing Interaction
(Empathy)
5. Responsiveness
C) Diagnostic Medical Services

1. Diagnostic Competence
2. Diagnostic Reliability Overall
Perceived
Service Quality
Hospital Hospitality Services
A) Hospital Employees and Premises

1. Tangibles
B) Admission
1. Responsiveness
2. Knowledge and Courtesy
(Assurance)
C) Food Service Events

1. Tangibles
D) Rooms and Housekeeping Events

1. Tangibles
2. Courtesy (Assurance)
E) Discharge Events
1. Knowledge and Courtesy Source: Author
(Assurance)
65
3.3 Limitations & Assumptions
3.3.1: Limitations:
L1: The elements per every dimension will be suiTable for the specific
Industry and needs reviewing when applied to another industry
L1: The sample size should be big to enable the researcher to utilize the
suiTable analysis techniques
3.3.2: Assumptions:
A1: A relationship exists between the model‘s variables
A2: Customers find the identified dimensions of service quality important to
them. This is based on research done by Zeithamal et al, 1990 Brown and
Swartz, 1989, Joby J. 1992, Walbridge SW and Delene LM, 1993, and
Carmen, 1990 where they established reliability for each of the dimensions,
and applied the model for different industries.
A3: The study is based on the hospital patients who had at least one overnight
stay only based on the personal interest of the researcher and the relevance of
the overnight stay to evaluate the hosiptal in-patient core medical service
offered
A4: The study applies to the Egyptian private healthcare sector only
3.4 Research Questions

3.4.1 Major Research Questions
Q1: What are the constructs and sub-constructs underlying healthcare service
quality?
Q2: What is the best measure of healthcare service quality among the eight
tested models?
Q2A: Is a performance-based measurement better for healthcare than
the (P-E) based measurement? Is a weighted scale better than a non-
weighted one? Thus should service quality in healthcare be measured
as:
SERVQUAL: P-E? or
Weighted SERVQUAL: Importance * (P-E)? or
SERVPERF: P? or
Weighted SERVPERF: Importance * (P)?
Q2B: Should an additive or interactive methodology be used for
measurement of HSQ?
Interactive SERVQUAL: (P-E)*(P-E)*(P-E)…
Weighted Interactive SERQUAL: W(P-E) * W(P-E) …..
Interactive SERVPERF: (P)*(P)*(P)……
Weighted Interactive SERVPERF: (P)*(P)*(P)……
Q3: Do consumer demographic (Age, Education, Socioeconomic Standard)
have an effect on variables of the research?
Q4: Does the service quality of certain dimensions have greater impact on the
overall perception than others?
Q5: What is the correlation between overall customer satisfaction on one hand
with behavioural intentions to return and recommend, value for money,
outcome to mother and outcome to baby on the other?
66
3.4.2: Minor Research Questions
Table 3.2: Demonstrating Dependent and Independent Variables to be used in the study and their Corresponding Research
Questions
Variables (Independent/Dependent) Research Question
A) SCALE DEVELOPMENT QUESTIONS
1. Individual Items in Each Scale / The Is an un-weighted performance-based measurement of service quality (un-
respondents‘ perception of the overall HSQ weighted SERVPERF) a more appropriate method for measurement of
service quality than SERVQUAL, weighted SERVQUAL and weighted
SERVPERF?
2. Individual Items in Each Scale / The Is an interactive methodology for calculating the measurement of service
respondents‘ perception of the overall HSQ quality for SERVPERF, SERVQUAL, weighted SERVQUAL and weighted
SERVPERF a more appropriate measure for service quality?
B) IDENTIFYING CONSTRUCTS AND SUB-CONSTRUCTS UNDERLYING HEALTHCARE SERVICE QUALITY
3. Physician Reliability / HSQ Is the sub-construct Physician Reliability an underlying factor for healthcare
service quality?
4. Physician Assurance Is the sub-construct Physician Assurance (Security) an underlying factor for
(Security)/ HSQ healthcare service quality?
5. Physician Interaction Is the sub-construct Physician Interaction (Responsiveness) an underlying
(Empathy/Responsiveness) / HSQ factor for healthcare service quality?
6. Physician's Professional Competence / HSQ Is the sub-construct Physician's Professional Competence an underlying
factor for healthcare service quality?
7. Nursing Tangibles Is the sub-construct Nursing tangibles an underlying factor for healthcare
/HSQ service quality?
8. Nursing Reliability Is the sub-construct Nursing Reliability an underlying factor for healthcare
/HSQ service quality?
9. Nursing Assurance (Security) Is the sub-construct Nursing Assurance (Security) an underlying factor for
/HSQ healthcare service quality?
67
10. Nursing Interaction (Empathy) / HSQ Is the sub-construct Nursing Interaction (Responsiveness) an underlying
factor for healthcare service quality?
11. Nursing Responsiveness / HSQ Is the sub-construct Nursing Empathy (Professionalism) an underlying factor
for healthcare service quality?
12. Diagnostic Service Competence / HSQ Is the sub-construct Diagnostic Service Competence an underlying factor for
healthcare service quality?
13. Diagnostic Service Reliability / HSQ Is the sub-construct Diagnostic Service Reliability an underlying factor for
14. Hospital Premises and employees Tangibility / Is the sub-construct Premises and employees an underlying factor for
HSQ healthcare service quality?
15. Admission Responsiveness / HSQ Is the sub-construct Admission Responsiveness an underlying factor for
16. Admission Knowledge & Courtesy Is the sub-construct Admission Knowledge an underlying factor for
(Assurance) / HSQ healthcare service quality?
17. Meals Tangibility/ HSQ Is the sub-construct Meals Tangibility an underlying factor for healthcare
service quality?
18. Rooms Tangibility Is the sub-construct Rooms Tangibility an underlying factor for healthcare
/ HSQ service quality?
19. Housekeeping Courtesy (Assurance)/HSQ Is the sub-construct Housekeeping courtesy an underlying factor for
20. Discharge Knowledge & Courtesy Is the sub-construct Discharge Knowledge (Assurance) an underlying factor
(Assurance)/ HSQ for healthcare service quality?
21. Scale Items & sub-constructs Is the scale generated for measurement of service quality in healthcare
reliable?
68
C) DEMOGRAPHICS QUESTIONS
22. Age What is the relationship between consumer Demographic Characteristics
(Age) and the variables within the constructs in the research?
23. Education What is the relationship between consumer Demographic Characteristics
(Education) and the variables within the constructs in the research?
24. Socioeconomic Standard What is the relationship between consumer Demographic Characteristics
(Socioeconomic Standard) and the variables within the constructs in the
research?
D) EFFECT OF INDIVIDUAL SUB-CONSTRUCTS ON THE OVERALL SATISFACTION, PERCEPTION AND PURCHASE
INTENTIONS
25. Individual Sub-constructs / The respondents‘ Does the service quality of certain service quality sub-constructs have a
perception of the overall HSQ significant impact upon the overall perception of service quality than others?
E) THE RELATIONSHIP BETWEEN OVERALL SATISFACTION, BEHAVIORAL INTENTIONS TO RETURN AND
RECOMMEND, VALUE FOR MONEY AND OUTCOME
26. The respondents‘ future purchase and What is the correlation between overall customer satisfaction with the
recommendation behaviour / Overall hospital stay and the patients' intention to return and recommend the hospital?
Satisfaction
27. The respondents‘ value for money / Overall What is the correlation between overall customer satisfaction with the
Satisfaction hospital stay and the value for money paid?
28. The outcome to the mother / Overall What is the correlation between overall customer satisfaction with the
Satisfaction hospital stay and the outcome to the mother?
29. The outcome to the baby / Overall Satisfaction What is the correlation between overall customer satisfaction with the
hospital stay and the outcome to the baby?
Source: Author
69
3.5: Research Hypothesis
A) Determine the best method for Healthcare service quality measures
among the tested measures
Hypothesis 1:
Null Hypothesis (Ho)
An un-weighted interactive performance based measurement service quality is
not a more appropriate measure for service quality for Healthcare Service
Quality Measures among the Tested Methods
Alternative Hypothesis (Ha)
An un-weighted interactive performance based measurement service quality is
not a more appropriate measure for service quality for Healthcare Service
Quality Measures among the Tested Methods
Hypothesis 1a:
An un-weighted performance based measurement of service quality (un-
weighted SERVPERF) is not more appropriate measure for service quality than
SERVQUAL, weighted SERVQUAL and weighted SERVPERF
An un-weighted performance based measurement of service quality (un-
weighted SERVPERF) is a more appropriate measure for service quality than
Hypothesis 1b:
An interactive methodology is not a more appropriate measure for service
quality than an additive methodology
An interactive methodology is a more appropriate measure for service quality
than an additive methodology
B) Identification of the sub-constructs patient's use in evaluation for HSQ
Hypothesis 2:
Null Hypothesis (Ho):
The sub-constructs Physician Reliability, Physician Assurance (Security),
Physician Interaction (Empathy/Responsiveness), Physician's Competence
(Assurance) ; Nursing Reliability, Nursing Assurance (Security), Nursing
Interaction (Empathy), Nursing Responsiveness ; Diagnostic Service
Competence, Diagnostic Service Reliability ; Hospital Premises and employees
Tangibles ; Admission Responsiveness, Admission Knowledge and Courtesy
(Assurance) ; Meals Tangibles ; Rooms Tangibles and Housekeeping Courtesy
(Assurance) ; Discharge and Courtesy (Assurance) do not have a significant
effect on healthcare service quality
Alternative Hypothesis (Ha):
The sub-constructs Physician Reliability, Physician Assurance (Security),
Physician Interaction (Empathy/Responsiveness), Physician's Competence
(Assurance) ; Nursing Reliability, Nursing Assurance (Security), Nursing
Interaction (Empathy), Nursing Responsiveness ; Diagnostic Service
Competence, Diagnostic Service Reliability ; Hospital Premises and employees
Tangibles ; Admission Responsiveness, Admission Knowledge and Courtesy
(Assurance) ; Meals Tangibles ; Rooms Tangibles and Housekeeping Courtesy
(Assurance) ; Discharge and Courtesy (Assurance) have a significant effect on
70
healthcare service quality
C) Examining the effect of consumer demographic characteristics on
Variables of the Research
Hypothesis 3:
Consumer Demographic Characteristics (Age, Income Level, Education) have
no significant effect on the variables of the research
Consumer Demographic Characteristics (Age, Income Level, Education) have
a significant effect on the variables of the research
Hypothesis 3a:
Consumer Demographic Characteristics (Age) have no significant effect on the
variables of the research
Consumer Demographic Characteristics (Age) have a significant effect on the
Hypothesis 3b:
Consumer Demographic Characteristics (Education) have no significant effect
on the variables of the research
Consumer Demographic Characteristics (Education) have a significant effect
on the variables of the research
Hypothesis 3c:
Consumer Demographic Characteristics (Socioeconomic Standard) have no
significant effect on the variables of the research
Consumer Demographic Characteristics (Socioeconomic Standard) have a
D) Examining the Effect of Each of the Identified Hospital Service Quality
Sub-constructs on patient's overall perception of service quality:
Hypothesis 4:
Some sub-constructs will not have significantly greater impact on the overall
perception of service quality than others
Some sub-constructs will have significantly greater impact on the overall
perception of service quality than others
E) Examining the Relationship between Overall consumer satisfaction on
one hand with Behavioural intentions to return and recommend, Value for
money and Outcome to mother and baby:
Hypothesis 5:
There is no correlation between overall customer satisfaction on one hand and
the patients' intention to return and recommend the hospital, value for money
and outcome to mother and baby on the other hand
71
There is significant correlation between overall customer satisfaction and the
patients' intention to return and recommend the hospital, , value for money and
outcome to mother and baby on the other hand
Hypothesis 5a:
There is no correlation between overall customer satisfaction and the patients'
intention to return and recommend the hospital
patients' intention to return and recommend the hospital
Hypothesis 5b:
There is no correlation between overall customer satisfaction and the value for
money
value for money
Hypothesis 5c:
There is no correlation between overall customer satisfaction and the outcome
to the mother
outcome to the mother
Hypothesis 5d:
There is no correlation between overall customer satisfaction and the outcome
to the baby
outcome to the baby
3.6 Research Methodology

3.6.1 Research Purpose
The purpose of this two-phase, sequential mixed methods study is to
review and synthesize existing knowledge about service quality models to fit
the healthcare sector. It aims to explore participant views with the intent of
using this information to develop and test an instrument with a sample from a
population.
The first phase was a qualitative exploration of the characteristics of
the healthcare service in Egypt upon which consumer build their perceptions
about the quality of the healthcare service. This was performed through
conducting a series of in-depth interviews from patients as well as business and
healthcare experts frequenting the private healthcare sector in Cairo. Then the
researcher conducted a pilot study to test the questionnaire and the reliability of
data. Final modification on the questionnaire format was done, prior to the
quantitative data collection procedure
In the second phase, themes and information from previous phase
were developed into a valid and reliable instrument for measurement of health
72
care service quality. A modified conceptual model of service quality was
constructed that was based on the work of previous authors in the field as well
as data gathered from the qualitative section of the study. Then a quantitative
survey for a sample of patients frequenting the private healthcare sector in
Greater Cairo, Egypt was performed to test the model.
3.6.2 Sample Selection/Size
Population: Individuals frequenting private hospitals in the greater Cairo
governorate.
Sampling Methods: Random sampling technique
Sampling Criteria: Females who have frequented a private hospital in the
past five years months for performing a successful childbirth (normal and
interventional), are of socioeconomic class A & B, have had at least a one
overnight stay in the hospital and are residing in Greater Cairo
Sample Size: Estimated to be 383 units
3.6.3. Development of Questionnaire
The questionnaire for the quantitative survey includes items extracted from the
literature review and was further subject to modifications following the
preliminary qualitative part of the research. The final questionnaire was
developed for the quantitative survey through the following steps:
A thorough literature review were performed and in parallel with in-
depth interviews with patients. This led to development of a
preliminary questionnaire (based on secondary data and the data from
the in-depth interviews).
In-depth interviews with experts further developed the previous
preliminary questionnaire and model constructs and tested its validity.
Finally, a pilot study was performed. The questionnaire was submitted
to a preliminary testing on a pilot group to test all aspects of the
questionnaire (question content, wording, sequence, form and layout,
question difficulty and instructions). The respondents of the pre-
testing were from the same population to be tested in the survey. This
enabled eliminating any potential problems in the questionnaire and
refining it.
A final questionnaire was developed and will be administered via a
full-fledged field survey.
The final questionnaire is composed of several sections:
1. For the first section, respondents will be asked to name a hospital
(within the healthcare service providers in Greater Cairo) that they
used for the evaluation and with which they are familiar and express
their perceptions about this hospital. The perceptions statements will
be given before the expectations statements to prevent any bias that
was previously mentioned in literature from measuring expectations
before perceptions. This questionnaire will be covering the patient‘s
actual perceptions (P) of the hospital service quality and the answers
are on a five-point Likert Scale
2. The second section covers the patient‘s expectations (E) of the
hospital service quality and the answers are on a five-point Likert
Scale
3. The third section containing statements to measure the feelings of
73
importance (W) that each patient assigns to each of the features
measured above and the answers are on a five-point Likert Scale
4. The fourth section contains a direct assessment of the overall service
quality of the hospital. The answers are on a five-point Likert Scale :
a. The patient's overall satisfaction
b. The patient's intentions to return and recommend
c. Value for money for the hospital service rendered
d. Outcome of the hospital stay
5. A section gathering information about the demographic characteristics
of the respondent
74
Table 3.3: Demonstrating Main Areas of Ideas and Questionnaire design
Construct Sub-construct Questions
Doctors Reliability Q5
Services Assurance (Security) Q6-8
Physician Interaction Q9-Q13
(Empathy/Responsiveness)
Hospital Hospitality Services Hospital Medical Services
Professional Competence Q14-17

Nursing Tangibles Q22
Services Reliability Q23
Assurance (Security/Courtesy) Q24-26
Responsiveness Q27
Empathy Q28-29
Expectations and Perceptions Section
Diagnostic Diagnostic Competence Q18-19

Services Diagnostic Reliability Q20-21
Hospital Tangibles Q1-4
Premises and
employees
Admission Responsiveness Q30
Services Knowledge and Courtesy Q31-32
Meals Tangibles Q33-35
Room and Tangibles Q36-37
Housekeeping Courtesy (Assurance) Q38
Discharge Knowledge and Courtesy Q39-40
Services (Assurance)
Hospital Premises and Employees Q41
Doctors Medical Services Q42
Diagnostic Medical Services Q43
Nursing Medical Services Q44
Importance
Admission Services Q45

Measures
Meals Q46
Rooms and Housekeeping Services Q47
Discharge Services Q48
Overall Consumer Satisfaction Q49
Future Purchase and Recommendation Intention Q50-51
Measures
Overall
Value for Money Q52

Outcome for mother Q53
Outcome for Baby Q54
Age Q55
Characteri
Demograp
Socioeconomic Income Q59

Education Q58
stics
Occupation Q56
hic
Geographic Location Q57

Source: Author
75
4. RESEARCH METHODOLOGY
The use of the scientific methodology of the research task is a sequential

process involving several clearly defined steps. These can be described as a
multi-stage process involving (Cooper and Schindler, 2001): First, formulation
of the research question through discovering the dilemma, defining the
research question and refining the research question through exploration. Then
second, development of the research proposal and third, review of previous
literature in the area. Also, fourth, identification of the research design (design
strategy composed of research type, purpose, time frame, scope and
environment, then data collection and sampling design then conduction of
questions and instrument for pilot testing and finally instrument revision) is
done. Fifth, data collection and preparation and sixth, data analysis,
interpretation and conclusions are made. Finally, research reporting and
replication from which managerial decisions can then be made based on the
business research.
The first three chapters of the present study have covered the first three
steps. This chapter will focus mainly on the fourth step. The chapter is
basically divided into three sections. The first section describes the research
design (purpose and process). The second section describes the sampling
procedure. The third and final section covers the data analysis methods.
4.1 Research Design

4.1.1 Purpose
The present sequential mixed research lies on the continuum of
research processes, starting with exploratory to descriptive and ending on the
analytical continuum to involve:
Starting with exploratory research to explore and identify the
characteristics of healthcare service quality that consumers base their
perceptions of the service quality upon in the private sector in Cairo,
Egypt.
Then based on those identified through a secondary literature review
and those collected through primary data, the research moved beyond
this to the descriptive and analytical stages:
o Data was collected describing consumer expectations,
perceptions and corresponding weights concerning the
private healthcare in Egypt, as well as consumer overall
satisfaction, overall perceived service quality and future
purchase and recommendation behaviour and consumer
demographics.
o As for the descriptive stage, several descriptive statistical
methods were used for description of the data.
o Then the research moved beyond the descriptive towards the
analytical continuum and will go beyond identifying these
characteristics, to analyzing them an understanding and
measuring the relationships between them.
76
4.1.2 Process
The process of the research constituted of a two-phase sequential
mixed study, first a qualitative phase then a quantitative phase was done. The
aim of the mixed methodology was to provide richness and direct consumer
insight from the phenomenological, qualitative section as well as the value of
statistical analysis and population generalization from the positivistic
quantitative section.
The exploratory, qualitative (phenomenological) phase of the research
identifying and describing healthcare characteristics was performed
through an extensive literature review and a series of in-depth
interviews. The latter was analyzed using qualitative data analysis
tools as content analysis (Hussey and Hussey, 1997, Mostyn, 1985,
Silverman, 1993) to extract data that was then the basis for finalizing
the questionnaire that was used in the survey.
The descriptive/analytical quantitative (positivistic) phase of the
research was performed through of a survey questionnaire (Babbie,
1997). A sample of patients was drawn from the population and
studied to make inferences about the population. A representative
sample was done and the use of statistical techniques enabled the
researcher to generalize these findings to the population. The
questionnaire was built on primary and secondary data collected in the
first phase, where the gathered data worked towards establishing a
tool for healthcare service quality measurement in Egypt.
o The data obtained from the questionnaire was described
using descriptive statistics as frequency distributions (means,
standard deviation etc) and descriptive graphs as frequency
histograms.
o Then the data was analyzed using quantitative statistical tools
as factor analysis, linear regression and correlation tests.
4.2 Sample Selection

4.2.1 Population
Population under study is the individuals frequenting private hospitals
in the greater Cairo governorate. This population features members of the A &
B class in Egypt who can afford to pay for the prices of privatized healthcare in
Egypt. According to the latest statistics from MEMRB (1996) (See Appendix
A & B), this portion of the population of the Cairo Governorate, a purely urban
area, is comprised of 11.5% of the population of Egypt and approximately
6,789,479 individuals. MEMRB classification for social class (based on
education, area of residence, domestic help, durables owned, profession and
household income) distinguished the AB class to be approximately 5% of the
population of urban and rural areas i.e. approximately 339,474 individuals.
4.2.2 Sampling Method for In-depth Interviews
In the first phase of the research, for the qualitative in-depth interviews,
judgmental sampling was performed as a form of convenience sampling based
on the researcher judgment. The researcher chose the subjects to be included in
the research based on their being representative of the population of interest. In
77
the second phase of the research, for the quantitative survey, random sampling
was done.
a) Choice of Patients
For the choice of patients who frequented private hospitals, they were chosen
based on having a recent experience in a private sector hospital as well as
covering a wide range of demographic criteria. Respondents varied in
Age varied from 20 to 45 (21, 26, 35 and 43).
Education included university graduates (2), Masters holder (1) and
PHD holder (1).
Occupations included a senior marketing executive, a graphic
designers, an IT specialist and a general manager.
Socioeconomic standard from A and B class (income levels ranged
from LE 4,000 to above LE 15, 000.
The variability in demographics ensured varied opinions and responses of
individuals covering all the sampling criteria to be used in the present research
b) Choice of Experts
The interviewees were chosen based on several criteria including the
relevance and depth of their experience in the field of research. Expert 1is
holder of a PHD in Business Administration (focused on healthcare services),
and has over 15 years of experience in the field of healthcare services. She is a
board member of the union of private healthcare providers in Egypt as well as
board member and coo-owner of El Ganzori Private Hospital in Heliopolis,
Cairo. She currently heads the public relations department of El Ganzori
Private Hospital as well as teaching healthcare management in the American
University in Egypt. Expert 2 is a professor of urology in Cairo University. He
is co-owner , general manager and board member of El Shorouk Private
Hospital in Mohandiseen, Cairo. He has over 30 years experience in healthcare
and healthcare management and is regarded as a guru in the business by all. He
has also worked in both private and public sector hospitals for over 30 years in
Egypt and abroad. Expert 3 is a lecturer of clinical pathology in Cairo
University. She has over 10 years experience in the diagnostics field and has
worked in both private and public sector hospitals for the past 15 years. She is
co-owner , general manager and board member of Tiba Mega-laboratories, one
of the largest and fastest growing diagnostics laboratories in Egypt which is
responsible for outsourcing of diagnostic services to a significant number of
private hospitals in Egypt. Expert 4 is a professor of Obstetrics and
Gynecology in Azhar University. He has worked in both private and public
sector hospitals for over 30 years in Egypt and abroad and has vast experience
with the Obstetrics and Gynecology hospitals and patients of all classes. He has
a huge flow of patients in his private practice which will enable him to draw
significant conclusions on their insights for their hospital experiences.
The choice of experts was deliberate to cover a wide range of
requirements by the researcher and gain from their experience in several fields:
First, the researcher targeted hospital owners who are conscious of
the overall framework of healthcare services and anxious to dissect
and analyze each aspect of the service provided in their
organizations to ensure satisfied and repeat patronage.
78
Second, the researcher targeted reputable physicians with vast
experience to ensure a large flow of patients in their chosen
specialties from which to draw their observations.
Third, the researcher targeted healthcare specialists (covers
occupations such as marketers, managers, instructors in the field)
who can draw on experience in the medical as well as the business
field to add depth to the research.
Finally, diagnostics experts were chosen since the departments
concerned with diagnostics in private hospitals are increasingly
being outsourced to diagnostic specialists in private mega-
laboratories and they act as profit centers within the hospital.
4.2.3 Sampling Stratification Variables
Several variables are used for stratification of the population and are
thought to be of significance in the service quality assessment for the
healthcare consumer in Egypt. These include age, sex, socioeconomic level,
geographic location, income level and education. The variables‘ different
groups are classified according to the census data of 1996 and the classification
of MEMRB, a multinational research agency that is one of the most respected
and reliable marketing research agencies in Egypt. The variables classification
is demonstrated in appendix A.
4.2.4 Sampling Criteria
Individuals were stratified based on the criteria dictated by the
MEMRB classification (detailed in Appendix A). The individuals selected for
the study included:
High Socioeconomic classes A and B
Females who have frequented a private hospital in the past five
years months for performing a successful childbirth (normal and
interventional)
Have had at least a one overnight stay in the hospital.
Are residing in Greater Cairo
Several factors influenced the choice of the above sampling criteria.
The sample was limited to females who and undergone a successful childbirth
(normal and interventional) to limit the error that could be present in the
research due to having a multitude of patients with different diseases included
in the study. One cannot compare perceptions of a patient coming in to an
internist with a stomach ache to one who is coming in to a cancer specialist
with a lung cancer. All the circumstances and the details of treatment of the
two patients will be different as well as the emotional difference between the
two thus will cause great bias and error in the current research. Thus the
researcher aimed to minimize the error through unifying the patients to one
speciality and one outcome. Thus Obstetrics and Gynaecology was chosen as a
speciality and the outcome of a successful childbirth was decided upon. The
patients had most probably undergone more or less the same procedure in their
hospital stay and the emotional aspect was most probably a happy one. Thus
error could be dramatically reduced from other mediating factors such as
emotional state, outcome and others.
The sample was also limited to private hospitals in Egypt since this
sector represents a separate sector in Egypt with different expectations from the
medical service and subsequently different perceptions and importance
79
weights. This stems from the fact that this sector pays for its medical services
and is not covered by insurance. And when they are covered by insurance (such
as the insurance provided for the professional syndicates such as engineering
syndicates, doctors syndicates etc), it pays an insignificant amount of the total
sum thus not making much difference in the choice of patients at the end. In
Egypt, patients choose their hospitals in the private based on the
recommendation of the private physician who referred them to one of the
hospitals where he practices. They then chose the hospital based on its
reputation based on word-of-mouth recommendations from relatives or friends
who had frequented this hospital and were satisfied or heard about it. The other
sectors demonstrated in the following Chart (Chart 4.1) get medical treatment
free of charge due to their being subsidized by the government. However, this
results in a vast difference in the quality of medical services provided in private
sector hospitals. Also, the fact that patients are paying substantial amounts of
money in cash for their service and are also usually of higher socioeconomic
standard and education influences their expectations, perceptions and
importance weighting. Thus to avoid the error due to the vast difference in
sectors of patients visiting the private sector hospitals from other sectors, the
sample was limited to private hospitals and other sectors could be addressed in
subsequent researches.
Figure 4.1: Demonstrating the classification of hospital by the Ministry of

Health in Egypt
Ministry of Health
Hospital
Classification
Educational
Hospitals Health Private
Ministry of Treatment University
And Insurance Sector Others
Health Foundation Hospitals
Institutes Hospitals Hospitals
Foundation
Police
Prison
Railroad
Source: Author
4.2.5 Sample Size
According to Sekran (2000), for a population of 75,000 individuals, a
sample of 382 would be representative and for a population of 1,000,000 a
sample of 384 is representative. Therefore, for the present research, based on
the estimated population size of 339,474, then a minimum sample size of 383
would be representative to the population and the results of the present research
80
sample can be safely generalized to the population. In the current research, a
sample of 450 individuals was collected.
4.2.6 Sampling Error
Sampling error refers to how well the sample represents the
population. This can be avoided by defining the sample frame in a
comprehensive way. In the case of the present research, the researcher
randomly interviewed individuals frequenting the oldest and most exclusive
private clubs in all areas of Greater Cairo targeting A and B class individuals.
This ensured access to the target segment desired and the randomness of the
sample selected as well as it being representative of the population of interest.
4.2.7 Non-Sampling Error
Non-sampling error refers to the difference between the true mean
value of the sample and the mean observed value. It can be decomposed into:
response error and non-response error.
Sources for response error were identified to be:
1- The desire of the respondent to appear interesting
2- The desire of the respondent to be impressive
3- The desire of the respondent to deceive the researcher
4- Fatigue
5- Lack of commitment
In this research, the respondents are A and B class patients who
frequented a private hospital recently. They are prosperous and with high self-
esteem, while the researchers (trained and paid interviewers) are young and
with average self-esteem. Also, respondents were not asked to name the
hospital they have frequented or any responsible individual thus the
respondents did not have a reason to appear interesting, impressive, or to
deceive the researchers especially in issues of high significance as healthcare
related issues.
The former patients were interviewed in the private club at their
leisure which certainly excludes fatigue. The questionnaires focus on a very
important subject which is the quality of healthcare being provided which is of
crucial importance especially since this is currently a heavily debated topic in
Egypt. Private healthcare in Egypt is not insured so patients are paying
substantial amounts of money for the healthcare service which makes it of
great importance to them to evaluate and upgrade the level of healthcare
provided in the hospitals they are frequenting. There is no doubt they were
committed to give honest answers.
Reasons for not responding could be that there are too long or too
many questions. They could also have no time to answer if interrupted by prior
engagements. Another reason could be poor wording, some of the statements
were being confusing or not understood. Also a poorly constructed or designed
questionnaire would make non-response valid. Finally, perhaps, some of the
questions do not apply to the respondent's hospital stay.
4.3 Data Analysis Methods

The use of qualitative research provides insight and understanding for
the problem whereas quantitative research seeks to quantify the data and apply
some form of statistical analysis. When a new research problem is being
addressed, quantitative research must be preceded by appropriate qualitative
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research. It is often viewed that qualitative and quantitative research is
complementary rather than competitive (Malhotra, 1999) and the argument of
integrating qualitative and quantitative research has been emphasized by
leading scholars in marketing (Churchill, 1979).
4.3.1 Qualitative Data Analysis
There are several reasons to use qualitative research. It is not always
possible to use fully structured methods to obtain information from people thus
a more flexible approach is called for. Another reason is obtaining information,
values, motivations and emotional drives that may be present on a
subconscious or conscious level. Open-ended questions provide more depth of
answering and the desired information can best be obtained through qualitative
methodology (Malhotra, 1999).
Qualitative procedures vary from indirect approaches such as
association, completion, construction and expressive techniques to direct
approaches as focus groups and in-depth interviews (Malhotra, 1999). The
current research used long, semi-structured, direct, personal in-depth
interviews aiming to uncover the beliefs of the experts and patients on the topic
at hand.
4.3.1.1 Development of the Instrument of the Research
While many authors decided to use the 22-item scale generated by
Zeithaml et al., 1988, many others used and tested different scales especially in
multi-service settings as hospital service. The present research will follow
several steps to generate a workable model and scale adapted and tested to
suite healthcare services in Egypt.
The current research went one-step back from Zeithaml et al., 1988
and incorporated some of the original 10 dimensions identified in their
previous work. Also other dimensions identified by works of other authors
were incorporated and finally new dimensions specifically relevant to the
Egyptian healthcare service market were identified to develop a new scale
customized to healthcare services in Egypt.
The following steps will be performed:
1. The underlying dimensions that make up the domain of the service quality
construct for healthcare services were uncovered as follows:
Identification, investigation and utilization of dimensions
uncovered through an extensive literature review that were
tested and found to affect patient satisfaction and perception
of the service performance (secondary data)
Performing qualitative in-depth interviews to obtain the
insights of experts in the field of healthcare services as well
as patients on the dimensions of healthcare service quality
that affect their satisfaction and perception of the service
performance (primary data)
2. Content analysis was used for the qualitative data analysis: This enabled
the researcher to convert the text obtained from the interviews to
numerical variables, which can then be used as a base for the quantitative
data analysis. After the in-depth interviews were performed, coding units
were determined. These consisted of all the characteristics of healthcare
service quality that are to be taken in consideration for evaluation of the
quality of the service performed by the hospital. The coding frame was
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constructed which listed the coding units vertically and thus permit the
analysis of each communication to be added on the horizontal axis. The
analysis was then conducted on frequency basis. Each factor‘s frequency
was counted on order to add or eliminate any factors which Egyptian
patients and experts deem relevant or irrelevant to their healthcare quality
perceptions.
3. Generating X number of items to represent these dimensions underlying
the hospital encounter service quality
4. A questionnaire was developed for use in the pilot study. It consisted of
several sections. Each section covering a hospital encounter of the general
framework (a construct) and the dimensions were across the each section
of the hospital encounter (as described above in model and questionnaire
development in chapter 3).
5. From the results of the pilot study, instrument revision was performed and
the final questionnaire was developed and finalized for full-scale
quantitative testing.
4.3.1.2: Development of the Structure of In-depth Interviews
Structure of In-depth Interviews with Patients
Primary data gathering for the qualitative research was performed in
parallel with the secondary data gathering phase. Several in-depth
interviews were performed with patient to gather their insight on what are
the factors that they as Egyptian patients expected and perceived in their
recent hospital experience.
Concurrently, the secondary data gathering process was performed
thus the researcher developed a solid base on the dimensions uncovered by
previous researchers for healthcare service quality. The interview took the
form of gathering the insight of the patients as well as asking direct
questions based on the work of previous authors. The interviewer started by
guiding the interviewees through a "semi-structured" tour of their hospital
stay starting with entering the premises, the admission process, being
admitted in their room, undergoing the medical service (doctor, nurse and
diagnostic), experiencing the hospitality experience (meals, rooms and
housekeeping) all the way to the discharge from the hospital. In each
encounter, which might be a potential construct in the research, the patients
were asked to describe what they expected and perceived. They were also
asked about the factors that they actually used in evaluating their hospital
experience upon.
From this tentative information, as well as the secondary literature
review, the researcher was able to come up with a preliminary
questionnaire that is based on the work of previous researchers and the
experiences of Egyptian healthcare patients. The questionnaire was thus
covering both the international standards for healthcare service quality
measurements as well as containing in-depth insight for the Egyptian
market. This questionnaire was to be further refined through the next
sections, namely the expert interviews and the pilot study.
Structure of In-depth Interviews with Experts
As for the expert in-depth interviews, they consisted of two main
sections. First, the experts were asked to give their opinions generally on
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what they believed to be the dimensions of importance in evaluation of
healthcare service quality for patients in Egyptian private sector hospitals
catering to the A and B class citizens. Second, the experts were
administered the preliminary questionnaire that was developed as described
in the previous section. The questionnaire was then further refined and
developed into the final questionnaire to be used in the pilot.
4.3.2 Quantitative Data Analysis
Quantitative data analysis was then used as a method for
quantification of obtained data. It is difficult to address complicated research
questions and a survey using univariate analysis techniques (Hair et al., 1998).
Multivariate techniques are defined as "statistical techniques which focus upon
and bring into bold relief the structure of simultaneous relationships among
three or more phenomenon" (Cooper and Schindler, 2001). They are
techniques which are used to analyze complicated sets of data when there are
several dependent and independent variables all of them potentially correlated.
In the current study, several statistical tools were applied to the data including
multivariate techniques as exploratory factor analysis and multiple linear
regression as well as correlation tests such as Pearson's correlation test.
4.3.2.1 Survey Research Design
In the present research, a survey approach was used. The survey
method is based on obtaining information through questioning the respondents
through a verbal interview, in writing or via computer. Typically, the questions
are structured and the questions are set and asked in a prearranged order. In
structured direct surveys, the most popular data collection method is through
questionnaires (Malhotra, 1999). The current research was applied through a
questionnaire containing fixed-alternative question with the respondent
choosing from a predetermined set of responses answered on a Likert scale.
4.3.2.2 Research Plan
Due to the diversity of opinions on the best way to measure service
quality and the lack of a conclusive framework finalized for the healthcare
industry, several steps were be undertaken in the present research. First, the
research identified the constructs and sub-constructs underlying healthcare
service quality. Second, the effect of each of the identified dimensions on
patient's overall perception was tested. Third, construction of eight alternative
scales for service quality measures and the testing all scales was done to
determine the most effective method for measurement. Fourth, the relationship
between consumer demographic criteria and the variables of the research was
tested. Finally, the relationship between overall consumer satisfaction on one
hand with behavioural intentions to return and recommend, value for money,
outcome to mother and baby was also tested.
Testing and Confirming the Constructs of Healthcare Service
Quality
For testing and confirming the underlying constructs of healthcare service
quality, exploratory factor analysis was performed. The main purpose of factor
analysis is to define the underlying structure of the data matrix provided by the
patient‘s expectations and perceptions of their hospital experience. It aims to
analyze the interrelationships between the large number of variables generated
in the current research by identifying a set of common underlying dimensions
(factors). Through factor analysis, separation of the sub-constructs underlying
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the hospital encounter was achieved. This resulted in description of data in a
much smaller number of concepts than our original variables (e.g. uncover X
number of constructs underlying the 40 variables identified for the hospital
service encounter).
In the current research, in spite of the researcher having a preconceived idea on
the actual structure of the data based on the theoretical literature support and
in-depth interviews, however, the current structure proposed for the Egyptian
market was not tested before in its present composition and was never tested
before for the Egyptian or even the Arab market. Thus there is no actual prior
constraints on the estimation of the components or their number thus an
exploratory approach was adopted aiming to identify the factors underlying the
variables identified for the healthcare market in Egypt private sector hospitals.
In addition, the factors identified should be independent of one another but
previous research uncovered overlap among the conceptual dimensions to be
tested thus both orthogonal (independent) as well as oblique (intercorrelation)
rotation was attempted. Finally, reassignment and restructuring of the
dimensions was done when necessary.
Construction and Testing of Alternative Scales for Service Quality
Measures
First, service quality was defined as eight different constructs. This is
following the research of Cronin and Taylor, 1992 who identified and tested
the first four constructs. Then the researcher attempted to test the same four
scales using an interactive instead of an additive methodology (through using
factor analysis and logistic regression) as shown in the following Table:
Table 4.1: Demonstrating the Scales Tested
Additive Methodology Interactive Methodology
SERVQUAL ∑ (P-E) (P-E) * (P-E)………..
Weighted ∑ [I* (P-E)] [I * (P-E)] * [I * (P-E)]…
SERVQUAL
SERVPERF ∑P P* P * P………
Weighted ∑ [I * (P)] [I*P] * [I*P] ….
SERVPERF
For testing of the scales, the following steps were performed:
1. Coefficient (Cronbach) alpha for scale reliability: Computation of
coefficient (Cronbach) alpha for total scale and for each dimension.
Deletion of items whose correlation were low, or whose correlation
produced a sharp effect in the plotted pattern and whose deletion
increases the coefficient alpha occured. An iterative sequence for
computing alpha followed by deletion was repeated until high alpha
values for all dimensions was achieved.
2. Factor Analysis: Performing factor analysis as previously described
in the previous step enabled the researcher to determine which of the
four scales SERVQUAL, Weighted SERVQUAL, SERVPERF,
Weighted SERVPERF best describes healthcare service quality in
the current research setting.
3. Logistic Regression Analysis to determine best model for
measuring service quality construct: Multiple regression analysis is
a tried and tested technique used to make predictions and understand
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the relative contributions of predictors to some predicted variables
(Malhotra, 1999). This was performed in the current research through
regressing the individual items comprising each scale against the
respondents‘ perception of the overall quality inherent in the service
offered by the hospital. For the dependent variable (perceived
healthcare service quality), several independent variables exist (all
identified individual sub-constructs of healthcare service quality).
Testing the effect of Sub-constructs on Overall Perception of
Healthcare Service Quality
Literature supports the idea that the service quality of certain factors in service
quality influences the overall perception of healthcare service quality more
than others in several industries. The current research uncovered the effect of
each of the identified sub-constructs on overall perception of healthcare service
quality for the healthcare industry. This was performed through regressing the
individual sub-constructs identified (independent variable) against the
respondents‘ overall perception of service quality for the service offered by the
hospital (dependent variable) through logistic regression analysis.
Examining the Relationship between Consumer Demographic Criteria
and the Variables in the Research
Discriminant analysis was performed to detect if different
demographic characteristics had different effects on the variables of
the research.
Examining the Relationship between Overall customer
satisfaction, on one hand and behavioural intentions to return and
recommend, Value for Money and Outcome to mother and baby
on the other hand
The relationship between overall customer satisfaction and
outcome to mother and baby was be tested using correlation test to
uncover the magnitude and the direction of the relationships.
A summary of the major research questions and the statistical tools to
be used for their analysis was also summarized in Table 4.2.
4.3.2.3 Pre-Analysis Data Screening
Several issues come forth during pre-analysis data screening. These include in
some cases missing data, extreme outliers, normality and linearity of the data.
Missing values: Missing data is one of the most persistent problems in
data analysis since some respondents will invariably leave some data
unanswered. Hair, 1998 proclaimed that the pattern of missing data is
more important than the amount missing. In the current research the
researcher will study the pattern of the missing data before any
missing data remedy is considered. If they could be termed ignored
(since < 5% of sample size) and randomly scattered, then specific
remedies for missing data are not needed and the missing data will be
disregarded.
Outliers: An outlier in a data set is an observation that is remote in
value from the others in the data set. It is either unusually large or an
unusually small in value when compared to other values within the
data set. However, outlier can be genuine result indicating an extreme
of behaviour of the process being studied. For this reason, the
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researcher should not attempt to routinely remove outliers without
further justification.
Normality: Multivariate normality is the assumption that each variable
and all linear combinations of the variables are normally distributed.
This assumption is readily tested since it is impractical to test an
infinite number of linear combinations of variables for normality and
the tests that are available are overly sensitive. Since Factor Analysis
will be used to summarize the relationships within the large set of
variables, then assumptions regarding the distribution of variables are
not in force in this case.
Linearity: Multivariate linearity implies that relations among pairs of
variables are linear. The analysis is ruined when linearity fails since
correlation measures only linear relationships and does not apply for
non-linear relationship. In the current research, the factor loading will
be treated with care and variables with loading less < 0.5 will be
eliminated (Hair, 1998).
4.3.2.4 Description of Data
Descriptive statistics were performed for the data on to display that the data is
generally as expected in terms of central tendency, dispersion measures,
skewdness and kurtosis and there are no out-of-bounds entries beyond the
expected range. This was done through graphs and numerical measures.
4.3.2.5 Instrument, Operationalization, and Data Measurement
The questionnaire was designed to measure the model devised by the
researcher for the Egyptian healthcare market. A set of questions were assigned
to each construct and the interrelationships among constructs, based on the
literature review were defined. The questions were mixed and scattered to
guarantee objectivity and genuine response from the respondents‘ side. The
measurement in this study relied mainly on Likert scales measurement with the
typical five options: Strongly Agree, Agree, Neutral, Disagree, Strongly
Disagree, on a numerical scale from 1 to 5.
4.3.2.6. Measurement Error
The use of multiple variables and the reliance on their combination in
multivariate techniques brings the issue of measurement error to the
foreground. Measurement error is the degree to which the observed values are
not representative of the ―true‖ values. To assess the degree of measurement
error present in any measure, the researcher must address the validity and
reliability. Validity is concerned with how well the concept is defined by the
measures, where reliability relates to the consistency of the measures
(Malhotra, 2000).
Validity: Validity is the degree to which a set of measures correctly
represents the concept of the study that they suppose to represent and is
free from any systematic or non-random error. (Tabachnick et al., 2001).
In this study, the researcher selected 5 experts of healthcare management
backgrounds, to classify the questions in the respected categories.
Reliability (Internal Consistency Reliability): Reliability in multivariate
models is the ―extent to which a set of variables is consistent in what it is
intended to measure. If multiple measurements are taken, the reliable
measures will all be very consistent in their values. It differs from validity
in that it relates not to what should be measured, but instead to how it is
87
measured.‖ (Hair et.al., 1998). There were a wide variety of internal
consistency measures that could be used. Cronbach‘s Alpha, one of the
most popular and widely used techniques for measurement of internal
consistency, will be used in the current research.
4.3.3. Research Design Strategy Chart

The section below summarizes the research design strategy process
Qualitative Approach
In-Depth Interviews
To explore what dimensions affect the customers‘ perception, satisfaction and
loyalty with healthcare service quality
Development of Survey Questionnaire
Pilot Testing and Random Sampling
Presenting and Analyzing Findings
Refining Questionnaire
Quantitative Approach
A hypothesis developed out of the literature review and the researcher's
experience
Data Collection – Survey Research- inductive approach
Questionnaires to collect the respondent’s responses
Validity test to guarantee that the questions measure exactly what they
should measure
Reliability test to guarantee the consistency of the respondents responses
Exploratory Factor Analysis

To analyze the interrelationships between the large number of variables
generated in the current research by identifying a set of common underlying
dimensions (factors)
Logistic Linear Regression
To understand the relative contributions of predictors to some predicted
variables
Pearson's Coefficient of Correlation
To uncover the magnitude and the direction of the relationships.
Analysis of Collected data using the SPSS software

Interpretation of Results
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Table 4.2: Demonstrating the Variables, research questions and analytical methods used for data analysis
Variables Research Question Analytical
Independent/Dependent Method Used
1. Individual Items in Each Is an un-weighted performance-based measurement of service Exploratory Factor
Scale quality (un-weighted SERVPERF) a more appropriate method for Analysis
measurement of service quality than SERVQUAL, weighted
SERVQUAL and weighted SERVPERF?
2. Individual Items in Each Is an interactive methodology for calculating the measurement of Logistic
Scale/ Overall Perceived service quality for SERVPERF, SERVQUAL, weighted Regression analysis
HSQ SERVQUAL and weighted SERVPERF a more appropriate
measure for service quality?
3. Sub-constructs 1-18 / Is the sub-construct X an underlying factor for healthcare service Logistic
Overall Perceived HSQ quality defined as ∑ (P-E) Regression analysis
Overall Perceived HSQ quality defined as ∑ [W*(P-E)] Regression analysis
Overall Perceived HSQ quality defined as ∑ (P) Regression analysis
Overall Perceived HSQ quality defined as ∑ [W*(P)] Regression analysis
Overall Perceived HSQ quality defined as (P-E)* (P-E) … Regression analysis
Overall Perceived HSQ quality defined as [W*(P-E)] * [W*(P-E)] Regression analysis
Overall Perceived HSQ quality defined as (P) * (P) …. Regression analysis
Overall Perceived HSQ quality defined as [W*(P)] * [W * P] …. Regression analysis
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11. Demographic Does consumer Demographic Characteristic (age) have an effect on Discriminant
Characteristics (Age) / 40 variables of the research? Analysis
variables tested
12. Demographic Does consumer Demographic Characteristics (education) have an Discriminant
Characteristics (Education) effect on variables of the research? analysis
/ 40 variables tested
13. Demographic Does consumer Demographic Characteristics (Socioeconomic) Discriminant
Characteristics (Socio- have an effect on variables of the research? Analysis
economic) / 40 variables
tested
14. Individual Sub-constructs / Does the service quality of certain service quality sub-constructs Logistic
The respondents‘ perception have significantly greater impact upon the overall perception of Regression analysis
of the overall HSQ service quality than others?
15. The respondents‘ future What is the correlation between overall customer satisfaction with Correlation Test
purchase and the hospital stay and the patients' intention to return and
recommendation behaviour / recommend the hospital?
Overall Satisfaction
16. The respondents‘ value for What is the correlation between overall customer satisfaction with Correlation Test
money/ Overall Satisfaction the hospital stay and value for money
17. The respondents‘ outcome What is the correlation between overall customer satisfaction with Correlation Test
to mother/ Overall the hospital stay and outcome to mother
Satisfaction
18. The respondents‘ outcome What is the correlation between overall customer satisfaction with Correlation Test
to baby/ Overall Satisfaction the hospital stay and outcome to baby
Source: Author
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5. QUALITATIVE RESEARCH AND PILOT STUDY
As mentioned before, the use of the scientific methodology of the research

task is a sequential process involving several clearly defined steps. First,
formulation of the research question through discovering the dilemma, defining the
research question and refining the research question through exploration. Then
second, development of the research proposal and third, review of previous
literature in the area. Also, fourth, identification of the research design (design
strategy composed of research type, purpose, time frame, scope and environment,
data collection and sampling design then conduction of questions and instrument
for pilot testing and finally instrument revision) is done. Fifth, data collection and
preparation and sixth, data analysis, interpretation and conclusions are made.
Finally, seventh, research reporting and replication and eighth, managerial
decisions could be made based on the business research. The first four chapters of
this study explained the first four steps. This chapter deals with the fifth and sixth
steps (data collection, preparation, analysis, interpretation and conclusions) for the
qualitative section of research. This led to development of the test pilot
questionnaire and the results, analysis and interpretations of the pilot study and
finally the amendments to be made to the questionnaire to be used in the survey and
their justifications.
5.1: Results Of In-depth Interviews

The in-depth interviews in the qualitative section of the research were
performed in one-to-one interviews by the researcher. In-depth interviews were
performed with 4 experts in the field and 4 patients who had visited private sector
hospitals in the last six months.
5.1.1.:Patient In-depth Interviews Respondents Profile:
The researcher chose four patients for in-depth interviews. For the choice of
patients who frequented private hospitals, they were chosen based on having a
recent experience in a private sector hospital as well as covering a wide range of
demographic criteria. Respondents varied in
Age varied from 20 to 45 (21, 26, 35 and 43).
Education included university graduates (2), Masters holder (1) and
PHD holder (1).
Occupations included a senior marketing executive, a graphic designers,
an IT specialist and a general manager.
Socioeconomic standard from A and B class (income levels ranged from
LE 4,000 to above LE 15, 000.
5.1.2: Results of In-depth Interviews with Patients

The in-depth interviews with patients provided the research with depth and
applicability to the Egyptian market. The patients were "walked through" their
encounter in a hospital they recently visited and a highlight of each encounter will
be summarized in the following section.
Patients started by remarking that the physical facilities of the hospitals were
quite important. Many of the smaller private hospitals in Egypt were just buildings
renovated into small hospitals thus their physical facilities are quite inadequate. The
patients stressed that the physical facilities, the landscape, the surroundings and of
the building itself were of prime importance in their initial impression of the
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hospital. The tasteful decoration of the buildings in terms of marble, new elevators,
cheerful paints were also commented on. Patients also noted that the equipment in
the hospital were also important. Hospitals that advertised and had sophisticated,
high technology equipment gave the hospital a better reputation. Finally, on
entering the hospital, the manners and appearance of the employees from the
janitors to the administration personnel definitely made an impression on the
patients about the service quality of the hospital. The politeness and the helpfulness
of all the staff were of utmost importance. Three patients of the four also
commented that a considerable sum of money was always given out in tips to the
staff to perform the service needed adequately. It was a bothersome aspect of the
hospital service but expected and even solicited in some cases by the staff.
During admission, all patients commented that the helpfulness and politeness
of the staff was quite important. This is the fist encounter of the patient with the
hospital staff and when this encounter runs smoothly and efficiently, it starts the
whole process out on the right foot. Two of the patients mentioned that admission
personnel who make patients' lives easier by simplifying the admission process,
providing clear and adequate information on all aspects of the hospital service from
the appointments to the prices make patients feel quite satisfied with the
preliminary encounter and give an overall good first impression to the hospital staff.
On entering the rooms, one of the first things mentioned by all the patients
was that they notice the layout and facilities in the room. Cheerful, well-decorated
rooms made an instant visual impression on patients. Spacious rooms allowing
ample space for visitors were also appreciated though patients commented that the
space is usually related to the price. The more expensive the rooms and suites, the
more spacious they were versus ordinary single or double rooms. The most
important aspect of the rooms stressed unanimously by the patients was the
cleanliness and disinfection of the rooms and bathrooms. One patient commented
that when the rooms had a strong smell of disinfectants and cleanliness, patients felt
more secure and happier about the level of cleanliness in the hospital. Additional
touches such as extra pillows and blankets, good air-conditioning, small
kitchenettes, adequate wardrobe space were also mentioned by the three of the
patients as extra touches that enhance satisfaction. Patients stressed the importance
of comforTable rooms during their hospital stay since staying in a hospital is
already a harrowing experience so staying in uncomforTable surroundings makes it
a miserable one too.
Next, patients were asked to comment on meals. All patients agreed that
hospital food is always bland tasting because hospitals try to make it light and
healthy to suite sick patients. But they stressed that light and healthy food could
also be cooked in a satisfactory and presenTable way to satisfy patients' palates.
The cleanliness and quality of the food presented was of utmost importance to all
patients and its presentation is hot and well cooked. The selection of the food was
stressed upon by two of the patients where they commented that their likes and
dislikes were rarely addressed. One of the patients commented that a simple process
such as asking the patient between two choices (like on airplanes) such as whether
they prefer meat or chicken for example or whether they prefer cheese or eggs for
breakfast would be highly appreciated without causing undue hassle for the
hospital. All patients agreed that food has to be prepared to suite patients cases. For
example, for diabetics low sugar food must be prepared and for liver patients
elimination of certain harmful foods.
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As for the medical service, patients had much to comment on this aspect of
their stay. Only two of the four commented on the actual outcome except to say if it
was successful or not. But the medical process was deemed difficult to judge since
they have limited medical knowledge. Three patients commented that the process
itself usually gave the impression if the service quality was good or not.
When asked about doctors in particular, they all agreed that they expected
their physicians to be of high medical competence and reputation and to treat and
diagnose them accurately. They all commented that they chose the hospital based
on the recommendation of the private physician who referred them to one of the
hospitals where he practices. They then chose the hospital based on its reputation
based on word-of-mouth recommendations from relatives or friends who had
frequented this hospital or heard about it. They stressed that they need their doctors
to listen to them, spend enough time examining them and explaining things, which
rarely happens. They unanimously agreed that in the majority of their encounters
they spend less than 15 minutes in the doctor's office, are given brusque and
uninterested answers to their questions, are usually never volunteered any medical
explanations of their conditions and are generally treated as if the doctors are doing
them a favour in diagnosing and treating their case at all. They all stressed that a
good doctor-patient relationship is non-existent among Egyptian medical
practitioners and rarely do doctors make an effort to satisfy the patient
psychologically as well as physically diagnosing and treating them
As for the nursing service, they all agreed that it is usually less than
adequate. Two of the patients commented that the nurses are usually skilled and
prompt in performance of the service assigned to them as taking samples and
dispensing medication but the personnel themselves are usually not very clean or
neat and maybe rude and uncaring on more than one occasion. They all commented
that the nurse is the person with whom the patient is most in contact with so they
have to fulfil their needs adequately. Nurses should be nice, pleasant and helpful to
their patients. They should seek to increase the patients' comfort and well-being.
They have to listen to what the patient needs and strive to fulfil it. Empathy and
responsiveness were main points stressed for nursing, Personal hygiene,
cleanliness, appearance, language and neatness should be monitored and improved.
For diagnostics, the accuracy of the tests was one of the main points stressed.
Three of the patients complained that they needed to repeat some of their tests
several times due to inaccuracy and some sent their samples to several laboratories
to cross-check the results. Two patients mentioned that the test were late thus
caused also postponing a procedure dependent on the test results thus casing undue
stress on the patient. Two patients also mentioned that their doctors in some cases
just order a standard battery of investigations without tailoring to the individual
case of each patient. They stressed that the accuracy, promptness and necessity of
the diagnostics is very important.
Finally, for the discharge process, all patients stressed that efficiency was of
the utmost importance since at this stage the patient is usually anxious to leave the
hospital and sometimes all the papers and bills are not ready and it takes a long time
to collect all bills from all hospital departments. They all stressed that the process of
discharge needs to be more efficient. Two patients also commented that when the
personnel answered their questions concerning their bills and what was included in
their insurance, this made the whole hospital process end on a good foot and seem
93
more satisfactory since the last encounter with the hospital usually makes a
memorable finale.
From the results of the previous interviews, the researcher was able to gather
insight on what Egyptian patients believed to be of importance during their hospital
stay. Several variables were adapted and added to the preliminary questionnaire in
addition to variables uncovered through the literature review. This preliminary
questionnaire was further subjected to validity testing through the following expert
interviews.
5.1.3: Expert In-depth Interviews Respondents Profile:
The researcher chose 4 experts with which to perform in-depth interviews. Expert
1is holder of a PHD in Business Administration (focused on healthcare services),
and has over 15 years of experience in the field of healthcare services. She is a
board member of the union of private healthcare providers in Egypt as well as
board member and coo-owner of El Ganzori Private Hospital in Heliopolis, Cairo.
She currently heads the public relations department of El Ganzori Private Hospital
as well as teaching healthcare management in the American University in Egypt.
Expert 2 is a professor of urology in Cairo University. He is co-owner , general
manager and board member of El Shorouk Private Hospital in Mohandiseen, Cairo.
He has over 30 years experience in healthcare and healthcare management and is
regarded as a guru in the business by all. He has also worked in both private and
public sector hospitals for over 30 years in Egypt and abroad. Expert 3 is a lecturer
of clinical pathology in Cairo University. She has over 10 years experience in the
diagnostics field and has worked in both private and public sector hospitals for the
past 15 years. She is co-owner , general manager and board member of Tiba Mega-
laboratories, one of the largest and fastest growing diagnostics laboratories in Egypt
which is responsible for outsourcing of diagnostic services to a significant number
of private hospitals in Egypt. Expert 4 is a professor of Obstetrics and Gynecology
in Azhar University. He has worked in both private and public sector hospitals for
over 30 years in Egypt and abroad and has vast experience with the Obstetrics and
Gynecology hospitals and patients of all classes. He has a huge flow of patients in
his private practice which will enable him to draw significant conclusions on their
insights for their hospital experiences.
5.1.4.: Results of In-depth Interviews with Experts
The first expert interviewed, focused on all aspects of the framework of the
hospital service. Since she has extensive experience in both the healthcare and the
management side, she has provided huge depth for the framework of the healthcare
services in Egypt as well as aided greatly in rewordings and adjustments in the
survey questionnaire.
She divided hospital service into medical and hospitality services and was of
the opinion that the personal interaction and the hospitality aspect of the service is
the aspect which patients can perceive and judge clearly while the most patients are
reluctant to pass judgment over the medical aspect of their hospital stay.
She mentioned that patients go to a hospitals through a referral from a doctor
working in that hospital. Doctors usually recommend several hospitals where they
are practicing and then leave the final choice for the patients. Patients then base
their choice based on several 'image attributes' which include size (the larger the
better), location convenience, availability of famous physicians with excellent
reputations, pricing, presence of the most up-to-date and sophisticated equipment
and the interpersonal relationship between patients and personnel. She also
94
mentioned that Greater Cairo alone contains 60% the private hospitals in Egypt thus
is a good location to base the research.
She then proceeded to dissect the hospital framework to include several
broad areas. These include hospital physical facilities and equipment, medical
service, diagnostics, hospitality services (meals and housekeeping), security
services, visitors services, cafeteria and gift shop services, administration services
(admission and discharge). She also stressed that the courtesy, responsiveness and
empathy provided by hospital employees in the interpersonal relationships between
the patients and the employees have a great impact on the perception of the hospital
service. She mentioned that the hospital could have performed the highest level of
medical service and the most successful outcome but the presence of rude or
uncaring employees could result in the patient not frequenting the hospital again.
She also mentioned that there are several criteria that greatly increase the
image of the quality of care provided by the hospital when available to patients.
These include continuity of care, credibility of services and successful outcome.
Continuity of care basically encompasses a feeling of continuity of the medical care
provided by the hospital during and after the hospital stay. Continuity during the
hospital stay includes availability of the same staff (doctors, nurses, technicians etc)
during consequent hospital visits since this elevates the feeling of security.
Continuity beyond the hospital borders includes availability of at-home nursing
services, rehabilitation and emergency-doctor home visits. The credibility of the
services was described in terms of delivering what was promised and getting good
value for the money paid in the hospital. For example, a marketing campaign
promising certain diagnostic techniques and foreign experts should be delivered as
promised or even better since this elevates the credibility of the hospital and ensures
satisfied and repeat patronage for such programs. The final point stresses was the
feeling of security and successful outcome perceived by the patient at the end of the
hospital stay. This is strongly linked to satisfaction and repeat patronage.
When presented with the preliminary test questionnaire, she proceeded to
suggest a few alternative wording for some sentences, combining several sentences
together, eliminating and adding several points. Overall, she was of the opinion that
the hospitality aspect of the experience should be emphasized and not overlooked
by stressing only on the medical aspect since this is the section of the service that
the patient evaluate very objectively while his judgment on the medical services is
usually quite subjective.
Several questions were combined since she believed that the difference in
wording did not garner several questions especially due to the length of the
questionnaire and rewording of several questions was performed.. For example,
doctors will always be on time and doctors will never make me wait were combined
into one phrase. Another example is the questions covering nurses service. The two
phrases "never too busy to respond" and "never make me wait" were combined and
reworded into "respond in a reasonable length of time". Another example in nursing
services is "give prompt service" was reworded into "perform the service required
(tests, procedures, medication dispensing) at exactly the right time". The rewording
and combination gave more details to the question as well as reduced the number of
questions. The medical service is by nature very precise and the generic form of the
Zeithaml, 1988 questionnaire containing generic phrases such as "prompt service"
was used as a base from which the more developed questionnaire was finalized.
95
Several questions were added since they were believed to be of relevance to
the medical community in Egypt as well as more detailed and tailored to the
healthcare field in particular. These include the applicability of the meals to the
individual case of the patient. For example, a diabetic patient should receive meals
tailored to his condition. In the admission section, employees were required to
provide information and direction for the hospital due to the lack of proper signage
in the Egyptian hospitals thus making manoeuvring Egyptian hospitals a real
ordeal. Finally, she also recommended adding a question concerned with the
credibility of pricing (value for money) in the overall satisfaction section since
private healthcare is paid for out of the patients own pockets. There are no
insurance programs thus making the value received for the money extremely
tangible and greatly affecting the satisfaction.
Expert 2 has provided a great wealth of knowledge for the current research in
the detailed aspects of the hospital service from the minute the patient walks in the
hospital until he/she steps out again. Due to the excellence of service of El Shorouk
Hospital, which basically targets A and A+ citizens, Expert 2 has spent
considerable time and finances on elevating the healthcare service quality in his
institute since the clients he caters to are extremely hard to please. Thus there was a
focus on the minute aspects of the hospital service delivery process in the current
interview.
The second expert interviewed also divided the delivery process into a
hospitality and medical encounter. He stressed that the two are interrelated in the
perceptions of the consumer and one cannot improve one while ignoring the other.
He also mentioned that due to the substantial amounts of money the patients are
paying in El Shorouk Hospital, they are expecting excellence in the healthcare
service provided to them. He also mentioned that the more expensive the service,
the higher the expectations of the patients thus excellence should be targeted.
The second experts also stressed on several problems faced by healthcare
service providers in Egypt, which he believed should be addressed through
monitoring and improvement. One of the major points stressed by Expert 2 was the
quality of the nursing service and the difficulty in obtaining high quality of service
from the nursing staff. To overcome this difficulty, the hospital provides training
courses on interpersonal skills and has strict rules of conduct for their staff.
Another problem with healthcare in Egypt is the lack of high interpersonal
skills among some of the repuTable doctors in Egypt. The doctor due to his
considerable experience in the field, in the majority of the cases can diagnose the
case after a brief discussion and examination. However, unfortunately, they do not
spend enough time with the patients to discuss and explain the case and seldom do
they react with empathy and responsiveness to the patients needs. Thus in spite of
their high competence and the fact that the patients are ensured of a good medical
outcome, the patients are usually unsatisfied with the encounter thus reflecting
negatively on the overall satisfaction.
He stressed that the constructs mentioned above need to be measured and
tracked very thoroughly by the hospital service providers since the effort ensured
by the hospital to ensure a successful medical outcome could be seriously
undermined by the interpersonal relationship between the patients and their medical
team. Deficient areas need to be handled swiftly thus comes the need for a
measurement scale to understand patient's expectations and their actual perceptions
of the hospital stay.
96
When presented with the model and the preliminary questionnaire, he
commented that their structure was overall excellent and there was no redundancy
in the questions. He also commented that the questions covered all the basic areas
quite sufficiently and the structure was sound and not long. He also recommended
several modifications.
"Hospital tangibles" was first treated as a separate construct by the
researcher. He recommended rewording to include hospital premises and
employees together and treating it as a part of the hospitality service. He made
several modifications in the wording of the original authors for the tangible section
to make it more applicable for the hospital service. He replaced "modern-looking
equipment" with "technologically advanced equipment" since the functionality and
ability of the hospital equipment has more relevance than appearance in the cases of
medial equipment. He also recommended detailing the term "physical facilities" to
include the buildings, landscape and physical layout.
As for the medical doctors section, the questions recommended to be
combined in the previous expert interview were agreed upon by the second expert.
He mentioned that doctors in Egypt were invariably late due to the nature of
"hospital-hopping" practiced by the major physicians in Egypt. The doctor may
visit up to 3 or 4 different hospitals in the same day and located all over Cairo, thus
making time precision almost impossible thus this section should not be stresses
upon too much since it is difficult to change. He also reworded the phrase
"examines me carefully before deciding what is wrong with me" to "examines me
carefully before diagnosing the case" aiming to guard patients' feelings.
As for the nursing section, he added several questions not mentioned in
previous literature but very relevant in the case of healthcare system in Egypt. The
points included nurses tangibles (high personal hygiene) and nurses interaction
(communicating in accepTable language). These are two dimensions essential in the
nursing service and taken for granted abroad due to the high socio-economic
standard of the nursing staff. However, they are usually lacking among the nursing
staff in Egypt due to the lower socio-economic standard of the nursing staff but are
of great importance when dealing with A and B class patients thus should be strictly
monitored and handled accordingly.
As for the hospitality section concerning the rooms and meals, he agreed
with Expert 1 concerning the main points discussed above but added that the
spaciousness of the rooms comes second to the cheerful visual appearance and
decorations of the rooms. He commented that some of the older hospitals have
spacious rooms with drab décor while some smaller rooms are excellently and
cheerfully decorated thus elevating the psychological mood of the patients.
He also mentioned several excellence criteria that are difficult to apply in
many hospitals due to financial constraints since these endeavours require
significant investments and follow-up. These include catering to location
convenience through having multiple satellite clinics available and continuity of
care such as at-home nursing and rehabilitation.
The third expert interviewed focused on the diagnostics section of the
questionnaire as well as the section concerned with doctors' medical service. In the
diagnostics section, she recommended adding a question concerned with the skills
of the technicians stressing that many patients request specific technicians to
perform their diagnostic tests who are of high skills and do not cause unnecessary
discomfort or pain to the patient.
97
She also commented that patients usually go to hospitals through the
recommendation of the doctor who they visit first in their private clinics. The
doctor refers the patient to one of the hospitals where they practice and the patient
then makes a decision for a certain hospital based on reputation and location
convenience. She was of the opinion that hospitals should make the effort to lure
the top practitioners in the field to their hospitals. Thus, she stressed the addition of
several questions that are also relevant very much to the mentality of the Egyptian
patient. In the professional competence section, she believed that patients judge and
choose doctors based on several criteria including excellent reputations, being
university professors or major consultants as well as being accredited with the
highest medical degrees.
She also recommended modifying the methodology of weights measurement
to weighing the construct as a whole and not the individual variables to reduce the
length of the questionnaire. She also thought the questionnaire should handle the
constructs in the sequence of events passed through by the patients when they enter
the hospital. So the questionnaire should start with entering the hospital (premises
and employees) followed by the admission then the rooms and housekeeping then
the medical service performed (nursing, doctors and diagnostics) and finally the
discharge process.
The fourth expert believed that expectations are heavily influenced with
demographic characteristics as the socio-economic, age and occupation while the
perceptions are strongly influenced by the outcome and satisfaction. Patients are
usually satisfied with the service even if the process was not excellent in the
incidence of a successful outcome. He perceived this in numerous situations since
Gynaecology and Obstetrics in the majority of cases results in happy outcomes (a
healthy baby). Thus with the birth of a healthy child, the happy mother usually
overlooks any unsatisfactory outcome of the hospital experience. He believed,
however, that medical aspects of the service should be focused upon for
Gynaecology and Obstetrics patients as they have a more profound impact on the
experience than the hospitality issue.
When asked his opinion on the preliminary questionnaire and model, he
made a few minor suggestions and agreed with the suggestions recommended by
other experts interviewed before him. He believed that the question in the
competence section concerned with doctors "admitting mistakes" should be
reworded since it undermines the confidence of the patient in the medical delivery
and could be "refer to a specialist". He also was of the opinion that in the nursing
section, patients should not be asked about the "knowledge" of the nurses but rather
the focus should be on the skills, courtesy, responsiveness and interpersonal skills.
This stems from the fact that the medical knowledge of the nursing staff in Egypt is
rather weak and they usually follow the doctors orders and do not take their own
initiative in the treatment process.
As for the hospitality section, he added that admission personnel should
handle the directions and information for patients due to lack of guiding signs in
most hospitals. He agreed that the quality and content to suite individual cases is
essential for meals. Finally, he believed that the appearance of the hospital
employees should be neat and clean and should be monitored strictly.
He believes in the usefulness of the tool being tested since by identifying
and measuring all aspects of the hospital service delivery process, the strengths as
well as the weaknesses, providers will have a greater understanding of patients'
98
expectations thus try to match them. They will also gather their insights on
perceptions of the actual hospital experience, thus will be able to handle the
deficient areas in the service delivery. Also by understanding which processes are
weighted most heavily by consumers, the hospital could accordingly relocate its
resources.
As a summing up of the expert interviews, the model in the current
research took the forms described in chapter 3. The hospital service encounter was
divided into eight construct (hospital premises and employees, doctors medical
services, nursing medical services, diagnostic medical services, admission, meals,
rooms and housekeeping and discharge). This framework as based on the work of
Woodside, Frey and Daly, 1989 and adjusted to the Egyptian healthcare market
based on the qualitative research results. For each of the constructs, several
underlying sub-constructs were uncovered based on the extensive literature review
and the expert and patient in-depth interviews. This is also demonstrated in chapter
3. The pilot questionnaire was finalized after the in-depth interviews and
administered on 10 patients following the criteria outlined in chapter 3 for sample
selection. The results of the pilot are summarized in the next section.
5.2: Results of Pilot Study

The pilot study was performed as described above and administered
through the methodology of "Verbal Protocols". This approach was particularly
useful for identifying the thought process of the respondents. Respondents were
asked to think aloud while answering the questionnaire and asked to voice their
opinion no matter how trivial they thought their comments might be. Everything the
respondents said was noted. The notes collected during the pilot study which
contained the respondents verbalized thought process were thus referred to as the
"protocol". Thus the pilot study provided the researcher with the results of the ten
samples as well as the protocol of the patients' thought process. The detailed results
are summarised in Appendix C. From this data, several amendments were made to
the questionnaire based on the pilot study. These included omission of some
questions, separation of the perceptions and expectations sections and changing the
method for weight measurements.
Omission of Questions: Q5, Q16 and Q24 will be omitted from the study due
to the following reasons:
o Q5 relates to pooling of tips by the hospital to avoid tip solicitation.
There was 80% non-response (8 out of 10 patients) in the perceptions
sections of the questionnaire since the respondents said this was not
applicable and not present in any of the hospitals they frequented.
They also commented in their expectations sections that even if it did
exist, they would still administer individual tips. This is because
tipping is a cultural concept in Egypt where the basic salaries for the
blue-collar jobs are quite low and the main income comes from tips
thus the workers will not deliver any semblance of a satisfactory
service if not tipped. Thus, the whole cultural concept needs to be
changed and it is not just an individual case of pooling tips in
hospitals.
o Q16 related to doctors admitting mistakes. There was 100% non-
response (10 out of 10 patients) in the perceptions sections of the
questionnaire since the respondents said this was not applicable and
99
did not happen with any of the doctors they frequented. The patients
criticized this question since they believe that doctors should not
bluntly admit absence of knowledge and should not make mistakes
anyway since this greatly undermines the confidence in the medical
profession. They believe that the wording was not understood and
could just be "refer the patient to a specialist when a diagnosis is not
reached".
o Q24 regarding error-free records maintained in hospitals was also
omitted. Ninety percent of the patients (9 out of 10) commented that
they were unaware of the accuracy and maintenance of the hospitals
records. They stressed that their records are usually stored in the
clinics of the private doctors that they visit whom referred them to the
hospital. Thus the question usually rendered a non-response for the
perceptions statements.
Separation of perceptions and expectations statements during
questionnaire administration: The pilot test included two different methods
for administration of the questionnaire. Each method was tested on 5 of the ten
respondents. The first method contained the perceptions statements (1-43) then
the expectations statements (1-43) following each other followed by the
importance then overall satisfaction then the demographics section. In the
second method, slight adjustments were made to the question phrasing and
both the expectations and perceptions statements were combined in one section
with the patient first stating what actually found in the hospital then
immediately adjacent to rate what he believes the hospital should actually
possess. This was similarly followed by the importance then overall
satisfaction then the demographics section.
o The researcher was hoping the second methodology would prove
effective aiming to reduce the size of the questionnaire since it is quite
lengthy and takes a considerably amount of time to be administered.
o However, after testing the results statistically, the first methodology
proved more efficient since the inter-correlation between the
expectations and perceptions proved quite high in the second
methodology. Thus the researcher decided to employ the methodology
employed by most researchers where the perceptions statements were
questioned followed by expectations followed by the importance then
overall satisfaction then the demographics section. This methodology
is heavily supported in literature and proved quite valid and reliable in
numerous previous researches.
o This conclusion was reached after conducting an independent t-test
among the two groups combined versus separated. The means of the
two groups are far from being similar and the variance is not truly
equal especially if the different means are considered (one is more
than twice the other) as demonstrated in the following Tables.
100
Table 5.1: Demonstrates the Means and Variances for the Two Methodologies,
n=10
SAMPLE N Mean Std. Deviation Std. Error Mean
DEF
1.00 168 -.65 1.045 .081
2.00 170 -1.44 1.065 .082
Table 5.2: Demonstrates the Independent t-test Results, n=10

Levene's t-test for Equality of Means
Test
for Equality
of Variances
F Sig. T df Sig. Mean Std. Error 95% Confidence
(2- Difference Difference Interval of the
tailed) Difference
Lower Upper
Equal .894 .345 6.852 336 .000 .79 .115 .561 1.012
variances
assumed
Equal 6.853 335.9 .000 .79 .115 .561 1.012
variances not
assumed
Changing the method of measurement of construct weights: The

methodology adopted was similar to that adopted by PZB, 1988 for weight
measurement where the respondents were asked to allocate a total of 100 points
among the eight features according to how important each feature is to the
respondent and to ensure that the sum of points allocated to the eight features
add up to 100. 7 out of 10 of the respondents complained that this section was
too complicated to do. In the case of PZB, 1988 respondents were dividing
over five dimensions so perhaps it was simpler to perform while the current
research has eight constructs thus making this exercise more complicated.
Cronin and Taylor, 1992 measured weights similarly to expectations and
perceptions on a Likert-scale but measured it for each of the individual items in
the questionnaire (22 items). Since the current research is following the
methodology of both Cronin and Taylor, 1992 and PZB, 1988 to a great
extent, a mixture of both their methodology for weight measurement will also
be adopted. Since the current research contains over 40 statements versus their
22, then the researcher will weigh the construct as a whole instead of the
importance of each individual statement (following the methodology of PZB,
1988) In addition, each construct will be weighed on a five-point Likert-scale
from least important to most important (following the methodology of Cronin
and Taylor, 1992).
101
CHAPTER 6: QUANTITATIVE RESEARCH RESULTS
The research was divided into 2 phases, a qualitative phase (whose results were
described in the previous chapter) and a quantitative phase. In this chapter, the
results garnered from the quantitative research are presented.
Figure 6.1: Demonstrating the Stages of the Research
C) STAGES OF THE
RESEARCH
First Phase Second Phase

Qualitative Quantitative
Secondary Data
Field Survey
Gathering
In-depth interviews
with Egyptian patients
In-depth interviews
with experts
Pilot Study
The chapter reports the testing of the hypothesis through the results garnered from
the administration of the quantitative surveys on the healthcare consumers. It is
divided into two main sections. The first section is concerned with descriptive
statistics for the survey. The second section is concerned with the quantitative data
analysis and it is further sub-divided into five parts. Each part is concerned with the
answer of one of the major research questions.
6.1 Descriptive Analysis

After data collection and preparation, data analysis and interpretation has
been performed. Many descriptive analysis techniques were done for the data. This
includes descriptive graphs as Frequency Histograms demonstrating the average
expectations, perceptions, weights and overall assessment in the hospital encounter.
Also relevant percentages and explanations are detailed to give a comprehensive
overview of the data gathered.
In the current research, the mode for any question is the answer which was
chosen the largest number of times for this question. Based on this fact, we
conclude that the majority of the respondents in the perceptions sections agreed
with 85% of the tested statements in perceptions section "A", while they were
neutral for 7.5 % of the tested statements, and they strongly agreed with 7.5 % of
102
the tested statements. On the other hand, the majority of the respondents agreed
/;..?with 75 % of the tested expectations statements, while they strongly agreed with
25 % of the tested statements.
6.1.1 Perceptions and Expectations of the Hospital Service Provided
The following section deal with the perceptions and expectations of patients with
the hospital services provided. It is divided into eight sections following the eight
major constructs in the research. Each section contains a summary of the results for
perceptions and expectations. Each section contains a Table that demonstrates what
the majority of the respondents thought for each statement as well as average
expectations or perceptions and a summary of disagreement, neutral and agreeing
respondents.
6.1.1.1 Perceptions and Expectations of Hospital Premises and Employees
6.1.1.1.1 Perceptions of Hospital Premises and Employees
The majority of individuals agreed that Hospital XYZ has the most technologically
advanced equipment (56.2%) and the materials associated with the service
(pamphlets, booklets, medical procures) clearly contain all the necessary
information at Hospital XYZ (39.3%). As for the physical facilities, the majority
(46.7%) were neutral about them. Finally, 33.9% of the individuals questions
agreed that employees at Hospital XYZ are extremely neat appearing. The detailed
percentages are included in the following Table 6.1 and are demonstrated in the
following Chart 6.2.
Table 6.1: Demonstrating percentage of average and summary of perceptions for

Strongly Disagree Neutral Agree Strongly
Disagree Agree
1. Hospital XYZ has the most technologically 10.1 3.4 14.6 56.2 15.7
advanced equipment
2. The physical facilities (buildings, landscape, 0.4 11.9 46.7 27.4 13.5
physical layout) at Hospital XYZ is visually
impressive
3. Employees at Hospital XYZ are extremely 2.0 12.1 26.5 25.4 33.9
neat appearing
4. Materials associated with the service 1.1 16.0 24.5 39.3 19.1
(pamphlets, booklets , medical procures)
clearly contain all the necessary information
at Hospital XYZ
AVERAGE PERCEPTIONS 3.4 10.85 28.08 37.08 20.55
SUMMARY PERCEPTIONS 14.25 28.08 57.63
6.1.1.1.2 Expectations of Hospital Premises and Employees

The majority of individuals agreed that excellent hospitals should have the most
technologically advanced equipment (58%) and the materials associated with the
service (pamphlets, booklets, medical procures) clearly should contain all the
necessary information at Hospital XYZ (47.6 %). As for the physical facilities, the
majority (34.4%) agreed that they should be visually impressive. Finally, 44.5% of
the individuals questions agreed that employees at Hospital XYZ should be
extremely neat appearing. The detailed percentages are included in the following
Table 6.2 and are demonstrated in the following Chart 6.2.
103
Table 6.2: Demonstrating percentage of average and summary of expectations for
Disagree Agree
1. Excellent hospitals should have the most 3.4 .7 7.0 58.0 31.0
technologically advanced equipment
2. The physical facilities (buildings, .4 2.5 30.1 34.4 32.6
landscape, physical layout) at excellent
hospitals should be visually impressive
3. Employees at Excellent hospitals should be 1.3 1.6 10.8 44.5 41.8
extremely neat appearing
4. Materials associated with the service .2 1.1 12.4 47.6 38.7
should clearly contain all the necessary
information at excellent hospitals
AVERAGE EXPECTATIONS 1.33 1.48 15.08 46.13 36.03
SUMMARY EXPECTATIONS 2.81 15.08 82.16
Chart 6.2: Demonstrating percentage of average perceptions and average

expectations for premises and employees
46.13
50
37.08 36.03
40
28.08
30 20.55
15.08
20 10.85
10 3.4 1.33 1.48
0
Disagree Agree
average perceptions avearge expectations
6.1.1.2 Perceptions and Expectations of Doctors Services

6.1.1.2.1 Perceptions of Doctors Services
The majority of individuals agreed that doctors in Hospital XYZ are always on time
55.7%), that they feel extremely safe in their transactions (35.3%) and that there
was always an experienced doctor who is aware of the case available at all times of
the hospital stay (41.8%). On the other hand, 36.6% agreed that the doctors had
very high level of knowledge required to answer their questions satisfactorily. The
majority of individuals agreed that doctors in Hospital XYZ hear very carefully
what they had to say (37.3%), were extremely careful in explaining what the
patient was expected to do in words they understood (39.1%) , spent enough time
with them (40.7%), examined then very carefully before deciding what is wrong
(36.6%)and finally 38% agreed that doctors in Hospital treated them with respect.
The majority of individuals agreed that where their medical care is concerned,
doctors in Hospital XYZ discussed all decisions with them (40.3%), have excellent
reputations (43.6%), were university professors or major consultants (39.8%) and
were accredited with the highest medical degrees (45.4%). The detailed percentages
are included in the following Table 6.3 and are demonstrated in the following Chart
6.3.
104
doctors services
Disagree Agree
Doctors
5. in Hospital XYZ are always on time 1.1 4.7 12.1 55.7 26.3
6. Patients of Hospital XYZ feel extremely .2 5.6 31.9 35.3 27.0
safe in their transactions
7. Doctors in Hospital XYZ have very high .9 7.9 20.4 34.2 36.6
level of knowledge required to answer my
questions satisfactorily
8. Excellent hospitals have an experienced 1.6 6.5 26.3 41.8 23.8
doctor who is aware of my case available at
all times of my hospital stay
9. Doctors in Hospital XYZ hear very carefully 1.1 12.1 28.1 37.3 21.3
what I have to say
10. Doctors in Hospital XYZ are extremely 1.3 6.5 22.0 39.1 31.0
careful in explaining what I am expected to
do in words understand
11. Doctors in Hospital XYZ spend enough time 1.3 10.6 20.7 40.7 26.7
with me
12. Doctors in Hospital XYZ examine me very 1.3 10.1 29.9 36.6 22.0
carefully before deciding what is wrong
with me
13. Doctors in Hospital XYZ treat me with 1.6 7.2 24.7 38.0 28.5
respect
14. Where my medical care is concerned, 2.0 9.2 20.5 40.3 27.9
doctors in Hospital XYZ discuss all
decisions with me
15. Doctors in Hospital XYZ have excellent 1.6 8.1 22.5 43.6 24.3
reputations
16. Doctors in excellent hospitals are 2.0 7.9 24.5 39.8 25.8
university professors or major consultants
17. Doctors in excellent hospitals are 1.6 7.9 20.7 45.4 24.5
accredited with the highest medical degrees
6.1.1.2.2 Expectations of Doctors Services
The majority of individuals agreed that doctors in excellent hospitals should be
always on time (50.1%), that they feel extremely safe in their transactions (44.3 %).
On the other hand, 48.3 % strongly agreed that the doctors should have a very high
level of knowledge required to answer their questions satisfactorily and that there
should always be an experienced doctor who is aware of the case available at all
times of the hospital stay (45.6 %). The majority of individuals strongly agreed that
doctors in excellent hospitals should hear very carefully what they had to say (45.8
%), should be extremely careful in explaining what the patient was expected to do
in words they understood (44.3 %) , should spent enough time with them (47.2 %),
should examine them very carefully before deciding what is wrong (48.5 %)and
finally 49.7 % agreed that doctors in Hospital should treat them with respect. The
majority of individuals strongly agreed that where their medical care is concerned,
doct ors in excellent hospitals should discuss all decisions with them (46.3%), have
excellent reputations (46.3%), were university professors or major consultants
(49%) and were accredited with the highest medical degrees (47.4 %). The detailed
percentages are included in the following Table 6.4 and in Chart 6.3.
105
doctors services
Disagree Agree
Doctors
5. in excellent hospitals should 1.3 1.6 5.2 50.1 41.8
always on time
6. Patients of excellent hospitals should feel .2 1.1 13.9 44.3 40.4
extremely safe in their transactions
7. Doctors in excellent hospitals should .4 1.6 6.3 43.4 48.3
have very high level of knowledge
required to answer patient's questions
satisfactorily
8. Excellent hospitals should have an .9 1.3 7.0 45.2 45.6
experienced doctor who is aware of the
patient's case available at all times of my
hospital stay
9. Doctors in excellent hospitals should hear .9 1.8 12.4 39.1 45.8
very carefully what the patient has to say
10. Doctors in excellent hospitals should be .4 .9 10.1 44.3 44.3
extremely careful in explaining what the
patient is expected to do in words she
understands
11. Doctors in excellent hospitals should 1.3 1.8 9.9 39.8 47.2
spend enough time with the patient
12. Doctors in excellent hospitals should .4 1.1 8.5 41.3 48.5
examine the patient very carefully before
deciding what is wrong with me
13. Doctors in excellent hospitals should 2.0 .7 5.4 49.7 42.2
always treat the patient with respect
14. Where the patient's medical care is .7 1.6 9.2 42.2 46.3
concerned, doctors in excellent hospitals
should discuss all decisions with the her
15. Doctors in excellent hospitals should 1.1 1.1 6.7 44.7 46.3
have excellent reputations
16. Doctors in excellent hospitals should be .7 1.1 7.4 41.8 49.0
17. Doctors in excellent hospitals should be 1.1 1.1 4.9 45.4 47.4
accredited with the highest medical
degrees

expectations for doctors services
43.95 45.62
50 40.6
40
26.59
30 23.41
20
8.02 8.22
10 1.35 0.88 1.29
0
Disagree Agree
average perceptions average expectations
106
6.1.1.3 Perceptions and Expectations of Diagnostic Services
6.1.1.3.1 Perceptions of Diagnostic Services [Diagnostic Competence (Q18,19)
and Diagnostic Reliability (Q20, 21)]
The majority of individuals agreed that doctors in Hospital XYZ never order never
order any unnecessary diagnostic medical procedures (59.6%) and laboratory tests
and X-rays in Hospital XYZ are always provided at the time they are promised
(52.4%). The majority also strongly agreed that tests and X-rays in the hospital
were always done right the first time (39.8%). On the other hand, the majority were
neutral as to that laboratory and X-ray technicians in hospital XYZ had the high
technical skills required to perform the service (54.6%). The detailed percentages
are included in the following Table 6.5 and Chart 6.4.
diagnostic services
Disagree Agree
.18 Hospital XYZ has the most 7.9 2.7 13.9 59.6 16.0
.19 The physical facilities (buildings, 1.3 10.6 54.6 22.7 10.8
landscape, physical layout) at Hospital
XYZ is visually impressive
.20 Employees at Hospital XYZ are 1.8 6.3 20.4 31.7 39.8
.21 Materials associated with the service .7 5.4 20.9 52.4 20.7
clearly contain all the necessary
information at Hospital XYZ
6.1.1.3.2 Expectations of Diagnostic Services [Diagnostic Competence (Q18,19)

and Diagnostic Reliability (Q20, 21)]
The majority of individuals agreed that doctors in excellent hospitals should never
order never order any unnecessary diagnostic medical procedures (57.8 %) and
laboratory tests and X-rays in Hospital XYZ should be always provided at the time
they are promised (56.6 %). The majority also agreed that tests and X-rays in the
hospital were always done right the first time (44.7 %) and that laboratory and X-
ray technicians in hospital XYZ should have the high technical skills required to
perform the service (41.3 %). The detailed percentages are included in the
following Table 6.6 and are demonstrated in the following Chart 6.4.
diagnostic services
Disagree Agree
18 Hospital XYZ has the most 3.4 .4 6.1 57.8 32.4
19 The physical facilities (buildings, .7 2.2 24.3 41.3 31.5
landscape, physical layout) at Hospital
XYZ is visually impressive
20 Employees at Hospital XYZ are 1.3 1.3 8.5 44.7 44.0
21 Materials associated with the service .7 .4 9.7 56.6 32.6
clearly contain all the necessary
information at Hospital XYZ
Average Perceptions 1.53 1.08 12.15 50.1 35.15
Summary Perceptions 1.305 12.15 42.615
107
expectations for diagnostic services
60
average
40
perceptions
20
average
0 expectations
Disagree Agree
6.1.1.4 Perceptions and Expectations of Nursing Services

6.1.1.4.1 Perceptions of Nursing Services (Nursing Tangibles (Q22), Nursing
Reliability (Q23), Assurance (Q24 to 26), Responsiveness (Q27) and Empathy
(Q28,29))
The majority of individuals agreed that nurses in Hospital XYZ have high personal
hygiene (62.7%), performed the service required (tests, procedures, medication
dispensing) at exactly the right time (36.8%), were consistently courteous (43.4%)
and always communicated in accepTable language (37.3%). On the other hand, the
majority of patients were neutral as to whether the nurses had level of knowledge &
skill needed to perform the service very well (38%). The majority of individuals
agreed that Nurses in Hospital XYZ always respond in a reasonable length of time
(41.3%), gave them personal attention (44.3%) as well as understood their specific
needs (45.2%). The detailed percentages are included in the following Table 6.7
and are demonstrated in the following Chart 6.5.
nursing services
Disagree Agree
22. Nurses in Hospital XYZ have high 1.3 3.6 18.9 62.7 13.5
personal hygiene (body and mouth odor,
nails, cleanliness of uniforms etc)
23. Nurses in Hospital XYZ have level of .7 6.1 38.0 32.8 22.5
knowledge & skill needed to perform the
service very well
24. Nurses in Hospital XYZ perform the 1.1 6.7 21.1 36.9 34.2
service required (tests, procedures,
medication dispensing) at exactly the
right time
25. Nurses in Hospital XYZ are consistently 1.3 9.9 26.3 43.4 19.1
courteous
26. Nurses in Hospital XYZ always .9 9.9 33.9 37.3 18.0
communicate in accepTable language
27. Nurses in Hospital XYZ always respond 1.3 7.0 26.7 41.3 23.6
in a reasonable length of time
28. Nurses in Hospital XYZ give me personal .9 5.8 23.6 44.3 25.4
attention
29. Nurses in Hospital XYZ understand my 2.5 8.3 24.9 45.2 19.1
specific needs
108
6.1.1.4.2Expectations of Nursing Services
The majority of individuals agreed that in excellent hospitals nurses should have
high personal hygiene (49.9%), should had level of knowledge & skill needed to
perform the service very well (44%) and should perform the service required (at
exactly the right time (47%). The majority of individuals also agreed that nurses
should be consistently courteous (43.1%), always communicated in accepTable
language (47%), should always respond in a reasonable length of time (48.3%) and
should understand their specific needs (50.3%). Finally, the majority of patients
strongly agreed that the nurses should them personal attention (46.7%). The
detailed percentages are included in the following Table 6.8 and Chart 6.5.
nursing services

Disagree Agree
22. Nurses in excellent hospitals should have 1.1 1.3 3.8 49.9 43.8
high personal hygiene (body and mouth
odour, nails, cleanliness of uniforms)
23. Nurses in excellent hospitals should .7 1.3 10.1 44.0 43.8
have level of knowledge & skill needed
to perform the service very well
24. Nurses in excellent hospitals should .9 .9 7.9 47.0 43.4
perform the service required (tests,
procedures, medication dispensing) at
exactly the right time
25. Nurses in excellent hospitals should be .7 1.3 14.4 43.1 40.4
consistently courteous to patients
26. Nurses in excellent hospitals should 1.3 .4 12.8 47.0 38.4
always communicate in accepTable
language with patients
27. Nurses in excellent hospitals should .4 1.6 9.2 48.3 40.4
always respond in a reasonable length of
time
28. Nurses in excellent hospitals should give .7 .9 7.0 44.7 46.7
patients personal attention
29. Nurses in excellent hospitals should .9 .9 7.4 50.3 40.4
understand the specific needs of their
patients

expectations for nursing services
60 46.79
42.99 42.16
40 26.68
21.93
20 7.16 9.08
1.250.84 1.08
0
Disagree average perceptions average expectations Agree
109
6.1.1.5 Perceptions and Expectations of Admission Service
6.1.1.5.1 Perceptions of Admission Responsiveness (Q30) and Knowledge and
Courtesy (Q 31, 32)
The majority of individuals agreed that in Hospital XYZ appointments are made
easily (57.5%), the admission personnel provided clear information (41.2%) and
were consistently courteous (50.6%). The detailed percentages are included in the
following Table 6.9 and are demonstrated in the following Chart 6.6.
Table 6.9: Table demonstrating percentage of average and summary of perceptions
for admission services
Disagree Agree
30. In Hospital XYZ, appointments are made 2.9 6.5 15.1 57.5 18.0
easily
31. Admission personnel in Hospital XYZ .5 3.0 39.3 41.2 15.9
provide clear information (e.g. directions,
schedules)
32. Admission personnel in Hospital XYZ are .4 6.1 25.8 50.6 17.1
consistently courteous
AVERAGE PERCEPTIONS 1.27 5.2 26.73 49.77 17
6.1.1.5.2 Expectations of Admission Responsiveness (Q30) and Knowledge and

Courtesy (Q 31, 32)
The majority of individuals agreed that in excellent hospitals appointments should
be made easily (50.6%), the admission personnel should provide clear information
(53.7%) and should be consistently courteous (52.8 %). The detailed percentages
are included in the following Table 6.10 and in the following Chart 6.6.
admission services
Disagree Agree
30. In excellent hospitals, appointments 2.9 .4 4.0 50.6 42.0
should be made easily
31. Admission personnel in excellent hospitals .4 2.5 10.3 53.7 33.0
should provide clear information (e.g.
directions, schedules etc) to patients
32. Admission personnel in excellent hospitals 1.1 .9 8.3 52.8 36.9
should be consistently courteous and
helpful to patients
110
expectations for admission services
60 49.7752.37
37.3
40 26.73
17
20 7.53
5.2
1.271.47 1.27
0
Disagree Agree
6.1.1.6 Perceptions and Expectations of Meals Services

6.1.1.6.1 Perceptions of Meals Tangibles (Q33, 34, 35)
The majority of individuals agreed that meals in Hospital XYZ were always served
at the right temperature (48.3%), were of excellent quality (45.2%) and were
carefully prepared to suite the case of each individual patient (49.9%). The detailed
percentages are included in the following Table 6.11 and Chart 6.7.
Table 6.11: Demonstrating percentage of average & summary of perceptions for
meals
Disagree Agree
33. Meals in Hospital XYZ are always 2.5 7.2 22.7 48.3 19.3
served at the right temperature
34. Meals in Hospital XYZ have excellent .2 4.9 28.3 45.2 21.3
quality
35. Meals in excellent hospitals should be 1.3 6.1 22.5 49.9 20.2
carefully prepared to suite the case of
each individual patient
6.1.1.6.2 Expectations of Meals Tangibles(Q33, 34, 35)

The majority of individuals agreed that meals in excellent hospitals should be
always served at the right temperature (47.2%) and should be carefully prepared to
suite the case of each individual patient (47%). They also strongly agreed that
meals should be of excellent quality (47.2 %) The detailed percentages are included
in the following Table 6.12 and are demonstrated in the following Chart 6.7.
Table 6.12: Demonstrating percentage of average & summary of expectations for meals

Disagree Agree
33. Meals in excellent hospitals should 1.3 1.6 7.2 47.2 42.7
always served at the right temperature
34. Meals in excellent hospitals should be of .4 .9 9.7 41.8 47.2
excellent quality
35. Meals in excellent hospitals should be .9 .9 6.3 47.0 44.9
carefully prepared to suite the case of
SUMMARY EXPECTATIONS 2 7.73 90.26
111
expectations for meals services
47.8
50 45.33 44.93
40
30 24.5
20.27
20
6.07 7.73
10
1.33 0.87 1.13
0
Strongly Disagree Neutral Agree Strongly Agree
Disagree average perceptions average expectations
6.1.1.7 Perceptions and Expectations of Rooms and Housekeeping Services

6.1.1.7.1 Perceptions of Rooms and Housekeeping Tangibles (Q36,37) and
Courtesy (Q38)
The majority of individuals agreed that rooms in Hospital XYZ were visually
appealing (46.3%), rooms and baths in Hospital XYZ were kept very clean (41.6%)
and the housekeeping staff in Hospital XYZ were consistency courteous (44.7%).
The detailed percentages are included in the following Table 6.13 and are
demonstrated in the following Chart 6.8.
6.1.1.7.2 Expectations of Rooms and Housekeeping Tangibles (Q36, 37) and

Courtesy (Q38)
The majority of individuals agreed that rooms in excellent hospitals should be
visually appealing (54.8%), rooms and baths in Hospital XYZ must be kept very
clean (50.8%) and the housekeeping staff in Hospital XYZ should be consistency
courteous (51.9%). The detailed percentages are included in the following Table
6.14 and are demonstrated in the following Chart 6.8.

Disagree Agree
36. Rooms in Hospital XYZ are visually 2.9 5.6 23.1 46.3 22.0
appealing
37. Rooms and baths in Hospital XYZ are .9 4.5 28.8 41.6 24.3
kept very clean
38. Housekeeping staff in Hospital XYZ are 1.6 4.3 24.7 44.7 24.7
consistency courteous
112
Disagree Agree
36. Rooms in excellent hospitals should be .9 1.3 5.4 54.8 37.5
visually appealing
37. Rooms and baths in excellent hospitals 0 .2 8.5 50.8 40.4
should be kept very clean
38. Housekeeping staff in excellent hospitals .9 1.1 7.2 51.9 38.9
should consistently be courteous

expectations for Rooms and Housekeeping services
60 52.5
50 44.2
38.93
40
25.53 23.67
30
20
4.8 7.03
10 1.8 0.6 0.87
0
Disagree average perceptions average expectations Agree
6.1.1.8 Perceptions and Expectations of Discharge services

6.1.1.8.1 Perceptions of Discharge Knowledge and Courtesy (Q39,40)
The majority of individuals agreed that Business office personnel in Hospital XYZ
answer questions (e.g. billing, insurance) very adequately (45.4%) and were
consistently courteous to patients (43.1%). The detailed percentages are included in
Table 6.15 and are demonstrated in the following Chart 6.9.
discharge services
Disagree Agree
39. Business office personnel in excellent 3.6 9.7 27.0 45.4 14.4
hospitals should answer questions (e.g.
billing, insurance) very adequately
40. Business personnel in excellent hospitals 2.9 9.0 28.1 43.1 16.9
should consistently be courteous to
patients
6.1.1.8.2 Expectations of Discharge Knowledge and Courtesy (Q39,40)

The majority of individuals agreed that in Excellent Hospitals, discharge personnel
should answer questions (e.g. billing, insurance) very adequately (54.4%) and
should be consistently courteous to patients (45.6%). The detailed percentages are
included in the following Table 6.16 and the following Chart 6.9.
113
discharge services
Disagree Agree
39. Business office personnel in excellent 1.3 1.3 16.2 54.4 26.7
40. Business personnel in excellent hospitals .9 1.6 15.7 45.6 36.2
should consistently be courteous to
patients
AVERAGE EXPECTATIONS 1.1 1.45 15.95 50 31.45

expectations for discharge services
Demonstrating Percentage of Average Perceptions and
Expectations for Discharge Services
60 50
44.25
40 31.45
27.55
15.95 15.65
20 9.35
3.25 1.1 1.45
0
Disagree Agree
6.1.2 Importance of the Hospital Service Provided

In the current research, the mode for any question is the answer which was chosen
the largest number of times for this question. Based on this fact, we conclude that
the majority of the respondents agreed with 37.5 % of the tested statements, while
they strongly agreed with 62.5 % of the tested statements. The following Table 6.17
and Chart 6.10 demonstrates what the respondents thought for each statement.
Table 6.17: Demonstrating percentage of average of importance for hospital

services provided
Premises/ Medical Diagnostic Nursing Admission Meals House Discharge
Employees Doctors Services Care Personnel keeping Services
Least 1.8 .2 .2 .2 .2 0 .5 .9
Important
Not 2.0 1.6 .9 .7 1.1 .2 1.1 1.1
Important
Neutral 11.3 7.0 23.3 26.0 16.7 16.9 14.4 14.9
Important 40.6 31.8 38.8* 37.7* 39.1 41.3 38.6 44.3*
Most 44.2* 59.4* 36.8 35.4 42.9* 41.5* 45.4* 38.7
Important
* The majority of respondents for each construct is marked
114
Chart 6.10: Demonstrating percentage of average of importance for hospital
services provided Demonstrating the Importance Percentages f or the Eight Constrcuts
100%
90%
36.8 35.4 38.7
80% 44.2 42.9 41.5 45.4
59.4
70%
60%
50% 37.7
38.8
40% 39.1 41.3 44.3
40.6 38.6
30%
31.8
20%
23.3 26
10% 11.3 16.7 16.9 14.4 14.9
7
2
1.8 1.6 1.1 1.1 1.1
0.2 0.9
0.2 0.7
0.2 0.2 0.2
0 0.5 0.9
0%
Hospit al Premises M edical Doct ors Diagnost ic Nursing Care A dmission M eals Housekeeping Discharge
and Employees Services Personnel Services
Least Imp Not Imp Neutral Imp Most Imp
6.1.3 Overall Assessment of the Hospital Service Provided

In the current research, the mode for any question is the answer which was chosen
the largest number of times for this question. Based on this fact, we conclude that
the majority of the respondents chose the answer "Important" for 83.33 % of the
tested statements, while they chose the answer "Not Important" for 16.67 % of the
tested statements. The following Table 6.18 and Chart 6.11 demonstrates what the
respondents thought for each statement:
Table 6.18: Demonstrating percentages for overall assessment of hospital services
Future Future Value Mother Baby
Satisfaction Purchase Recommendation for Money Outcome Outcome
Strongly
Disagree 1.4 0.2 31.2 0 0 0.2
Disagree 0.7 2.7 35.2 1.6 0.5 1.1
Neutral 6.5 31.6 30.5 16.7 25.5 16.3
Agree 53.3 36.3 2.3 58.7 36.8 42.9

Strongly
Agree 38.1 29.1 0.9 23 37.2 39.5
* The question for future recommendation was worded
Chart 6.11: Demonstrating percentages for overall assessment of hospital services
100%
90%
80% Strongly Agree
70%
60% Agree
50% Neutral
40%
30% Disagree
20% Strongly Disagree
10%
0%
Satisfaction Future Purchase
Future Recommendation
Value for MoneyMother OutcomeBaby Outcome
115
6.2 Quantitative Data Analysis
Quantitative data analysis will now be used as a method for quantification
of the survey performed. Due to the difficulty of addressing complicated research
questions and a survey using univariate analysis techniques, then multivariate
techniques that will analyze the structure of simultaneous relationships among three
or more phenomenon will be used due to the presence of several dependent and
independent variables all of them potentially correlated. In the current study,
several statistical tools were applied to the data including reliability studies through
Cronbach Alpha as well as multivariate techniques including exploratory factor
analysis, ordinal logistic regression, correlation tests such as Pearson's correlation
test and discriminant analysis.
Due to the diversity of opinions on the best way to measure service quality
and the lack of a conclusive framework finalized for the healthcare industry, several
steps were undertaken in the present research and are summarized in the following
Table.
Table 6.19: Summarizing the steps undertaken in the research

Section Steps Taken
Section Measurement of error through testing for reliability and validity of the
6.2.1 data
Section Construction of eight alternative scales for service quality measures
6.2.2 and the testing all scales to determine the most effective method for
measurement will be performed (Using Exploratory Factor Analysis
and Logistic Regression)
Section Factor Analysis to compare between the 4 scales (SERVQUAL,
6.2.2.1 SERVPERF, WEIGHTED SERVQUAL, WEIGHTED SERVPERF)
Section Ordinal Logistic Regression to determine whether an interactive versus
6.2.2.2 an additive methodology should be used
Section Identification the constructs underlying healthcare service quality
6.2.3 (Using Exploratory Factor Analysis and Ordinal Logistic Regression)
Section Factor Analysis to demonstrate the constructs of the research
6.2.3.1
Section Ordinal Logistic Regression to establishing the relationship between
6.2.3.2 the constructs identified for healthcare service quality measures and
overall perceived service quality
Section Identifying sub-constructs of healthcare service quality and testing the
6.2.4 effect of each of the identified sub-constructs on patient's overall
perception of service quality (Using Ordinal Logistic Regression).
Section Identifying the relationship between overall customer satisfaction and
6.2.5 behavioural intentions to return and recommend, value for money and
outcome will also be tested (Using Pearson Correlation)
Section Identifying the relationship between consumer demographic criteria
6.2.6 and the variables in the research (Using Discriminate Analysis).
116
The steps of the research are demonstrated in Figure 6.12 below:
Figure 6.12: Demonstrating the Steps of the Research Analysis Process
Research
Analysis
Process
Descriptive Analytical
To describe patterns inherent To statistically analyze data
within results through through multivariate analysis
tabulation and frequency techniques
distributions
Construction of eight Identifying the Identifying the

alternative scales for Identify the Testing the effect of relationship between relationship
service quality constructs each of the customer satisfaction between
Measurement measures and the underlying identified sub- and behavioral consumer
of Error testing all scales to healthcare constructs on intentions to return demographic
determine the most service patient's overall and recommend value criteria and the
effective method for quality perception of for money and variables in the
measurement service quality outcome research
Validity Factor analysis Logistic Pearson Discriminant

Factor Analysis Correlation
Regression Analysis
Reliability Logistic Logistic

Regression Regression
117
6.2.1: Measurement of Error
Measurement error is the degree to which the observed values are not representative
of the ―true‖ values. To assess the degree of measurement error present in any
measure, the researcher addressed the validity and reliability.
6.2.1.1. Validity
Validity is concerned with how well the concept is defined by the
measures, whereas reliability relates to the consistency of the measures (Field,
2002). In other terms, validity is the degree to which a set of measures correctly
represents the construct of interest that they are supposed to represent.
Content validity (internal validity) focuses upon the appropriateness of the
material, operationalizaion technique, the skills to be demonstrated in the
instrument and their alignment with the study outline. In the current research
several measures were undertaken to ensure content validity. The researcher has:
• Searched the literature for previous use of the employed technique
• Employed subject matter experts and expert definitions (in related study field)
• Conducted several in-depth interviews with experts in the field to assess the
internal validity of the survey questionnaire and modeling methodology
From the results garnered by using the above mentioned methods, the researcher
concluded that the content validity is accepTable.
6.2.1.2. Reliability
In internal consistency reliability estimation, the reliability of the instrument is
judged by estimating how well the items that reflect the same construct yield
similar results. There is interest in the results consistency for different items related
to the same construct within the measure. Cronbach Alpha (ά) is one technique to
measure internal consistency reliability. Cronbach Alpha is equivalent to the
average of all possible split half correlations. Table 6.20 demonstrates the results of
Cronbach Alpha for each set of variables used in the present research:
Table 6.20: Demonstrating Cronbach Alpha for the Variables in the Research
Variables Number of Items Cronbach Alpha
Perceptions 40 0.9004
Expectations 40 0.9429
Overall assessment 6 0.5273
Importance 8 0.8061
6.2.2 Determining the Best Method for Healthcare Service Quality Measures
among the tested methods:
6.2.2.1: Factor Analysis to compare between the 4 scales (SERVQUAL,
SERVPERF, WEIGHTED SERVQUAL, WEIGHTED SERVPERF)
In order to determine the best method for measurement of service quality, several
different methods for measurement were attempted. The scale will be developed
using the 4 different inputs described by Cronin and Taylor, 1992. The different
models included:
• SERVQUAL: measurement of the difference between expectations and
perceptions (E-P)
• WEIGHTED SERVQUAL: measurement of the difference between
expectations and perceptions multiplied by weights [W*(E-P)]
• SERVPERF: An un-weighted performance based measurement (P)
• WEIGHTED SERVPERF: A weighted performance based measurement
(W*P)
118
Testing the SERQUAL Method for assessing service quality:
Factor analysis was performed using all 40 variables representing the difference
between expected and perceived service quality, all variables with loading less
than 0.5 were eliminated, and repeated the factor analysis process. The results
(detailed in appendix 4) demonstrated that the rotation converged in 23 iterations
that were not consistent with the framework the researchers had formulated in the
current research thus this model was not proven to be the most appropriate
measurement for service quality for the current field of research.
Testing the WEIGHTED SERVQUAL for assessing service quality
Factor analysis was performed using all 40 variables representing the weighted
SERVQUAL method for measurement of service quality [W*(P-E)], all variables
with loading less than 0.5 were eliminated, and repeated the factor analysis process.
The results (detailed in appendix D) demonstrated that the rotation converged in 21
iterations that were not consistent with the framework the researchers had
formulated in the current research thus this model was not proven to be the most
appropriate measurement for service quality for the current field of research.
Testing the SERPERF Method for assessing service quality:
Factor analysis was performed using all 40 variables representing the Perceived
service quality (P), all variables with loading less than 0.5 were eliminated, and
repeated the factor analysis process. The results (detailed in appendix D)
demonstrated that the rotation converged in 28 iterations that were not consistent
with the framework the researchers had formulated in the current research thus this
model was not proven to be the most appropriate measurement for service quality
for the current field of research.
Testing the WEIGHTED SERPERF Method for assessing service quality:
We performed factor analysis using all 40 variables representing the Importance
*Perceived service quality, eliminated all variables with loading less than 0.5, and
repeated the factor analysis process. The results were as follow:
Determinate = 1.788E-11 is < 0.00001, means that there is some bivariate
correlation > 0.8 in the correlation matrix. This proves the presence of multi-
collinearity. The results are demonstrated in Tables 6.21 and 6.22.
Table 6.21: Demonstrating KMO and Bartlett's Test for WEIGHTED SERVPERF
Method
Kaiser-Meyer-Olkin Measure of Sampling Adequacy. .925
Bartlett's Test of Sphericity Approx. Chi-Square 10092.889
Df 780
Sig. .000
KMO =0.925 is > 0.5, meaning that the sample size was adequate for the factor
analysis technique. Bartlett‘s measure tested the null hypothesis that the original
correlation matrix is an identity matrix. In order to be able to use Bartlett test of
sphericity should be significant <0.05.
119
Table 6.22: Demonstrating Total Variance Explained for WEIGHTED SERVPERF
Method
Initial Eigen values Extraction Sums Rotation Sums of
of Squared Loadings Squared Loadings
Component Total % of Cumulative Total % of Cumulative Total % of Cumulative

Variance % Variance % Variance %
1 12.944 32.359 32.359 12.944 32.359 32.359 7.031 17.577 17.577
2 4.462 11.155 43.514 4.462 11.155 43.514 5.421 13.553 31.130
3 2.198 5.494 49.009 2.198 5.494 49.009 2.744 6.860 37.991
4 1.653 4.132 53.141 1.653 4.132 53.141 2.634 6.585 44.575
5 1.484 3.709 56.850 1.484 3.709 56.850 2.342 5.854 50.429
6 1.407 3.517 60.367 1.407 3.517 60.367 2.330 5.825 56.254
7 1.297 3.243 63.609 1.297 3.243 63.609 2.256 5.639 61.893
8 1.065 2.662 66.272 1.065 2.662 66.272 1.752 4.379 66.272
9 .927 2.316 68.588
10 .793 1.982 70.570
11 .764 1.911 72.481
12 .686 1.715 74.196
13 .680 1.700 75.896
14 .597 1.492 77.388
15 .589 1.473 78.860
16 .552 1.379 80.240
17 .541 1.353 81.592
18 .496 1.241 82.833
19 .477 1.193 84.026
20 .462 1.155 85.181
21 .448 1.121 86.302
22 .432 1.081 87.383
23 .426 1.065 88.448
24 .393 .984 89.431
25 .376 .941 90.372
26 .359 .897 91.269
27 .341 .851 92.121
28 .338 .846 92.967
29 .327 .818 93.785
30 .303 .757 94.542
31 .286 .714 95.256
32 .278 .695 95.951
33 .262 .655 96.605
34 .233 .582 97.187
35 .229 .572 97.759
36 .207 .518 98.277
37 .198 .495 98.772
38 .177 .442 99.213
39 .174 .435 99.648
40 .141 .352 100.000
Extraction Method: Principal Component Analysis.
They explained almost 66 % only of the variance. The rest could not be explained
by the variables included in the analysis. As can be seen in Table 6.23, the rotation
converged in 8 iterations that were consistent with the framework the researchers
had formulated in the current research thus this model was proven to be the most
appropriate measurement for service quality for the current field of research. Thus
factor analysis has demonstrated that the model is constructed from 8 major
constructs defined in Table 6.23.
120
Table 6.23: Demonstrating Rotated Component Matrix and Constructs of the
Research
Component
1 2 3 4 5 6 7 8
Doctor Nursing Diagnostic Premises Rooms Meals Admission Discharge
Medical Service Service and
Service Employees
DP17 Doctors being accredited with .765
the highest medical degrees
DP5 Doctors being on time .758
DP16 Doctors being university .754
professors or major
consultants
DP15 Doctors having excellent .737
reputations
DP6 Patients feeling extremely .692
DP12 Doctors examining the patient .689
very carefully before deciding
what is wrong
DP11 Doctors spending enough .678
time with the patient
DP10 Doctors being extremely .675
careful in explaining what the
patient is expected to do in
words they understand
DP8 Presence of an experienced .657
doctor who is aware of the
patient's case available at all
times of hospital stay
DP13 Doctors always treating the .650
patient with respect
DP7 Doctors having very high .646
level of knowledge required
to answer patient's questions
satisfactorily
DP9 Doctors listening very .635
carefully to what the patient
has to say
DP14 Doctors discussing all .625
decisions concerned with
patient's medical care with
them
DP29 Nurses understanding the .786
specific needs of their patients
DP22 Nurses having high personal .782
hygiene (body and mouth
odour, nails, cleanliness of
uniforms etc)
DP28 Nurses giving patients .769
personal attention
DP27 Nurses responding in a .761
reasonable length of time
DP24 Nurses performing the service .754
required (tests, procedures,
medication dispensing) at
DP26 Nurses communicating in .709
accepTable language with
patients
121
DP23 Nurses having the level of .697
knowledge & skill needed to
perform the service very well
DP25 Nurses being consistently .674
courteous to patients
DP21 Lab tests and X-rays being .829
provided at the time they are
promised
DP20 Lab tests and X-rays being .746
done right the first time
DP18 Doctors order only necessary .737
diagnostic medical procedures
DP19 Laboratory and X-ray .662
technicians having high
technical skills required to
perform the service
DP4 Materials associated with the .750
service (pamphlets, booklets ,
medical procures) clearly
containing all the necessary
information at excellent
hospitals
DP1 The most technologically .716
advanced equipment
DP3 Neat Appearance of .713
employees
DP2 Visually impressive physical .668
facilities (buildings,
landscape, physical layout)
DP38 Housekeeping staff being .777
consistently be courteous
DP37 Rooms and baths kept very .769
clean
DP36 Rooms being visually .730
appealing
DP34 Meals being of excellent .782
quality
DP35 Meals being carefully .771
prepared to suite the case of
DP33 Meals served at the right .769
temperature
DP31 Admission personnel being .807
consistently courteous and
helpful to patients
DP32 Admission being consistently .783
courteous and helpful to
patients
DP30 Admission personnel .728
providing clear information
(e.g. directions, schedules etc)
to patients
DP40 Business personnel being .780
consistently be courteous to
patients
DP39 Business office personnel .753
answering questions (e.g.
billing, insurance) very
adequately
122
From the above results, the researcher has failed to reject the hypothesis that:
An un-weighted performance based measurement of service quality (un-weighted
SERVPERF) is not more appropriate measure for service quality than
As a conclusion, the researcher has demonstrated that a weighted

SERVPERF is the most appropriate measure for service quality in
healthcare
6.2.2.2 Determining Whether Additive or Interactive methodology is better for

HSQ
The constructs used for measurement of healthcare service quality were
identified through the previous step. The variables were tested in four different
models (SERVQUAL, Weighted SERVQUAL, SERVPERF and Weighted
SERVPERF) and the Weighted SERVPERF method proved the best in case of
describing healthcare service quality for the current segment. In addition to testing
the 4 different models described above, the researchers wanted to test whether an
additive or interactive methodology for measurement is best. Testing through both
simple linear regression and ordinal logistic regression were attempted. Also, to
establish a relationship between variables used for healthcare service quality
measures and overall perceived service quality, ordinal logistic regression was
performed. Once the four models were tested and the best model determined, the
model proven to be the most significant (WEIGHTED SERVPERF) was regressed
against the overall perception of service quality to give an insight on the
relationship between the variables used for healthcare service quality measures and
overall perceived service quality.
Simple linear regression was attempted to link between the variables used
for healthcare service quality measures and overall perceived service quality.
However, the results were not significant promoting the idea of resorting to an
interactive methodology for testing. Ordinal logistic regression was then used for
testing the model and the results proved significant linking the variables used for
healthcare service quality measures and overall perceived service quality as well as
uncovering several relationships between the constructs. This led to the conclusion
that interactive methodology was more significant for measurement of healthcare
service quality as well as confirming the model proposed by the researchers.
The logistic regression is a test that is useful for situations in which one
wants to predict the presence or absence of a characteristic or outcome (Dependent
Variable) based on values of a set of predictor variables (Independent variables)
Tabachnick & Fidell (1996). Although, it is similar to the linear regression analysis,
the ordinal logistic regression is more suiTable for models where the dependent
variable is categorical. A categorical variable is one that is restricted to codes
values. In the current research, the code values were on a Likert scale of 1 to 5. The
questions were for the variety of hospital services and the responses were ranging
from ―Strongly Disagree‖ with the statement to ―Strongly Agree‖ (SD, D, N, A,
SA). The dependent variable in the current research is ―Overall Perceived Service
Quality‖ and consists of a construct formed from six variables. The variables
covered six variables including overall satisfaction, behavioural intention to return
123
and recommend, value for money and outcome. The responses were ranging from
―Strongly Disagree‖ with the statement to ―Strongly Agree‖ (SD, D, N, A, SA).
The next Tables demonstrate the output of the Minitab analysis after entry of the
data.
To be able to conduct the ordinal logistic regression we had to prepare the
data for such assignment. For each one of the 8 constructs (independent variables ),
the indicators values (questions representing each construct) were added and a score
was created representing the construct. These 8 construct scores were used in
conducting the ordinal logistic regression. These represent the independent
variables. Table 6.24 shows the estimates of the coefficients, standard error of the
coefficients, z-values, and p-values.
Table 6.24: Logistic Regression for Constructs and Overall Perceived Service
Quality
Predictor Name Coefficient St Dev Z P Odds 95% CI
of Ratio Lower
Construct Upper
Const( 1) 0.476 1.741 0.27 0.784
Const( 2) 2.476 1.470 1.68 0.092
Const( 3) 3.126 1.458 2.14 0.032
Const( 4) 4.536 1.473 3.08 0.002
Const( 5) 5.066 1.483 3.42 0.001
Const( 6) 5.825 1.495 3.90 0.000
Const( 7) 6.602 1.507 4.38 0.000
Const( 8) 7.479 1.515 4.94 0.000
Const( 9) 8.219 1.519 5.41 0.000
Const(10) 8.802 1.520 5.79 0.000
Const(11) 9.561 1.522 6.28 0.000
Const(12) 11.578 1.540 7.52 0.000
Const(13) 12.294 1.565 7.86 0.000
Const(14) 14.118 1.805 7.82 0.000
DP Sub 1 Premises -0.01424 0.01790 -0.80 0.426 0.99 0.95 1.02
& Employees
DP Sub 2 Doctor -0.006966 0.007229 -0.96 0.335 0.99 0.98 1.01
Service
DP Sub 3 Diagnostic -0.023671 0.006844 -3.46 0.001 0.98 0.96 0.99
services
DP Sub 4 Nursing -0.00825 0.01370 -0.60 0.547 0.99 0.97 1.02
Services
DP Sub 5 Admission -0.04472 0.02205 - 0.043 0.96 0.92 1.00
services 2.03
DP Sub 6 Meals service 0.004008 0.008861 0.45 0.651 1.00 0.99 1.02
DP Sub 7 Rooms and -0.03092 0.02365 - 0.191 0.97 0.93 1.02
Housekeeping 1.31
Service
DP Sub 8 Discharge -0.03290 0.03483 - 0.345 0.97 0.90 1.04
Services 0.94
DP Sub 1* -0.0001233 0.0003471 -0.36 0.722 1.00 1.00 1.00
DP Sub 7
DP Sub 2* 0.00003204 0.0000579 0.55 0.580 1.00 1.00 1.00
DP Sub 4
DP Sub 5* 0.0009262 0.0006916 1.34 0.181 1.00 1.00 1.00
DP Sub 8
Log-likelihood = -899.496
Test that all slopes are zero: G = 142.930, DF = 11, P-Value = 0.000
124
When the logit link function seen in Table 6.24 above is used, the
calculated odds ratio, and a 95% confidence interval for the odds ratio are seen. The
coefficient for each predictor is the estimated change in the link function with a one
unit change in the predictor, assuming that all other factors and covariates are the
same. The values labeled Const(1) and Const(2) are estimated intercepts for the
logits of the cumulative probabilities of satisfaction levels. Next displayed is the
last Log-Likelihood from the maximum likelihood iterations, with a p-value of
0.000, indicating that there is sufficient evidence to conclude that at least one of the
coefficients is different from zero.
Table 6.25: Demonstrating Goodness-of-Fit Tests for construct logistic regression

analysis
Method Chi-Square DF P
Pearson 5664.088 5883 0.979
Deviance 1796.219 5883 1.000
Table 6.25 displays Pearson, and deviance goodness-of-fit tests. In our

example, the p-value for the Pearson test p-value for the deviance test is 0.979,
indicating that there is insufficient evidence that the model does not fit the data
adequately. If the p-value is less than the selected level, the test would indicate
sufficient evidence for an inadequate fit.
Table 6.26: Demonstrating Measures of Association: (Between the Response

Variable and Predicted Probabilities) for construct logistic regression analysis
Pairs Number Percent Summary Measures
Concordant 55039 69.5% Somers' D 0.40
Discordant 23567 29.8% Goodman-Kruskal Gamma 0.40
Ties 573 0.7% Kendall's Tau-a 0.35
Total 79179 100.0%
Measurement of Association displayed in Table 6.26 above show the

number and percentage of concordant, discordant and tied pairs, and common rank
correlation statistics. These values measure the association between the observed
responses and the predicted probabilities.
The Table of concordant, discordant, and tied pairs is calculated by pairing
the observations with different response values. The pair is discordant if the
opposite is true. The pair is tied if the cumulative probabilities are equal. In our
case, 69.5% of pairs are concordant, 29.8% are discordant, and 0.7% are ties. These
values can be used as a comparative measure of prediction, for example, in
evaluating predictors and different link functions.
Somers‘ D, Goodman-Kruskal Gamma, and Kendall‘s Tau-a are
summaries of the Table of concordant and discordant pairs. The numbers have the
same numerator: the number of concordant pairs minus the number of discordant
pairs. The denominators are the total number of pairs with Somers‘ D, the total
number of pairs excepting ties with Goodman-Kruskal Gamma, and the number of
all possible observation pairs for Kendall‘s Tau-a. These measures most likely lie
between 0 and 1, where larger values indicate a better predictive ability of the
model.
125
From the above results, the researcher has rejected the hypothesis that: An
interactive methodology is not a more appropriate measure for service quality than
an additive methodology
As a conclusion, the researcher demonstrated that an interactive

methodology is superior for testing healthcare service quality using the
WEIGHTED SERVPERF scale
6.2.3: Identification the constructs underlying healthcare service quality

(Using Exploratory Factor Analysis and Ordinal Logistic Regression)
6.2.3.1: Factor Analysis to demonstrate the constructs of the research
Factor analysis performed in section 6.2.1 demonstrated that WEIGHTED
SERVPERF is the most appropriate measure of healthcare service quality among
the four tested scales. Table 6.23 also demonstrates how the variables of the
research converged into 8 iterations which are the constructs identified in the
current research.
As a conclusion, the researcher has concluded that there are eight sub-
constructs underlying healthcare service quality which include hospital
premises and employees, doctor medical service, nursing medical service,
diagnostic medical service, admission, discharge, rooms and housekeeping
and finally meals.
Section 6.2.3.2: Establishing the relationship between the constructs identified

for healthcare service quality measures and overall perceived service quality
To establish a relationship between constructs previously identified
through factor analysis for healthcare service quality measures and overall
perceived service quality, ordinal logistic regression was performed. Each of the
constructs as well as several possible relationships between the constructs were
regressed against the overall perception of service quality to give an insight on the
relationship between the constructs and overall perceived service quality.
From the previous results of logistic regression seen in section 6.2.2, the
researcher concluded the existence of a relationship between constructs previously
identified through factor analysis for healthcare service quality measures and
overall perceived service quality. The constructs were also grouped as seen in Table
6.24 in relationship to the overall perceived service quality.
Several relationships were uncovered. A relationship was detected
between doctors and nursing medical services. Another relationship was observed
between hospital premises and rooms and housekeeping services. Finally, another
relationship was uncovered between admission and discharge services. Thus the
model classification would be as seen in Table 6.27
126
Table 6.27: Demonstrates the levels of the model of the research
Model 1st level Model 2nd Level Model 3rd Level
Medical Services Personal Services Doctors
Nurses
Technical Services Diagnostics
Hospitality Services Physical Facilities Hospital Premises
Rooms and Housekeeping
Administrative services Admission
Discharge
Hotelier Services Meals
Thus as a result, the researcher was able to identify several interactions between the
constructs and link them to overall perception of service quality.
As a conclusion, the researcher was able to establish the relationship
between the constructs identified for Healthcare Service Quality
Measures and Overall Perceived Service Quality as well as develop
relationships between the different constructs of the research
6.2.4: Identifying sub-constructs of healthcare service quality and testing the

effect of each of the identified sub-constructs on patient's overall perception of
service quality (Using Ordinal Logistic Regression)
6.2.4.1 : Identifying sub-constructs of healthcare service quality
The researchers also aimed to identify the sub-constructs underlying
healthcare service quality. In an attempt to formulate a more extensive model for
healthcare service quality, the new model was tested for healthcare using sub-
constructs identified for the original SERVQUAL scale, and others identified for
healthcare service quality by other researchers. The model proposed by the
researchers is composed of 18 sub-constructs underlying healthcare service quality.
Ordinal logistic regression was then used for testing the model and the
results proved significant linking the sub-constructs uncovered by the researchers
for healthcare service quality measures and overall perceived service quality as well
as uncovering several relationships between the sub-constructs. This also confirmed
the conclusion that interactive methodology was more significant for measurement
of healthcare service quality as well as confirming the model proposed by the
researcher.
The sub-constructs were regressed against the overall perception of service
quality to confirm the relationship between them and in addition several
relationships were tested among the sub-constructs. Several relationships were
uncovered among the sub-constructs proving that there is inter-relationship between
the sub-constructs within the constructs. The sub-constructs identified for
healthcare service quality are summarized in Table 6.28. The results are
demonstrated in Table 6.29, 6.30 and 6.31.
127
Table 6.28: Demonstrating sub-constructs used in the current research with the
questions corresponding to each sub-construct
Sub-construct Questions
1. Doctor Reliability Q5
2. Doctor Assurance (Security) Q6-8
3. Doctor Empathy / Responsiveness (Physician Interaction) Q9-Q13
4. Doctor Professional Competence Q14-17
5. Nursing Tangibles Q22
6. Nursing Reliability Q23
7. Nursing Assurance (Security/Courtesy) Q24-26
8. Nursing Responsiveness Q27
9. Nursing Empathy Q28-29
10. Diagnostic Competence Q18-19
11. Diagnostic Reliability Q20-21
12. Hospital Premises and employees Tangibles Q1-4
13. Admission Events Responsiveness Q30
14. Admission Events Knowledge and Courtesy (Assurance) Q31-32
15. Food Tangibles Q33-35
16. Room and Housekeeping Tangibles Q36-37
17. Room and Housekeeping Courtesy (Assurance) Q38
18. Discharge Knowledge and Courtesy (Assurance) Q39-40
In the following results, the researcher aimed to test within-construct

relationships. Guided by the results in previous section where constructs were
established, the following relationships were attempted:
A) Among Medical Personal services: Between doctors and nurses constructs
Variable 19 = Variable 1* Variable 6 (Doctor Reliability* Nursing Reliability)
Variable 20 = Variable 2* Variable 7 (Doctor Assurance (Security)* Nursing
Assurance (Security/Courtesy))
Variable 21 = Variable 3* Variable 8 (Doctor Empathy / Responsiveness *
Nursing Responsiveness)
Variable 22 = Variable 3* Variable 9 (Doctor Empathy / Responsiveness *
Nursing Empathy )
Variable E 23 = Variable 4* Variable 10 (Doctor Professional Competence *
Diagnostic Competence)
B) Among Hospitality Administrative Services: Between Admission and
Discharge:
Variable 24 = Variable 14* Variable 18 (Admission Events Knowledge and
Courtesy * Discharge Knowledge and Courtesy)
C) Among Physical Facilities Services: Between Hospital Premises and Rooms:
Variable 25= Variable 12* Variable 16 (Hospital Premises and employees
Tangibles * Room and Housekeeping Tangibles)
Table 6.29 demonstrates the last Log-Likelihood from the maximum

likelihood iterations. A p-value of 0.000 was seen, indicating that there is sufficient
evidence to conclude that at least one of the coefficients is different from zero.
128
Table 6.29: Demonstrating Results of Ordinal Logistic Regression for Sub-
constructs and demonstrates Across-Construct Relationships
Predictor Coef StDev Z P Ratio Lower Upper
Const( 1) 0.855 1.755 0.49 0.626
Const( 2) 2.881 1.514 1.90 0.057
Const( 3) 3.539 1.505 2.35 0.019
Const( 4) 4.966 1.522 3.26 0.001
Const( 5) 5.504 1.531 3.59 0.000
Const( 6) 6.286 1.544 4.07 0.000
Const( 7) 7.100 1.555 4.57 0.000
Const( 8) 8.017 1.563 5.13 0.000
Const( 9) 8.787 1.568 5.61 0.000
Const(10) 9.391 1.570 5.98 0.000
Const(11) 10.172 1.573 6.47 0.000
Const(12) 12.228 1.593 7.68 0.000
Const(13) 12.951 1.618 8.00 0.000
Const(14) 14.784 1.857 7.96 0.000
Var 1 -0.10936 0.07276 -1.50 0133 0.90 0.78 1.03
Var 2 -0.00499 0.03814 -0.13 0.896 1.00 0.92 1.07
Var 3 0.02415 0.02423 1.00 0.319 1.02 0.98 1.07
Var 4 -0.01996 0.02300 -0.87 0.385 0.98 0.94 1.03
Var 5 -0.10748 0.03599 -2.99 0.003 0.90 0.84 0.96
Var 6 -0.10853 0.07961 -1.36 0.173 0.90 0.77 1.05
Var 7 -0.02071 0.04146 -0.50 0.617 0.98 0.90 1.06
Var 8 0.1247 0.1146 1.09 0.276 1.13 0.90 1.42
Var 9 0.06121 0.06108 1.00 0.316 1.06 0.94 1.20
Var 10 -0.03313 0.05014 -0.66 0.509 0.97 0.88 1.07
Var 11 -0.08655 0.02358 -3.67 0.000 0.92 0.88 0.96
Var 12 -0.02306 0.01844 -1.25 0.211 0.98 0.94 1.01
Var 13 -0.02555 0.02967 -0.86 0.389 0.97 0.92 1.03
Var 14 -0.03933 0.03498 -1.12 0.261 0.96 0.90 1.03
Var 15 0.004615 0.008973 0.51 0.607 1.00 0.99 1.02
Var 16 -0.02857 0.03693 -0.77 0.439 0.97 0.90 1.04
Var 17 -0.08445 0.02810 -3.01 0.003 0.92 0.87 0.97
Var 18 -0.01681 0.03636 -0.46 0.644 0.98 0.92 1.06
Var 1*Var 6 0.006042 0.004195 1.44 0.150 1.01 1.00 1.01
Var 2*Var 7 0.0000893 0.0007869 0.11 0.910 1.00 1.00 1.00
Var 3*Var 8 -0.000683 0.001309 -0.52 0.602 1.00 1.00 1.00
Var 3*Var 9 -0.0003436 0.0007021 -0.49 0.625 1.00 1.00 1.00
Var 4*Var 10 0.0004726 0.0006798 0.70 0.487 1.00 1.00 1.00
Var 14*Var 18 0.000873 0.001094 0.80 0.425 1.00 1.00 1.00
Var 12*Var 16 0.0001108 0.0005281 0.21 0.834 1.00 1.00 1.00
*Log-likelihood = -886.325
*Test that all slopes are zero: G = 169.273, DF = 25, P-Value = 0.000
Table 6.30: Demonstrating Goodness-of-Fit Tests for Sub-constructs and Across-

Construct Relationships
Method Chi-Square DF P
Pearson 5777.257 5869 0.801
Deviance 1769.876 5869 1.000
Table 6.30 displays Pearson, and deviance goodness-of-fit tests. In the current
research, the p-value for the Pearson test p-value for the deviance test is 0.801,
indicating that there is insufficient evidence that the model does not fit the data
adequately. If the p-value is less than the selected a level, the test would indicate
sufficient evidence for an inadequate fit.
129
Table 6.31: Measures of Association: (Between the Response Variable and
Predicted Probabilities) for Sub-constructs and Across-Construct Relationships
Pairs Number Percent Summary Measures
Concordant 56614 71.5% Somers' D 0.44
Discordant 22059 27.9% Goodman-Kruskal Gamma 0.44
Ties 506 0.6% Kendall's Tau-a 0.39
Total 79179 100.0%
Table 6.31 of concordant, discordant, and tied pairs is calculated by

pairing the observations with different response values. The pair is discordant if the
opposite is true. The pair is tied if the cumulative probabilities are equal. In our
case, 71.5% of pairs are concordant, 27.9% are discordant, and 0.6% are ties. These
values can be used as a comparative measure of prediction. For example, you can
use them in evaluating predictors and different link functions.
Somers‘ D, Goodman-Kruskal Gamma, and Kendall‘s Tau-a are
summaries of the Table of concordant and discordant pairs. The numbers have the
same numerator: the number of concordant pairs minus the number of discordant
pairs. The denominators are the total number of pairs with Somers‘ D, the total
number of pairs excepting ties with Goodman-Kruskal Gamma, and the number of
all possible observation pairs for Kendall‘s Tau-a. These measures most likely lie
between 0 and 1 where larger values indicate a better predictive ability of the
model.
Thus the researcher rejected the null hypothesis that the sub-constructs
Physician Reliability, Physician Assurance (Security), Physician Interaction
(Empathy/Responsiveness), Physician's Competence (Assurance) ; Nursing
Reliability, Nursing Assurance (Security), Nursing Interaction (Empathy), Nursing
Responsiveness ; Diagnostic Service Competence, Diagnostic Service Reliability ;
Hospital Premises and employees Tangibles ; Admission Responsiveness,
Admission Knowledge and Courtesy (Assurance) ; Meals Tangibles ; Rooms
Tangibles and Housekeeping Courtesy (Assurance) ; Discharge Knowledge and
Courtesy (Assurance) do not have a significant effect on healthcare service quality.
As a conclusion, the researcher has identified the sub-constructs for
healthcare service quality as well as demonstrated relationships between
several sub-constructs within each construct
6.2.4.2: Testing the effect of each of the identified sub-constructs on patient's

overall perception of service quality
The results demonstrated in Table 6.29 demonstrates that coefficient P-
Value of variables 5, 11, 17 were < (0.05). Thus the researcher failed to reject the
null hypothesis that states that “Some sub-constructs will not have significantly
greater impact on the overall perception of service quality than others‖. Thus the
researcher concluded that sub-constructs Nursing Tangibles and Hospital Premises
and employees Tangibles have significantly impact on overall perception of service
quality.
From the above results the researcher has rejected the hypothesis that some sub-
constructs will not have significantly greater impact on the overall perception of
service quality.
130
As a conclusion, the researcher has identified nursing
tangibles, Hospital Premises and Employees Tangibles as well as
Room and Housekeeping courtesy to have a significant impact on
overall perception of service quality.
6.2.5: Identifying the relationship between overall customer satisfaction and

outcome
Detection of a relationship between overall customer satisfaction and other
variables was attempted using Pearson Correlation. The correlation coefficients
between overall satisfaction (D1) and the rest of the variables (D2, D3, D4, D5 and
D6) which represents recommendation behaviour, future purchase behaviour, value
for money, outcome for mother and outcome for baby respectively is represented by
significant correlation (P < 0.01). The results are demonstrated in Table 6.32.
Table 6.32: Demonstrates Correlation Between Overall customer satisfaction and

Behavioural intentions to return andCorrelations
recommend, Value for money and Outcome
D1 -
dependent D2 D3 D4 D5 D6
D1 - dependent Pearson Correlation 1 .364** -.199** .410** .255** .303**
Sig. (2-tailed) . .000 .000 .000 .000 .000
N 443 443 443 443 443 443
**D2
Correlation isPearson
significantCorrelation
at 0.01 level.364**
(2 tailed) 1 -.025 .305** .293** .273**
Sig. (2-tailed) .000 . .593 .000 .000 .000
From the above N results, the researcher 443 was443able to443 reject the
443 following
443 hypotheses
443
that:
D3 Pearson Correlation -.199** -.025 1 -.267** -.039 -.167**
ThereSig.is(2-tailed)
no correlation between.000 overall customer
.593 . satisfaction
.000 .414 and.000the
patients'
N intention to return 443 and recommend
443 443 the hospital
443 443 443
D4 TherePearson
is noCorrelation
correlation between
.410** overall customer
.305** -.267** satisfaction
1 .378** and.359**
the value
for money
Sig. (2-tailed) .000 .000 .000 . .000 .000
ThereN is no correlation between 443 overall
443 customer
443 satisfaction
443 443 and443 medical
D5 outcome
PearsontoCorrelation
the mother .255** .293** -.039 .378** 1 .358**
ThereSig.is(2-tailed)
no correlation between.000 overall customer
.000 .414 satisfaction
.000 . and.000medical
N
outcome to the baby 443 443 443 443 443 443
D6 Pearson Correlation .303** .273** -.167** .359** .358** 1
As a conclusion , the researcher was able to detect correlation between
Sig. (2-tailed) .000 .000 .000 .000 .000 .
overall customer satisfaction and behavioural intentions to return and
N 443 443 443 443 443 443
recommend, value for money, outcome to mother and outcome to baby
**. Correlation is significant at the 0.01 level (2-tailed).
131
6.2.6: Demographic Factors and their Relationship with Variables of the
Research
The basic idea underlying discriminant analysis was to find out if the
groups differ with regard to the mean of a feature variable. This variable was then
used to predict group membership (Hair et al, 1998).
To apply discriminate analysis, we must first specify which variable is the
dependent and which variables are the independent. The dependent variable should
be categorical and the independent variables are metric (Hair et al., 1998).
In this study, we took the demographics to be the dependent variables, one
at a time, while independent variables were the variables (questions) of the survey.
In stepwise discriminant analysis, stepwise estimation involves entering the
independent variables into the discriminate function one at a time on the basis of
their discriminating power. We used this approach in order to be able to consider a
large number of independent variables for inclusion in the function.
For discriminate data analysis, the researcher used three independent
variables which are age, education and income level. The researcher also used the
model that resulted successfully from the factor analysis ―weighted perception =
W*P‖
6.2.6.1: Testing Age as a Discriminating Variable using Discriminate Data
Analysis
In the following section, the researcher has attempted testing ―age‖ as a
discriminating variable using discriminate data analysis techniques. The researcher
also used the model that resulted successfully from the factor analysis ―weighted
perception = W*P‖. The results are summarised in the following Tables 6.33, 6.34
and 6.35.
Table 6.33: Demonstrating Tests of Equality of Group Means for variable ―Age‖
Wilks' Lambda F df1 df2 Sig.
Importance 1 * P1 .999 .261 1 421 .610
DP2 1.000 .001 1 421 .978
DP3 .998 .677 1 421 .411
DP4 1.000 .080 1 421 .777
DP5 .999 .211 1 421 .646
DP6 .999 .310 1 421 .578
DP7 .996 1.571 1 421 .211
DP8 .999 .371 1 421 .543
DP9 .997 1.056 1 421 .305
DP10 .997 1.153 1 421 .284
DP11 .999 .540 1 421 .463
DP12 .997 1.102 1 421 .294
DP13 1.000 .000 1 421 .989
DP14 1.000 .026 1 421 .872
DP15 .999 .340 1 421 .560
DP16 .998 1.018 1 421 .314
DP17 1.000 .174 1 421 .677
DP18 1.000 .197 1 421 .658
DP19 1.000 .047 1 421 .828
DP20 .997 1.390 1 421 .239
DP21 .999 .295 1 421 .587
DP22 1.000 .039 1 421 .844
DP23 .993 3.122 1 421 .078
DP24 1.000 .191 1 421 .662
DP25 1.000 .083 1 421 .773
DP26 .997 1.291 1 421 .256
132
DP27 .993 2.846 1 421 .092
DP28 1.000 .076 1 421 .783
DP29 .999 .404 1 421 .525
DP30 .992 3.590 1 421 .059
DP31 .999 .318 1 421 .573
DP32 .987 5.747 1 421 .017
DP33 .992 3.392 1 421 .066
DP34 .993 2.820 1 421 .094
DP35 .999 .558 1 421 .455
DP36 .999 .213 1 421 .645
DP37 .999 .432 1 421 .511
DP38 .998 .693 1 421 .406
DP39 1.000 .141 1 421 .708
DP40 .999 .468 1 421 .494
Summary of Canonical Discriminant Functions

Table 6.34: Demonstrating Eigenvalues for the variable ―Age‖
Function Eigenvalue % of Variance Cumulative % Canonical Correlation
1 .147 100.0 100.0 .358
a First 1 canonical discriminant functions were used in the analysis.
Table 6.35: Demonstrating Wilks' Lambda for the variable ―Age‖

Test of Function(s) Wilks' Lambda Chi-square df Sig.
1 .872 55.073 40 .057
In this analysis, we tried to observe the overall impact of the discriminant function.
It was worth noticing that the function was statistically not significant (more than
0.05), as measured by chi-square statistics.
6.2.6.2: Testing Education as a Discriminating Variable using Discriminate
Data Analysis
In the following section, the researcher has attempted testing ―education‖
as a discriminating variable using discriminate data analysis techniques. The
researcher also used the model that resulted successfully from the factor analysis
―weighted perception = W*P‖. The results are summarised in the following Tables
6.36, 6.37 and 6.38.
Table 6.36: Demonstrates Tests of Equality of Group Means for the variable
―Education‖
Importance 1 * P1 .998 .872 1 420 .351
DP2 .999 .419 1 420 .518
DP3 .998 .964 1 420 .327
DP4 .993 2.925 1 420 .088
DP5 1.000 .048 1 420 .827
DP6 .995 2.020 1 420 .156
DP7 1.000 .003 1 420 .957
DP8 1.000 .030 1 420 .862
DP9 .999 .279 1 420 .598
DP10 .999 .276 1 420 .600
133
DP11 1.000 .097 1 420 .756
DP12 1.000 .001 1 420 .979
DP13 .998 .650 1 420 .421
DP14 .999 .521 1 420 .471
DP15 .987 5.655 1 420 .018
DP16 .999 .397 1 420 .529
DP17 .999 .336 1 420 .562
DP18 .999 .238 1 420 .626
DP19 .998 .997 1 420 .319
DP20 1.000 .017 1 420 .897
DP21 .999 .212 1 420 .646
DP22 .998 .651 1 420 .420
DP23 1.000 .013 1 420 .910
DP24 .998 .657 1 420 .418
DP25 .993 2.995 1 420 .084
DP26 .999 .473 1 420 .492
DP27 1.000 .039 1 420 .843
DP28 .996 1.489 1 420 .223
DP29 1.000 .000 1 420 .994
DP30 1.000 .007 1 420 .935
DP31 .997 1.166 1 420 .281
DP32 .999 .346 1 420 .557
DP33 1.000 .094 1 420 .759
DP34 .999 .584 1 420 .445
DP35 .999 .396 1 420 .529
DP36 1.000 .051 1 420 .822
DP37 .999 .542 1 420 .462
DP38 1.000 .000 1 420 .985
DP39 .982 7.745 1 420 .006
DP40 .991 3.798 1 420 .052

Table 6.37: Demonstrating Eigenvalues for the variable ―Education‖
1 .130 100.0 100.0 .340
Table 6.38: Demonstrating Wilks' Lambda for the variable ―Education‖
1 .885 49.039 40 .155
It was worth noticing that the function was statistically not significant (more than
0.05), as measured by chi-square statistics.
134
6.2.6.3: Testing Income Level as a Discriminating Variable using Discriminate
Data Analysis
In the following section, the researcher has attempted testing ―income
level‖ as a discriminating variable using discriminate data analysis techniques. The
researcher also used the model that resulted successfully from the factor analysis
―weighted perception = W*P‖. The results are summarised in the following Tables
6.39, 6.40, 6.41, 6.42, 6.43, 6.44, 6.45 and 6.46.

Table 6.39: Demonstrating Eigenvalues for the variable ―Income Level‖
1 .176 100.0 100.0 .387
Table 6.40: Demonstrating Wilk‘s Lambda for the variable ―Income Level‖
1 .850 64.999 40 .007
Table 6.41: Demonstrating Tests of Equality of Group Means for the variable
―Income Level‖
Importance 1 * P1 1.000 .083 1 421 .773
DP2 1.000 .018 1 421 .893
DP3 1.000 .171 1 421 .679
DP4 .995 1.986 1 421 .160
DP5 .998 .671 1 421 .413
DP6 .996 1.878 1 421 .171
DP7 1.000 .205 1 421 .651
DP8 .997 1.350 1 421 .246
DP9 .999 .337 1 421 .562
DP10 .998 .984 1 421 .322
DP11 .998 1.052 1 421 .306
DP12 .996 1.530 1 421 .217
DP13 1.000 .067 1 421 .795
DP14 1.000 .083 1 421 .774
DP15 1.000 .053 1 421 .818
DP16 .999 .389 1 421 .533
DP17 .997 1.366 1 421 .243
DP18 .988 5.077 1 421 .025
DP19 .975 10.662 1 421 .001
DP20 1.000 .025 1 421 .876
DP21 .993 3.092 1 421 .079
DP22 .989 4.555 1 421 .033
DP23 .978 9.538 1 421 .002
DP24 .992 3.236 1 421 .073
DP25 .990 4.160 1 421 .042
DP26 .970 12.840 1 421 .000
DP27 .975 10.859 1 421 .001
DP28 .980 8.385 1 421 .004
DP29 .991 3.859 1 421 .050
DP30 .996 1.561 1 421 .212
DP31 .999 .298 1 421 .586
DP32 1.000 .028 1 421 .868
DP33 .988 5.007 1 421 .026
DP34 .991 3.763 1 421 .053
135
DP35 .988 5.114 1 421 .024
DP36 .986 6.146 1 421 .014
DP37 .991 3.968 1 421 .047
DP38 .974 11.189 1 421 .001
DP39 .987 5.463 1 421 .020
DP40 .982 7.542 1 421 .006
It was worth noticing that the function was statistically significant (less than 0.05),
as measured by chi-square statistics, and the function accounts for 100 % of the
variance explained by the function.
Table 6.42: Demonstrating Standardized Canonical Discriminant Function

Coefficients for the variable ―Income Level‖
Function
Importance 1 * P1 -.368
DP2 -.190
DP3 -.271
DP4 .314
DP5 .052
DP6 -.345
DP7 -.034
DP8 -.205
DP9 .208
DP10 .304
DP11 .007
DP12 -.143
DP13 .037
DP14 -.115
DP15 -.005
DP16 .386
DP17 -.411
DP18 .397
DP19 .227
DP20 -.476
DP21 -.001
DP22 -.269
DP23 .138
DP24 -.037
DP25 .049
DP26 .329
DP27 .333
DP28 .194
DP29 -.213
DP30 .409
DP31 -.182
DP32 -.219
DP33 -.074
DP34 .105
DP35 .113
DP36 .111
DP37 -.071
DP38 .251
DP39 -.071
DP40 .196
136
Table 6.43: Demonstrating Structure Matrix for the variable ―Income Level‖
Function
DP26 .416
DP38 .389
DP27 .383
DP19 .379
DP23 .359
DP28 .336
DP40 .319
DP36 .288
DP39 .272
DP35 .263
DP18 .262
DP33 .260
DP22 .248
DP25 .237
DP37 .231
DP29 .228
DP34 .225
DP24 .209
DP21 .204
DP4 .164
DP6 -.159
DP30 .145
DP12 -.144
DP17 -.136
DP8 -.135
DP11 -.119
DP10 .115
DP5 -.095
DP16 .072
DP9 .067
DP31 .063
DP7 -.053
DP3 -.048
Importance 1 * P1 -.033
DP14 -.033
DP13 -.030
DP15 -.027
DP32 -.019
DP20 .018
DP2 .016
* Pooled within-groups correlations between discriminating variables and standardized canonical
discriminant functions variables ordered by absolute size of correlation within function.
The results demonstrated included discriminant function coefficients and the

structure matrix of discriminant loadings as well. Rotation, using Varimax
technique, of the discriminant function facilitates interpretation. The discriminant
loading was treated in the same way as the factor loading < 0.5 were rejected,
leading to believe that the 6 factors were the only significant factors in the
discriminant equation. We conclude the income level does discriminate the sample.
The six factors that were significant included factors 7,13,15,21,24 and 25 which
correspond to ―Doctors having very high level of knowledge required to answer
patient's questions satisfactorily‖, ―Doctors always treating the patient with
respect‖, ―Doctors having excellent reputations‖, ―Lab tests and X-rays being
137
provided at the time they are promised‖, ―Nurses performing the service required
(tests, procedures, medication dispensing) at exactly the right time‖ and ―Nurses
being consistently courteous to patients respectively‖.
Table 6.44: Demonstrating Functions at Group Centroids for the variable ―Income
Level‖
Function
Income level 1
"<=2,000 , 4000 " .639
4,001 - >9,000 -.274
* Unstandardized canonical discriminant functions evaluated at group means
The researcher also checked that the classification factor (income level) that was
proposed is successful. The classification function coefficients was used to make
group membership predictions, and the group means profiles each group by a Z
score of the function used that included variables based on the rotated coefficients
only. It is clear from the Table below that this function could predict 60% of the
total sample size.
Table 6.45: Demonstrating Classification Results for the variable ―Income Level‖
Predicted Group Membership Total
Income level "< =2,000 , 4000 " 4,001 - >9,000

Original Count "< =2,000 , 4000 " 81 50 131
4,001 - >9,000 126 186 312
% "< =2,000 , 4000 " 61.8 38.2 100.0
4,001 - >9,000 40.4 59.6 100.0
a 60.3% of original grouped cases correctly classified.
From the above research, the researcher has failed to reject the hypotheses that state
that consumer demographic characteristics (Age) have no significant effect on the
From the above research, the researcher has failed to reject the hypotheses that state
that consumer demographic characteristics (Education) have no significant effect on
the variables of the research
From the above research, the researcher has rejected the hypothesis that:
Consumer demographic characteristics (Socioeconomic Standard) have no
As a conclusion, the researchers were able to detect that the income

level does discriminate the sample
138
6.3: Challenges Confronted by the Researcher
During the pilot study and the survey, the researcher was faced by several
challenges and problems. The next section identifies these challenges and problems
and presents how the researcher succeeded in resolving them during the quantitative
phase of the research (collection of the survey).
1. There was difficulty in encountering candidates who fit the selection criteria as
well as a large number of the patients encountered randomly were excluded
from the pilot. This was due to several reasons including
a) Many females had their last child before five years
b) Others had the childbirth abroad (not in a hospital in Greater Cairo)
c) For others, the last hospital experience had an unsuccessful outcome.
d) Some patients were not interested in participating in a questionnaire during
their leisure time in the sports clubs.
To handle the difficulty in reaching the target segment encountered during the pilot
study, the following steps were done by the researcher during the survey:
a) The stage for collection of primary data was prolonged to encounter more
patients in the designated data collection areas
b) The researcher focused during training of the interviewers on methods to
motivate and interest the patients in answering the survey including
information on the time of the survey, the importance for upgrading the level of
private healthcare in Egypt and their role in achieving this through
participating in the current research.
2. Some missing values were found in the collected surveys during the pilot
study. During the survey, the researcher succeeded in appointing a well-trained
interviewer along with the researcher herself to collect the data in one-to-one
interviews to avoid the occurrence of missing data, the surveys were re-
checked by the researcher before ending the interview and finally phone
numbers of candidates were collected (when permitted) for further questioning
and clarification if needed during analysis.
3. The pilot study had a sample size of ten, which is small when compared to the
number of variables investigated. However, the aim of the pilot study
constituted of several factors:
To evaluate the successful execution of questionnaire
To determine the length of time it takes the respondents to answer due to
the lengthy nature of the questionnaire since respondents tend to refrain
from participating in lengthy surveys
To make sure of the comprehensibility of all the questions for the
participants
To gather data for simple descriptive statistics
To test the applicability of the questionnaire on the Egyptian private
healthcare market
This was done with the aim of refining and finalizing the questionnaire for the
next stage in the research and the pilot proved successful for the aims it was
performed for. In the field study, however, the sample size amounted to 450
questionnaires thus allowing for application of the quantitative statistical
analysis techniques described.
4. The unavailability of resources and literature that demonstrated the use of a
healthcare service quality model in the Arab region.
139
7. DISCUSSION
Service organizations are playing an increasingly important role in the

economy of less-developed countries. The sector is continuing to increase and a
large portion of new jobs are being created in service industries. The success of a
service organization lies centrally within the boundaries of satisfied and repeated
customers. Consumers have become more quality-conscious in the past era and the
benefits of quality in contributing to market shares and the return-on-investment of
firms has been clearly demonstrated. Service quality has been directly linked to
repeat sales, positive word-of-mouth and recommendation. Thus the importance of
measuring of service quality is understandably high. Delivery of higher level of
service quality is becoming more and more the core of service providers‘ efforts in
positioning themselves more effectively in the marketplace.
In the tangible goods sector, quality has been clearly defined. However,
the problem inherent in the implementation of a higher level of service quality has
been identified by several researchers. Service quality is an elusive construct that
has proved difficult to measure. The methodology for measurement has been
explored deeply and conceptualized thoroughly by many marketers. Many
researchers have described measures for service quality. Professional services,
which are those provided by professionals as doctors or lawyers such as healthcare
services, legal services etc, have been classified as close to pure services. Although
consumer satisfaction and service quality literature is extensive, a focus defining
relationships between perceived service quality, consumer satisfaction and
repurchase behaviour in healthcare has been less studied and each issue was treated
in isolation of the others. Also the criteria upon which consumers base their
judgment for the quality of healthcare provided and their importance has been
discussed by several authors but rarely in a developing country concept.
Our research has investigated several main points. These include how
service quality should be conceptualized and measured, the constructs and sub-
constructs underlying healthcare service quality upon which consumers base their
judgment and several relationships including the relationship between consumer
satisfaction with the healthcare provider on one side and re-purchase behaviour,
value for money and outcome on the other side. Finally, the relationship between
demographics and the variables of the research has also been researched.
The next chapter leads a discussion on the results found in the current
research. Each main finding is treated in a section and then a summary of the key
findings, illustration of confirmation or rejection of the relevant hypothesis,
comparing and contrasting with the existing literature n that issue and finally the
contributions of the research concerning this point is done. The following Table 7.1
demonstrates the sections and sub-sections in the following chapter.
140
Table 7.1: Summarizing the layout undertaken in the research discussion
Section Steps Taken
Section 7.1 Establishment of the Model:
Section 7.1.1 Establishing Weighted SERVPERF as the Ideal Model
in the Current Research Setting
Section 7.1.1.1 Summary of Key findings of the Survey
Section 7.1.1.2 Confirmation/Rejection of Hypothesis

Section 7.1.1.3 Comparing and contrasting research results to existing
literature
Section 7.1.2 Identifying Constructs & Sub-Constructs Underlying
Healthcare Service Quality
Section 7.1.2.1 Summary of Key findings of the Survey
Section 7.1.2.2 Confirmation/Rejection of Hypothesis
Section 7.1.2.3 Comparing and contrasting research results to existing
literature
Section 7.1.3 Contribution
Section 7.2 Effect of Certain Sub-Constructs on Overall Perceived
Service Quality
Section 7.2.1 Summary of Key findings of the Survey
Section 7.2.2 Confirmation/Rejection of Hypothesis
Section 7.2.3 Comparing and contrasting research results to existing
literature
Section 7.3 Link between Satisfaction and Service Quality
literature
Section 7.4 Relationship between Demographics and Service
Quality
literature
141
7.1. Establishment of the Model:
7.1.1 Establishing Weighted SERVPERF as the Ideal Model in the Current
Research Setting
7.1.1.1 Summary of Key findings of the Survey:
As a summary to the key findings in the survey, factor analysis was
performed on all 40 variables in the survey to determine the best method for
measurement of service quality. Several different methods for measurement were
attempted. The scale will be developed using the 4 different models (SERVQUAL,
WEIGHTED SERVQUAL, SERVPERF, WEIGHTED SERVPERF). The rotation
converged in 8 iterations that were consistent with the framework the researchers
had formulated in the current research thus this model was proven to be the most
appropriate measurement for service quality for the current field of research.
In addition, the researchers wanted to test whether an additive or interactive
methodology for measurement is best. Testing through both simple linear
regression and ordinal logistic regression were attempted. Through ordinal logistic
regression, a P-Value = (0.000) (Table 6.24) was seen thus the results proved
significant and the researcher was able to establish that an interactive model for
measurement is superior for testing healthcare service quality using the
WEIGHTED SERVPERF scale versus an additive one.
7.1.1.2 Confirmation/Rejection of Hypothesis:
From the mentioned results, the researcher has failed to reject the hypothesis (H1a)
that an un-weighted performance based measurement of service quality (un-
weighted SERVPERF) is not more appropriate measure for service quality than
SERVQUAL, weighted SERVQUAL and weighted SERVPERF.
In addition, from the mentioned results, the researcher has rejected the hypothesis
(H1b) that an interactive methodology is not a more appropriate measure for service
quality than an additive methodology.
7.1.1.3 Comparing and contrasting research results to existing literature:
Concerning how service quality should be conceptualized and measured,
literature review has varied in its support for the measurement model. Several
researchers support the (expectation-perceptions) based measurement while other
researchers suggest that a performance-based or (importance*perceptions)
measurement for many services including healthcare is better.
The current research proposes a model that supports service quality being
measured as (importance*perceptions). This was proposed after an extensive factor
analysis followed by logistic regression using the different models (SERVQUAL,
SERVPERF, Weighted SERVQUAL, Weighted SERVPERF) in a healthcare
setting for obstetrics patients in private hospitals. Weighted SERVPERF emerged
as the ideal model in this situation. The research also showed that an interactive
model for measurement is superior for testing healthcare service quality using the
WEIGHTED SERVPERF scale versus an additive one. The research also
succeeded in establishing a relationship between variables used for healthcare
service quality measures and overall perceived service quality.
Several schools support the definition that service quality is composed of
both expected and perceived service in other industries such as retail banking, credit
card, securities brokerage and product repair and maintenance. The Nordic School
(Gronroos, 1980, 1982, 1983, 1984) defined perceived service quality as being
primarily dependent on two variables, expected and perceived service. The ―Gap
Analysis School‖ recognized that a key set of discrepancies or gaps existing
142
regarding service delivery to consumers. ―Gap 5‖ is on the consumer side, and it
shows the difference between a consumers‘ actual and perceived quality of service.
Parasuraman et al., (1985) developed the SERVQUAL, a 22-item instrument for
assessing customer perceptions of service quality in service and retailing
organizations and this school supports measuring service quality by using a
(expectations–performance) based measure (Parasuraman et al., 1988).
Baxter, (2004) tested the SERVQUAL model on occupational health
hospital in Nottingham and concluded that it is possible to adapt the standard
SERVQUAL tool and apply it within the occupational health setting.
Several other authors including Cronin and Taylor (1992, 1994), Mazis et
al., (1975), Churchill and Suprenant, (1982) and Woodruff et al., (1983)
suggested including only a performance-based measure of service quality in several
industries including banks, pest-control, dry cleaning and fast-food. Paul, (2003)
also concluded that SERVPERF without importance weights appears to be the
better model for measurement of service quality in periodontists. Other researchers
such as Gazibarich, (1996) proposed that the both the two instruments
SERVQUAL and SERVPERF might be used as instruments for measuring dietetic
service quality.
On the other hand, several researchers confirmed the importance of using
importance measures in purely professional settings as healthcare. Carman (1990)
performed studies on several healthcare sectors including an acute-care hospital as
well as a dental clinic. It was suggested that expectations can be collected in terms
of perception-expectation difference rather than directly ask each question
separately or even to gather "mean expectations" and get the difference between
perceptions and 'mean expectations'. As for importance, the author also
recommended that means (rather than individual importance weights) are be
satisfactory.
Hill and McCrory, 1998 measured service quality through conceptualizing it
as (perceptions minus importance) at Belfast maternity hospitals for both clinical
and non-clinical service factors from both the patient‘s and the staff‘s sides.
The current research supports the weighted SERVPERF for healthcare. From
the consumers‘ side, the importance ratings enable the provider to analyze the
importance of his services from the consumer‘s side where the majority of
consumers might rate meals for example as more important the room‘s decorations.
Thus the provider can properly allocate resources for improvement. Also, in the
case of several defective services points, addition of weights enables hospital
providers to map the relative importance of areas needing improvement in the
hospital where they can start with areas deemed most important in the improvement
planning process and move to the next in importance and so forth.
The use of perceptions only has been supported by many researchers who
argue that addition of expectations is unnecessary especially in healthcare services
where expectations from providers usually range from high to very high due to the
importance of all levels of the service provided. If expectations are gathered
periodically (e.g. every year) for the hospital, the provider can use consumer‘s
insights for the long-term planning and improvement process for the hospital. But
for the on-going satisfaction surveys concerning tracking of the actual service
experience on a day-to-day basis, the provider needs to detect the perceptions of
what is happening now in the establishment service provision to provide short-term
solution then start on long-term planning.
143
7.1.2 Identifying Constructs & Sub-Constructs Underlying Healthcare Service
Quality
7.1.2.1 Summary of Key findings of the Survey:
Factor analysis was performed using all 40 variables representing the
Importance *Perceived service quality, eliminated all variables with loading less
than 0.5, and repeated the factor analysis process. The rotation converged in 8
iterations that were consistent with the framework the researchers had formulated in
the current research thus this model was shown to be the most appropriate
measurement for service quality for the current field of research. Thus factor
analysis has demonstrated that the model is constructed from 8 major constructs
that include doctor‘s medical service, nursing service, diagnostic service, hospital
premises and employees, rooms and housekeeping, meals, admission and discharge
services.
After confirmation of the constructs, the research also established a
relationship between variables used for healthcare service quality measures and
overall perceived service quality through ordinal logistic regression. In addition,
several relationships were uncovered. A relationship was detected between doctors
and nursing medical services. Another relationship was observed between hospital
premises and rooms and housekeeping services. Finally, yet another relationship
was uncovered between admission and discharge services. Thus the model on the
construct level would be as seen in Figure 7.1.
After confirmation of the constructs of the research, the researcher further
investigated the consistency of the sub-constructs of the research using logistic
regression. The sub-constructs were regressed against the overall perception of
service quality to confirm the relationship between them and in addition several
relationships were uncovered among the sub-constructs (Table 6.29, 6.30 and 6.31).
A p-value of 0.000 was seen. Thus the research has succeeded in demonstrating that
the sub-constructs Physician Reliability, Physician Assurance (Security),
Physician's Empathy (Professionalism), Physician Interaction
Professionalism (Responsiveness) ; Diagnostic Service Competence, Diagnostic
Service Reliability ; Hospital Premises and employees Tangibles ; Admission
Responsiveness, Admission Knowledge , Admission Courtesy (Assurance) ; Meals
Tangibles ; Rooms Tangibles and Housekeeping Courtesy (Assurance) ; Discharge
Knowledge and Discharge Courtesy (Assurance) have a significant effect on
healthcare service quality.
7.1.2.2 Confirmation/Rejection of Hypothesis:
Thus the researcher rejected the null hypothesis (H3) that the sub-constructs
Physician Reliability, Physician Assurance (Security), Physician Interaction
Professionalism(Responsiveness) ; Diagnostic Service Competence, Diagnostic
Responsiveness, Admission Knowledge and Courtesy (Assurance) ; Meals
Knowledge and Courtesy (Assurance) do not have a significant effect on healthcare
service quality
144
7.1.2.3 Comparing and contrasting research results to existing literature:
In healthcare, service quality has been regarded as a multi-dimensional
construct. It has been envisioned to be composed of two main parts: quality as
perceived by the consumer and quality in fact (Paul, 2003).
In healthcare service quality literature, two main dimensions of service
quality are stressed by many authors and include technical (or outcome) quality and
functional (or process) quality. Technical quality is described as the technical
accuracy of the medical diagnosis and procedures or conformity with professional
specifications. The functional quality is described as the way in which healthcare
services are delivered to patients. Objective measurement instruments were
standardized for technical quality while there are few objective measures for the
functional quality thus mainly subjective evaluation is used in judgment of this
section (De Man et al., 2002). Donabedien (1992) also states that the research
concluded that health care is conceived as consisting mainly of two parts, a
technical task and an interpersonal exchange.
(Paul, 2003) noted that consumers find difficulty in the evaluation of
healthcare services and they rarely know on which feature of the health service to
base their judgments on or how best to evaluate those feature they chose to evaluate
especially when patients try to evaluate the more technical features of the
healthcare service such as the qualifications of the medical staff or the outcome or
improvement of the patient's condition. Patient's typically assessed the hospitality
section of the medical experience such as staff attentiveness, responsiveness, the
comfort provided by the hospital etc while the technical aspect of the healthcare
experience was deemed difficult to judge due to lack of medical technical
knowledge necessary to evaluate the technical (medical) aspects of healthcare in an
effective manner.
With regards to construct development, there are two main methodologies
that researchers have used for development of constructs using factor loading
analysis. One is based upon the use of ―dimensions‖ of service quality and the other
is based on ―function areas‖ in service quality.
The first methodology follows the school of Parasuraman et al., 1985
where service quality constructs were classified into key categories based on
characteristics of the service provision and measured as ―dimensions‖ including
reliability, responsiveness, tangibles, assurance and empathy. Various authors
tested along these broad lines with addition of more dimensions. Modification of
SERVQUAL can be found in the studies by Cronin and Taylor, 1992, Mowen et
al, 1993, Brown and Swartz, 1989, Joby, 1992, Schlegelmitch et al., 1992,
Walbridge and Delene, 199, De Man et al., 2002, Baxter, 2004 among others.
The second methodology was using the function areas of the service as the
constructs where the variables loaded on factors representing hospital functions (or
service experiences) such as admission, tangible accommodations, food, privacy,
nursing care, discharge planning and patient accounting (billing) among many other
function areas. This is a ―blueprint‖ of sorts and the dimensions are included within
each function area but factor loadings were confirmed along functions rather than
dimensions. The second methodology was heavily supported in literature for
service bundles that include multiple service encounters such as hospitals by several
authors including Kiam-Caudle and Marsh, 1975, Woodside et al., 1989 and
Carman, 2001 among others.
The current research advocates the use of function areas in measurement of
145
service quality. The research was based on hospitals maternity settings and the
whole hospital experience was analyzed thus patients were exposed to a multi-
function hospital environment that involved both hospitality and medical technical
aspects.
Figure 7.1: Demonstrates the Model of the Research on the Construct Level
Healthcare Service
Quality
Medical Services Hospitality Services
Personal Technical Physical Administrative Hotelier

Services Services Facilities Services Services
Doctors Medical Hospital

Diagnostics Admission Meals
Service Premesis
Rooms and
Nursing Service Discharge
Housekeeping
Many authors have identified dimensions for measurement of healthcare

service quality. Prior to the work of Parasuraman et al., 1985 several authors made
noTable contributions in the field. Hulka et al., 1975 identified communication,
measurement of patient‘s attitude towards the system, physician and medical care
received and physician awareness of medical concerns as dimensions for healthcare
service quality. Ware et al, 1977 proposed art of care, technical quality of care,
accessibility/convenience, finances, physical environment, availability, continuity,
efficacy/outcome of care as dimensions for healthcare service quality. Wolf et al.,
1978 identified cognitive/information transfer component of consultation, affective
or caring domain of consultation, behavioral skillfulness of physicians as
dimensions for healthcare service quality. Kiam-Caudle and Marsh, 1975 proposed
Practice premises, receptionists, appointment system, personnel doctor system,
doctor‘s method of work, use of paramedical staff as dimensions for healthcare
service quality. Wooley et al., 1978 proposed Satisfaction with outcome, continuity
of care, patient expectations, doctor-patient communication as dimensions for
healthcare service quality. Feletti et al., 1986 identified several dimensions
concerned with competence and physician care. They include competence in a
physical domain, competence in the emotional domain, competence-social
awareness, competence-physical examination and information transfer. They also
include physician as a model, amount of time for consultation, perceived amount of
continuity of care by the physician, mutual understanding in the doctor-patient
relationship and patient‘s perception of their individuality.
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Parasuraman et al., 1985 proposed a new methodology for measurement
of service quality. This school recognized that a key set of discrepancies or gaps
exist regarding executive perceptions of service quality and the tasks associated
with service delivery to consumers. Gap 5 is on the consumer side, and it shows the
difference between a consumer‘s actual and perceived quality of service. They
concluded that service quality determinants used by consumers do not tend to vary
substantially across service industries and were classified into 10 key categories:
reliability, responsiveness, competence, access, courtesy, communication,
credibility, security, understanding/knowing the customer and tangibles then later
summarized to five which include tangibles, assurance, empathy, responsiveness
and reliability.
Carman, 2001 proposed that multi-function encounters in one stay such as
hospitals, factor analysis results were different than other settings. The study only
measured perceptions of the service encounter. The factors that resulted included
admission service, tangible accommodations, food, privacy, nursing care,
explanation of treatment, access and courtesy afforded to visitors, discharge
planning and patient accounting (billing). Nursing was twice as important as other
factors. Also the authors noted that repeated items concerned with dimensions did
not load on one factor e.g. responsiveness was questioned for several functions
(discharge, nursing and admission) and rather loaded on factors representing the
hospital functions described above than on the dimension ―responsiveness‖. They
recommended that retailers in such multi-faceted environment settings need to
measure the quality of each function alone with items that items that are similar to
the PZB instrument. Woodside et al., 1989 proposed a ―blueprint‖ for healthcare
service quality consisting of admission, nursing care, meals, housekeeping,
technical services and discharge.
Brown and Swartz, 1989 identified healthcare service quality dimensions to
be professionalism, auxiliary communications, professional responsibility,
physician interaction, staff interaction, diagnostic professional competence, time
convenience and location convenience. Joby, 1992 proposed that healthcare service
quality dimensions were competence, credibility, security, courtesy,
communication, understanding/knowing the consumer, access (availability), core
medical services and physical environment (tangibles 2).
The current research classified service quality as function areas which were
referred to as ―constructs‖ and then service quality dimensions within each
construct were referred to as ―sub-constructs‖. The constructs identified were in
line with those proposed by Carman, 2001 and Woodside et al., 1989 described
above. The main function areas of the hospital were divided mainly into medical
and hospitality; a view also shared by many researchers including Gronroos, 1980,
1982, 1983, 1984, Donabedien (1992). Sub-constructs identified were based on the
work of many authors most notably Parasuraman et al., 1985, Brown and Swartz,
1989 and Joby, 1992 among others.
Division of the hospital service quality into two main sectors, medical and
hospitality enables managers to focus on each section. Traditionally, improving
quality in healthcare was basically focused on improving the quality of medical
services performed for the patients and enhancing it through better doctors, higher
qualified nurses and better diagnostic equipment. Identification of hospitality as an
essential component of the hospital encounter and demonstrating its relevance in
the service encounter for the patient is of great importance.
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Previous research has confirmed that the majority of patient‘s feel incapable
of judging the medical aspect of the hospital service further than a successful versus
an unsuccessful outcome. In the case of the present research, the mother is capable
of judging the medical encounter in terms of a successful outcome for her and her
baby and that they suffered no harm or complications from their hospital stay but
usually no more than that. She cannot judge whether the doctor performed an
excellent delivery and suturing or could it have been done better. She cannot judge
whether any pain or discomfort during and after the operation was the minimal
level that could be done for her or could another doctor have done a better job. She
cannot judge the accuracy of the diagnostic tests performed for her. To sum it up,
she cannot judge the technical aspect of the medical service. Thus the hospitality
section of the encounter plays an important role in the judgment of the mother who
lacks the technical knowledge to judge the medical aspect further than the outcome
in her case.
The majority of patients ranked medical and hospitality services as being
―most important‖ and ―important‖. By summing up the percentages that agreed that
medical services were important or most important, the research showed 91.2%,
73.1% and 75.6% of patients for doctors, nursing and diagnostics consecutively.
By summing up the percentages that agreed that hospitality services were important
or most important, the research showed 84.8%, 82%, 82.8%, 84% and 83% of
patients rated hospital premises and employees, admission, meals, rooms and
housekeeping and discharge consecutively as being important or most important.
Thus average importance for medical services was 80% while for hospitality
services was 83.3% thus stressing the importance of the hospitality sector in the
hospital service delivery process. Thus medical providers should also focus great
attention on the hospitality sector of the delivery since it was demonstrated to be of
equal importance to the patient as the medical aspect.
Grote et al., 2007 found that patients consider non-clinical factors such as
comforTable rooms and convenient registration process when choosing where to
choose treatment. Most patients stated that they would be willing to switch
hospitals for better services and amenities. 60% of patients were grouped as
comfort, amenity and control seekers who stressed the importance of hospitality
related services such as welcoming staff members, information on medical terms
and condition and hospital amenities such as high quality bedding, room design,
good room service and home-like environments.
7.1.3 Contribution
The researcher has proposed that the current research ha both theoretical
and practical applications. Theoretically, the research has aided healthcare
managers and marketers to identify all dimensions that patients use for evaluation
of the level of service provided in their organizations and would have a valid and
reliable scale by which they could measure the service quality in their
organizations. The research has successfully defined the constructs of perceived
service quality as (WEIGHTED SERVPERF) for healthcare settings. It has also
validated and established relationships between overall perceived service quality
and the constructs and sub-constructs in the research. The researcher has also
successfully established relationships between the constructs on a higher level and
between the sub-constructs across construct on the lower level. Through the
mentioned steps, a model for healthcare service quality that highlights all the
constructs and sub-constructs that patients use for evaluation of healthcare service
148
quality as applied for private sector hospitals in the obstetrics department has been
structured and can be seen in Figure 7.2 and Figure 7.3. In addition, the researcher
developed a valid and reliable scale which healthcare marketers can deploy for
measurement of the service quality in their organizations (WEIGHTED
SERVPERF).
On a more practical note, through application and modification of the
model for each individual hospital, hospitals will own a valid and reliable scale to
measure their clients‘ satisfaction through a tailored sophisticated measurement
tool. On identifying areas of service quality excellence and areas of service quality
short-falls, healthcare managers and marketers would be able to determine what
leads to customer satisfaction and return and recommendation behaviour. They
would be able to recognize the factors that could lower customer dissatisfaction and
disloyalty and bad word-of-mouth behaviour.
Administration of satisfaction surveys based on a tried and tested model
will enable them to identify defective areas of contact and train them to improve
service quality areas. Managers would be able to detect areas requiring correction
concerning the actions and attitudes of their staff including doctors, nurses as well
as all contact personnel such as admission and discharge personnel, housekeeping
and kitchen staff that is needed to satisfy and retain customers.
Through application of the model and the scale in their hospitals,
managers would be able to pin-point areas of service quality short-falls within their
hospital. Hospitals will then be able to judiciously allocate their resources to
improve service in identified areas thus be able to achieve goals of customer
satisfaction and retention. The researcher has proposed that managers and marketers
would then be able to tailor their strategies thus offer the best services that match
their client‘s needs. Overall, implementing such measures over several private
hospitals in Egypt will lead to a higher level of healthcare service quality provision
in Egypt.
7.2 Effect of Certain Sub-Constructs on Overall Perceived Service Quality

7.2.1 Summary of Key findings of the Survey:
The researcher has also identified some sub-constructs to have greater
impact on the overall perception of service quality than others in the current
research setting for obstetric patients in private hospitals in Egypt. Logistic
regression was performed and P-value was <0.05 thus proving significant (Table
6.29). The results demonstrate that coefficient P-Value of variables 5, 11, 17 were
< (0.05). These include nursing tangibles, hospital premises and employees‘
tangibles as well as room and housekeeping courtesy.
7.2.2 Confirmation/Rejection of Hypothesis:
From the above results the researcher has rejected the hypothesis
(Hypothesis 4) that some sub-constructs will not have significantly greater impact
on the overall perception of service quality.
7.2.3 Comparing and contrasting research results to existing literature:
Literature suggests that Tangibles and Personal Attention weigh most
heavily in customer perceptions of store quality and that store quality weighs more
heavily on customer loyalty than does the quality of the product (Jacoby and
Olson, 1985, Carman 2001). Carman, 2001 also uncovered that nursing was twice
as important as other factors.
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Hill and McCrory, 1998 measured service quality conceptualized as
(perceptions minus importance) at Belfast maternity hospitals. They uncovered that
hygiene/cleanliness ranked as one of the top most important issues in the hospital
while patients were disinclined to be judgmental about clinical staff since they often
felt unqualified to judge clinical expertise.
In the Egyptian healthcare private sector service, patients
frequenting private obstetrics hospitals are usually paying significant sums of
money for their medical service. The nurse is the patient‘s main contact with the
hospital medical service provided. She is the one who greets the patient, caters the
basic on-going medical needs of the patient, responds at all hours of the day while
the doctor usually appearing at first arrival, during the later stages of delivery and at
the final departure except if complications occur. The nurse is regarded as the
medical service provided by the hospital thus reflects directly on the hospital
service provision while in the case of Obstetrics in Egypt, the doctor is usually
chosen by the patient beforehand and then refers them to the hospital thus not
judged as really ―belonging‖ to the hospital since he refers the patient to choose
between several hospitals he practices in. The nursing service is regarded as a direct
judgment for the service provided by the hospital thus arose the significance of its
role in the overall perception of service quality.
In the Egyptian healthcare market, the level of nursing service tends to be
from moderate to poor. The socio-economic and educational level of personal
pursuing this field of work is on the low side. Thus an average level of service
provision from the nursing staff in hospitals is usually seen. Nursing schools are
below-average and nurses are not highly medically trained and thus they are not
empowered to take medical decisions concerning patient‘s health. From this arose
the fact that nursing tangibles (which is concerned with the appearance, the
language, the cleanliness etc) having a significant impact on service quality.
Patients are aware of the above facts and do not really want their nurses to take
medical decisions but they expect the nurses to talk in accepTable language, dress
well, smell good and be neat appearing and it makes a big difference if they are
since this reflects that the hospital‘s service is excellent and compares better than
their competitors who suffer the same problem.
While expectations from nursing was on the high side (with 89% of
patients agreeing and strongly agreeing about nursing staff as regards reliability,
assurance, empathy and responsiveness providing excellent service), the
perceptions were on the low side (65% of patients agreeing and strongly agreeing
about that nursing staff as regards reliability, assurance, empathy and
responsiveness did actually provide excellent service).
Since expectations are high while perceptions of service proved to be not
matching expectations, this provides opportunities for healthcare managers to
improve the level of nursing provided. Hospital providers could provide in-house
training to their nurses concerning nurse-patient interaction and stress the
importance of portraying empathy and responsiveness to patient‘s needs. They can
also improve the reliability and assurance of nursing through also providing
medical training programs to their staff to improve their skills. Some private
hospitals have already started such programs. Others have employed foreign
nursing senior staff to help train and implement better services. Such efforts have
given an edge to these hospitals over their competitors.
On a similar note, we can discuss housekeeping courtesy. The patient
150
usually comes in contact with housekeeping several times a day when they clean
morning and evenings and usually are the ones who respond to any hygiene needs
of the patient in her room and bathroom. The courtesy afforded by this staff directly
reflects that the hospital makes an effort and employs individuals of better caliber
than the norm to cater to their needs. The lower socio-economic level of individuals
doing these jobs makes their personnel usually over-familiar, unclean and blatantly
soliciting for tips. And due to the high contact nature with the housekeeping staff
during hospital stay; their courtesy does have great impact on the service provided
by the hospital in the eyes of the patient.
Finally, hospital premises and employees tangibles constitute a direct
reflection of the hospital. The more elaborate the decorations and the physical
premises, the more technologically advanced the hospital equipment and the more
detailed and professional looking are the hand-outs in the hospital, the better it is
for the image of the hospital. Patients tend to view bigger and more luxurious as
better. And it goes without saying that in medicine, technology is the cutting edge
in medical diagnosis accuracy. The more advanced the medical equipment, the
better the diagnosis and outcome for the patient. In Egypt, patients do not usually
expect brochures about medical services and most patients were neutral about them.
However, hospitals who provide newsletters and brochures detailing medical offers
and procedures usually gain an edge over their counter-parts where such practices
are not the norm. Finally, the appearance of all employees in the hospital gives an
immediate impression of the level of service for the hospital. Good-looking and
neat employees instill confidence in the service provider and directly influence
opinions of patients entering the hospital for service.
Services are generally classified as equipment-based such as motion
picture theatres, airlines etc and people-based using unskilled or skilled labour such
as plumbing services and janitors and at the end of the spectrum lays the
professional people-based services such as lawyers, consultants and physicians. The
value of the human interaction in such people-based services is very important and
the role of service quality is not just a technical aspect but encompasses a very
strong human aspect as well (Berkowitz, 2006).
Healthcare services are characterized by intangibility, inconsistency,
inseparability and a high level of human interaction. Due to the intangible nature of
services; services cannot be felt, touched or heard before they are encountered, a
major challenge in services is that consumer interactions with the processes and the
individuals who are performing the service are often the basis by which consumers
evaluate the service itself. Also healthcare services in a hospital are delivered by
people, the nurse, the physician, the administrative team handling the paperwork in
the hospital etc. While in product manufacture, exact standards can be developed
whether in the assembly line of a car or in the manufacturing of any FMCGs, in
people-delivered services; it is a whole different story. The characteristic of
inconsistency is inherent in the delivery. No two surgeons perform the same
procedure in exactly the same way. Each has a noTable difference in proficiency in
performing the same procedure. Two administration clerks in a hospital who have
received the same training course for the job will deliver the service differently
based on their personal motivation, morale or attitude. The objective for effective
service delivery by management is to reduce the inconsistency to achieve as much
standardization as possible and this can be achieved through consistent training.
Services are inseparable is that they cannot be separated from the service provider
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and in healthcare is often referred to as the ―bedside manner‖ of the physician. Due
to the high interaction between the customer (patient) and the healthcare service
provider, the quality of interaction is a very important consideration (Berkowitz,
2006).
Previous literature has also stressed that consumers find difficulty in the
evaluation of healthcare services and they rarely know on which feature of the
health service to base their judgments on or how best to evaluate those feature they
chose to evaluate since healthcare by nature in a multi-service operations that
involves many encounters and facets. This is especially true when patients try to
evaluate the more technical features of the healthcare service such as the
qualifications of the medical staff or the outcome or improvement of the patient's
condition which patients find themselves unable to assess. Patients do not actually
have the technical knowledge to evaluate the technical (medical) aspects of
healthcare in an effective manner. Thus typically, patient's can usually assess the
―human aspect‖ of the service delivery ; for example the attentiveness, the
responsiveness, the comfort provided by the service provider, the length of the wait
before treatment etc (Paul, 2003).
7.2.4 Contribution:
In the current research, the researcher aimed to design a model to pursue
both the human and the technical aspects of service quality that consumers might be
able to evaluate. Certain factors such as the quality of life, recovery, complications
etc where patients were not able to form an informed assessment were not included
in the model. Other technical factors such as the qualifications and reputations of
the medical staff, medical outcome were explored. The human factor was
thoroughly investigated to encompass a wide variety of issues such as assurance,
empathy, patient interaction, responsiveness, courtesy and others. The researcher
has based the model to encompass both entities in service quality delivery. The
dimensions and the sub-dimensions used in the current study are demonstrated in
the Figure 7.2.
As regards to the model development, there are two main methodologies
that researchers have used for development of constructs using factor loading
analysis. One is based upon the use of ―dimensions‖ of service quality and the other
is based on ―function areas‖ in service quality to be the major constructs of the
research. As explained before, in the current research, the researcher has attempted
the use of function areas in measurement of service quality. However, underneath
each function area, the researcher has further subdivided the main constructs into
sub-constructs along the lines of the ―dimensions‖ mentioned by some authors. The
dimensions encompass both purely technical aspects and human factors mentioned
above. The following Table 7.1 demonstrates the use of constructs and sub-
constructs mentioned above. The Table illustrates how the researcher attempted to
link between the constructs (function areas) and the sub-constructs (dimensions) to
develop the model demonstrated in Figure 7.3 (where the grey boxes show the final
sub-constructs in the current research).
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Table 7.2: Demonstrates the Use of Constructs and Sub-Constructs
Doctors Nurses Diagnostic Hospital Rooms & Admission Discharge Meals
Premises Housekeeping
Reliability
Assurance
Interaction
Tangibles Competence
Knowledge
Courtesy
Responsiveness
The researcher has proposed that the research will have both theoretical
and managerial implications. Through proposing a framework for the constructs
and sub-constructs of healthcare service quality in private hospitals in Egypt,
management can implement and identify areas of excellence or improvement
through the hospital. The researcher enables marketers and managers to identify
and determine what promotes customer satisfaction and return and recommendation
behaviour and what are the factors that led to customer dissatisfaction and
disloyalty and bad word-of-mouth behaviour. They would also be able to
understand the right actions and attitudes required from their staff medical and non-
medical required to keep their patients satisfied. In addition, management
practically can would be able to tailor their strategies thus offer the best services
153
that match their client‘s expectations. Hospitals will be able to judiciously allocate
their resources to achieve their goals of customer satisfaction and retention
Figure 7.2: Demonstrating the Model of the Research on the Construct and Sub-
Construct Level
Healthcare Service
Quality
Medical
Services
Personal Technical
Services Services
Doctors Nursing
Diagnostics
Service Service
Physician Nursing Diagnostic

Reliability Reliability Service Reliability
Nursing
Physician
Assurance Diagnostic Service
Assurance
(Security/Coutesy Competence
(Security)
)
Physician's Nursing
Responsiveness/ Interaction
Empathy (Empathy)
(Interaction)
Physician's Nursing
Competence Professionalism
(Assurance) (Responsiveness)
Nursing Tangibles
Hospitality
Services
Physical Administrative Hotelier

Facilities Services Services
Hospital Rooms and

Admission Discharge Meals
Premesis Housekeeping
Discharge
Hospital Premises Rooms Admission Meals
Knowledge and
and employees Knowledge and
Tangibles Discharge Tangibles
Tangibles Courtesy
Courtesy
Housekeeping
Admission
Courtesy
responsiveness
(Assurance)
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7.3 Link between Satisfaction and Service Quality
In the current research, the researcher was able to detect a strong
correlation between overall customer satisfaction and behavioural intentions to
return and recommend. The correlation coefficients between overall satisfaction
(D1) and the rest of the variables (D2, D3, D4, D5 and D6) which represents
recommendation behaviour, future purchase behaviour, value for money, outcome
for mother and outcome for baby respectively is represented by significant
correlation (P < 0.01) (Table 6.32).
From the above results, the researcher was able to reject the following hypotheses
that:
H5a: There is no correlation between overall customer satisfaction and the
patients' intention to return and recommend the hospital
H5b: There is no correlation between overall customer satisfaction and the
value for money
H5c: There is no correlation between overall customer satisfaction and
medical outcome to the mother
H5d:There is no correlation between overall customer satisfaction and
medical outcome to the baby
Many authors have linked customer satisfaction with intentions to
repurchase, positive word of mouth and consumer satisfaction is assumed to be of
significant effect on repeat sales, positive word-of-mouth and consumer loyalty.
Woodside et al., 1989 have shown that consumer judgments of specific
service events within service acts influences their overall patient satisfaction with
the service act and that satisfaction with the service acts influences overall
consumer satisfaction with the service encounter.
Smith and Houston, 1983, Kotler, 1988, Churchill and Surprenant, 1982
John J, 1992 also linked customer satisfaction to behavioural intentions to
repurchase from the same provider as well as linking service quality with consumer
satisfaction. Ross et al., 1987 also agreed that the success of retaining or attracting
patients may result from patient satisfaction with the medical service they receive
and linked satisfaction or dissatisfaction of the patient with the hospital experience
with the patient‘s willingness to remain within the same service provider or any
individual physician (repurchase behaviour).
In the current research, the researcher was able to detect a strong
correlation between overall customer satisfaction and behavioural intentions to
return and recommend. As seen from previous literature, when consumers, who in
the case of the current research are patients, are satisfied with the service quality
delivered, they are most likely to repurchase the product/service i.e. they will
frequent the hospital again for any future medical complaints. Since the main aim
of hospital marketers is to increase the demand for the services of the organization,
thus the importance of keeping clients satisfied arises. Since it costs five times less
to keep a current customer than it is to get a new customer (Kotler, 1988) then
current patients are prime targets for return behaviour especially when patients are
satisfied with the hospital service provided.
155
Positive-word-of-mouth also plays a very important role in choosing a
healthcare provider in Egypt. In Egypt, doctors usually refer obstetrics patients to
the hospital where they can give birth usually giving them a choice between several
hospitals. Then the patient chooses between one of the proposed hospitals. Many
factors come to play in this decision including price, location and most importantly
reputation of the hospital. As a culture, Egyptians rely heavily on word-of-mouth in
their choice of service providers be it restaurants, lawyers, doctors etc preferring to
go to the professional recommended to them by a friend, relative or other reliable
source of information who has been ―previously tried‖ by them. Thus when patients
exit the hospital satisfied with the experience, they are most likely to generate good
word-of-mouth for the hospital and recommend it to friends and relatives thus
ensuring future patronage by new patients.
As for outcome and value for money, they have been previously linked to
service quality perceptions in literature. Walburg et al., 2006 defined factors are
relevant in evaluation of the results of the care process to include patient
assessment, patient satisfaction, outcomes (seen as clinical and functional
outcomes) as well as the costs of the healthcare services provided. Walburg et al.,
2006 combines all these variables in a model demonstrated as ―Outcome
Quadrants". In the current research, the researcher was able to detect a strong
correlation between overall customer satisfaction and value for money and outcome
to mother and baby.
In the case of value for money, the link between costs of healthcare and
satisfaction with the service provided in quite significant in Egypt. This stems from
the fact that nearly all patients frequenting private hospitals in Egypt are usually
paying for their medical services out of their own pockets with only a small
percentage being partially or fully covered through insurance. If the value from the
service obtained does not match what the patient expected for what he paid (i.e. it
was too expensive for what he got a service in return) then the patient will deem the
whole encounter with this service provider not satisfactory. On the other hand, if
the service provided the patient with sufficient value for what he paid or even
exceeded his expectations, then the patient will probably leave the hospital satisfied
with the encounter. His choice when needing future medical service will be
influenced by his past experience where he/she will deem the service provider ―not
worth what I paid‖ thus will most probably seek some other provider for his/her
needs. And vice versa, if she believes she ―got her money worth‖, she will most
likely come to the hospital again in future needs, obstetrics or otherwise.
Finally comes the importance of outcome and its link to satisfaction for
obstetrics patients in Egypt. Due to the unpredicTable nature of medicine as a
service with many factors being out of the hand of the medical teams as well their
incompetence in others, some patients may suffer unfavourable medical outcomes
during their hospital experiences such as unnecessary medical complications. Also,
the issue of mal-practice suits are almost non-existent in Egypt. Thus many patients
find themselves suffering from unfavourable outcomes from their hospital stays,
which they cannot do anything about. In the current research, outcome as been
strongly linked to satisfaction with the hospital services thus highlighting to
healthcare providers that the outcome of the encounter is attributed to the hospital
itself and ultimately influence their satisfaction with the hospital as whole and not
just with the responsible party, be it the faulty diagnostics, the nursing, the doctor or
the hospital service itself.
156
7.3.4 Contribution
The research has both theoretical and practical implications. On a practical
note, healthcare providers need to measure patients‘ satisfaction due to its high
correlation with issues essential to the hospital bottom-line and the reputation of the
hospital in the market. Swan et al, 1985 stated that improvement of services that
receive low satisfaction ratings or services that are strongly correlated with the
patient‘s future intentions to utilize the hospital would improve patient satisfaction.
By identifying defective areas through implementation of the scale and the model,
the service provider could address each need and reallocate resources accordingly
thus aiming to improve patients perceptions and eventually satisfaction with the
services provided by the hospital. And since patient‘s satisfaction has been strongly
linked to future purchase and recommendation behaviour in the current research
and in countless previous researches, this stresses the importance of measuring
patient satisfaction in hospitals in Egypt.
7.4. Relationship between Demographics and Service Quality

The current research has established that income level has an effect on
certain variables in the research as a discriminating variable. The current research
linked income with several variables including ―Doctors having very high level of
knowledge required to answer patient's questions satisfactorily‖, ―Doctors always
treating the patient with respect‖, ―Doctors having excellent reputations‖, ―Lab tests
and X-rays being provided at the time they are promised‖, ―Nurses performing the
service required (tests, procedures, medication dispensing) at exactly the right time‖
and ―Nurses being consistently courteous to patients respectively‖. On the other
hand, age and education did not have a significant on variables of the research.
From the above research, the researcher has failed to reject the hypotheses
(H3a) that states that consumer demographic characteristics (Age) have
no significant effect on the variables of the research
From the above research, the researcher has failed to reject the hypotheses
(H3b) that states that consumer demographic characteristics (Education)
have no significant effect on the variables of the research
From the above research, the researcher has rejected the hypothesis (H3c)
that states that: Consumer demographic characteristics (Socioeconomic
Standard) have no significant effect on the variables of the research
The current research has established that income level has an effect on the
variables in the research (mentioned above in section 7.4.1) as a discriminating
variable. In summary, the above variables are mainly concerned with knowledge
and reputation of doctors, the courtesy and respect of doctors and nurses and the
timeliness of diagnostic and nursing service provision.
The effect of demographics on quality was supported by many researchers
including Webster et al., 1989 found that consumer demographic characteristics
have a significant effect on their consumers expectations and perceptions of quality
for professional services and not for non-professional services. Katherine &
Hathcote (1994) findings also indicated that race, marital status and income yielded
significant differences.
157
As mentioned previously, nearly all patients frequenting private hospitals
in Egypt are usually paying for their medical services out of their own pockets with
only a small percentage being partially or fully covered through insurance. Thus it
comes to notice that income level will definitely have an impact on the service in
the hospital. The higher the income level, the more finicky and demanding are the
patients. They expect a very high level of service to match the amount of money
paid for this medical service. Higher income brackets in Egypt also usually travel
abroad and are in most cases subjected to a high quality of service from foreign
service providers such as in retail, food and beverage and hospitality. Thus they in
turn hope for a similar level of service when they use Egyptian service providers. It
is clear from the above research that higher income levels demand a high level of
medical care from their providers whether in terms of knowledge, reputation,
courtesy and timeliness.
7.4.4 Contribution:
The research has demonstrated both theoretical and practical implications.
On the practical side, healthcare service providers need to pay attention to the
income level of the patients frequenting their hospitals and tailor their services to
match their expectations from the service provided. Implementation of the model
and the sale will enable management to identify perceptions and areas of service
quality short-falls. Management should then note defective areas in their
perceptions and act accordingly. They need to stress on timeliness of the service
delivery as well as always having doctors with renowned reputation and excellent
medical knowledge available for their service with higher income levels. Such
practices are starting to take the name of ―boutique‖ medical practices abroad,
where patients who are willing to pay an extra premium over their insurance get
extra perks such as longer consultation times and special waiting rooms in out-
patient clinics. In Egypt, hospitals could try and cater more exclusive services to
higher paying patients such as those patients who are staying in suites. They are
usually of higher income brackets and their expectations from the service providers
are usually higher than others. Thus special services such as hiring foreign nurses of
higher efficiency for those rooms, having repuTable doctors on-call to handle their
cases when needed after hours instead of relying on the in-house residents,
providing more time for consultations thus doctors provide more information and
better rapport could have a significant impact on the satisfaction of these patients
with the service quality offered and they would become more loyal to this service
provider.
158
8. CONCLUSION, IMPLICATIONS AND DIRECTIONS
FOR FUTURE RESEARCH
Following an extensive literature review and completion of the qualitative

and quantitative phases of the research, many factors were identified for Healthcare
service quality. These researchers have included some of the original 10
dimensions that were identified by Zeithaml et al., 1989 and others that they
thought proved relevant to healthcare from the works of Brown SW & Swartz TA,
1989, Joby J. 1992, Walbridge SW & Delene LM, 1993 & Woodside et al., 1989
and Carmen, 1990. Additional factors were included from the results of the
qualitative research (in-depth interviews with patients and experts and pilot study).
This resulted in formulation of a wide-ranging model containing a broad
array of constructs and sub-constructs thought to affect healthcare service quality in
the private healthcare sector in Egypt. The model was tested and showed
significance for constructs and sub-constructs. The constructs and sub-constructs
that affect healthcare service quality were identified through factor analysis and
logistic regression. The model suggests that there are eight major constructs for
service quality that include that include doctor‘s medical service, nursing service,
diagnostic service, hospital premises and employees, rooms and housekeeping,
meals, admission and discharge services. In addition, eighteen sub-constructs were
identified that include Physician Reliability, Physician Assurance (Security),
Physician's Empathy (Professionalism), Physician Interaction (Empathy /
Responsiveness), Physician's Competence (Assurance) ; Nursing Reliability,
Nursing Assurance (Security), Nursing Interaction (Empathy), Nursing
Professionalism (Responsiveness) ; Diagnostic Service Competence, Diagnostic
Responsiveness, Admission Knowledge , Admission Courtesy (Assurance) ; Meals
Knowledge and Discharge Courtesy (Assurance). Several sub-constructs including
nursing tangibles, hospital premises and employees‘ tangibles as well as room and
housekeeping courtesy were found to have a more significant impact on overall
service quality than others. In addition, eight different scales to be tested and
Weighted SEVPERF was identified as the ideal method for measurement of
healthcare service quality among the tested methods in the current research settings.
The effect of moderating variables (demographics) was also tested through
discriminant analysis. The variable income was linked with several variables
including ―Doctors having very high level of knowledge required to answer
patient's questions satisfactorily‖, ―Doctors always treating the patient with
respect‖, ―Doctors having excellent reputations‖, ―Lab tests and X-rays being
provided at the time they are promised‖, ―Nurses performing the service required
(tests, procedures, medication dispensing) at exactly the right time‖ and ―Nurses
being consistently courteous to patients respectively‖. On the other hand, age and
education did not have a significant on variables of the research
Finally, correlation between overall consumer satisfaction on one hand and
behavioural intentions to return and recommend, value for money and outcome on
the other hand were established.
As a conclusion, through the above research, the researcher was able to
provide a comprehensive model for healthcare service quality in Egypt. A valid and
reliable scale that will enable healthcare marketers and managers to evaluate the
159
level of healthcare service quality in their organizations, to pinpoint the weak areas
and upgrade the quality of the service provided was also established. The model
developed in the current research is demonstrated in Figure 8.1.
Figure 8.1: Demonstrating the Model of the Research on the Construct and Sub-
Construct Level
Healthcare Service
Quality
Medical
Services
Personal Technical
Services Services
Doctors Nursing
Diagnostics
Service Service
Physician Nursing Diagnostic

Reliability Reliability Service Reliability
Nursing
Physician
Assurance Diagnostic Service
Assurance
(Security/Coutesy Competence
(Security)
)
Physician's Nursing
Responsiveness/ Interaction
Empathy (Empathy)
(Interaction)
Physician's Nursing
Competence Professionalism
(Assurance) (Responsiveness)
Nursing Tangibles
Hospitality
Services
Physical Administrative Hotelier

Facilities Services Services
Hospital Rooms and

Admission Discharge Meals
Premesis Housekeeping
Discharge
Hospital Premises Rooms Admission Meals
Knowledge and
and employees Knowledge and
Tangibles Discharge Tangibles
Tangibles Courtesy
Courtesy
Housekeeping
Admission
Courtesy
responsiveness
(Assurance)
160
The researcher had stated that the model to be tested is expected to have
both theoretical and managerial implications. On a theoretical note, using the
developed model and tool, healthcare managers and marketers would be able to
identify all dimensions that patients use for evaluation of the level of service
provided in their organizations. They would have a valid and reliable scale by
which they could measure the service quality in their organizations as well as
determine what leads to customer satisfaction and return and recommendation
behaviour. They would also be able to recognize the factors that could lower
customer dissatisfaction and disloyalty and bad word-of-mouth behaviour.
On a more practical note, using the above data, healthcare personnel can
push for the right actions and attitudes required from their staff including doctors,
nurses, admission and discharge personnel, housekeeping and kitchen staff that is
needed to satisfy and retain customers. They can promote interactions that are likely
to yield positive impact upon customers‘ decision. The hospitals would be able to
tailor their strategies thus offer the best services that match their client‘s
expectations as well as judiciously allocate their resources to achieve their goals of
customer satisfaction and retention.
Areas that generate strong interest among the consumers need hospital
providers to focus on them and implement strong service strategies. Investing in
them will become essential to remain competitive within in an already competitive
environment. Hospital senior executives should try and create bundles of services
that would establish a distinctive experience for the patient and build a strong brand
for the hospital. This will compel patients to seek their services versus other
competitors and establish strong brand loyalty for the hospital.
Overall, implementing this study will lead to a higher level of healthcare
service quality provision in Egypt and better customer satisfaction. This would also
enable the country to eventually establish international healthcare standards and
certifications in the private sector that will enable them to compete in other field
such as establishing healthcare tourism and attracting foreign investors in the local
market. Also due to the similarity of culture between Egypt and other Arab
countries, the current framework could be studied and tested in other Arab countries
and slightly modified to suit each country. This would provide the Arab world with
a model with which to elevate the level of healthcare in it. The model and scale
could serve as a starting point that could be adapted to each individual hospital and
applied for elevation of service quality there.
Numerous researches have also linked satisfaction and service quality.
Managers and marketers are now focusing on linking financial performance
(aiming to providing efficient low-cost/high-value services as measured by
financial and operating indicators), medical outcome (producing consistently
favourable clinical results as measured by medical records) and perceived service
quality (delivering service experiences that meet customer needs as measured by
customer satisfaction surveys) (Furse et al, 1994). Many studies have shown a
strong link between customer satisfaction and firm profitability. Using 200 of the
Fortune 500 firms across 40 industries, Anderson et al. (2004) show that while
market share has no impact on shareholder value, a 1% change in ACSI (as
measured by the American Customer Satisfaction Index on a 0-100 scale) is
associated with a 1,016% change in shareholder value as measured by Tobin's q.
This implies that 1% improvement in satisfaction for these firms will lead to an
increase in a firm's value of approximately $275 million. Thus on a practical note,
161
improving patient satisfaction and elevation of service quality will lead to
improvements in financial performance of hospitals thus translating the marketing
efforts into tangible results that would ultimately benefit the organization in a
measurable way to stockholders and owners.
However, it is important to note that in matters that deal with service
quality, including customer services and customer satisfaction, the desire to
improve must be supported by commitment by senior management. The decisions
to take concrete steps for improvement and the allocation of resources to make it
possible have to be committed by senior management. To achieve success, a culture
for good customer service has to be embedded through all levels of the organization
and has to constitute a part of management‘s business strategy. The reason so many
organizations are struggling with the challenge of improving service is insufficient
leadership. The main root of the deficient service is not usually the system, the
structure or the research but it is rather in the people themselves in the organization
who have leadership responsibilities and do not or cannot do the job (Zeithaml et
al., 1990).
Thus for implementation of service quality, the organization has to focus
not just on steps of improving service quality in terms of satisfaction surveys and
such, but they also have to focus on the soft aspects that deal mainly with the
employees and how they will need to change to implement this strategy. Many
issues such as resistance to change, inadequate training, centralization of authority
etc will be seen and can hamper organizational change. Managers should pin-point
such focus areas concerning internal culture, perform detailed analysis of the
current situation and implement critical success factors for implementation.
Management also needs very close monitoring and evaluation systems to also
support successful implementation.
Many hospitals and medical groups have difficulty adjusting to a
marketing-oriented organization. Embedding the culture of marketing and a
customer-focused culture through the organization is not a simple task. The
organization requires first pressure to be marketing oriented from top-management,
the capacity to achieve this through allocation of the proper people and resources, a
cleared shared vision of the market as well as development of an action plan
consisting of actionable steps with clear areas of responsibility to achieve these
goals. Once a decision has been made to focus on improving customer service,
Zeithaml et al (1990) have pin-pointed a six-step model to start getting quality
service improvement off the ground in any organization starting with first getting
ready for the hard work, collecting any relevant data, organizing for change
stressing on the freedom factor, having management's commitment to quality and
promoting the right people. They recommended that following these basic steps
allows the development of quality in customer services. The human aspect comes
clearly into focus and must be focused upon for the successful implementation of
any organizational cultural change. Issues in implementation such as benchmarking,
training, monitoring, definition of responsibility areas and critical success factors,
levels of management and all other internal issues that may hamper successful
implementation have to be addressed and dealt with in the planning phase before
beginning any implementation. Thus the role of changing the mindsets, habits,
skills and knowledge of the people who work in the organization to a service and
quality oriented culture is a major challenge and one that needs to be partaken from
day one in any intended organizational change.
162
Finally, there are several fields for future research which include testing
with a larger sample of patients to be able to apply more sophisticated statistical
tools. Also, there is great potential to test the model in settings other than obstetrics
such as cancer or paediatrics and detecting the effect of moderating variables such
as the effect of emotional impact on expectations and perceptions. The role of prior
knowledge could be also addressed in future research. Other healthcare settings
such as out-patient clinics, emergency departments or one-day surgery could be
investigated to detect how to adapt such a model to settings without in-patient stays.
The model could also be tested in the public sector and researchers could compare
and contrast the differences between expectations and perceptions among private
and public hospital users and how each sector can tailor their efforts to suite their
target segment. The model can also be tested in other developing countries and in
other Arab countries to see methods of adapting it to suit the needs of patients in
other countries.
163
REFERENCES
1. Articles
Aaker, David, Robert Jacobson. (1994). The financial information content of
perceived quality, Marketing Res. 31(2) 191-201.
Alba K.W. and Hutchinson J.W. (1987), ―Dimensions of consumer expertise‖,
Journal of Consumer Research, 13, 411-454
Anderson D.C. (1981), ―The Satisfied Consumer Service Return Behaviour in the
Hospital Obstetrics Field‖ Journal of Healthcare Marketing 2 Fall pp 25-
33
Anderson, Eugene W., Claes Fornell, Sanal Mazvancheryl. (2004).Customer
satisfaction and shareholder value. /. Marketing 68(4)172-185.
Anderson, Eugene W., Claes Fornell, Roland Rust. (1997). Customer
satisfaction, productivity, and profitability: Differences between good and
services. Marketing Sci. 16(2) 129-145.
Anderson, Eugene W., V. Mittal. (2000). Strengthening the satisfaction- profit
chain, Service Res. 3(2) 107-120
Anderson, Eugene W., Claes Fornell, Donald R. Lehmann. (1994). Customer
satisfaction, market share, and profitability: Findings from Sweden,
Marketing 58(3) 53-66.
Appleby, J (2006), ―Hospital industry faces competition, quality pressure‖, USA Today
Babakus, E and Boller, G W (1992). ―An Empirical Assessment of the Servqual
Scale,‖ Journal of Business Research, 24(3), 253-68.
Babakus E and Mangold WG (1992), ―Adapting the SERVQUAL scale to
hospital services: an empirical investigation‖ Health Services Research 26
(6) 767-786
Baxter, L. (2004) ―Nottingham occupational health puts its quality of services to
test with the Parasuraman‘s SERVQUAL tool‖, Occupational Health,
March, Vol. 56, Issue 3
Beales, H., Mazis M.B., Salop S.C. and Staelin R. (1981), ―Consumer Research
and Public Policy‖, Journal of Consumer Research, Vol. 8, June pp 11-22
Berry L.L., Parasuraman, A. and Zeithaml, V.A. (1988) ―The Service Quality
Puzzle‖, Business Horizons, 31, No.5, pp.3543.
Berkowitz, Eric N (2006), ―Product Strategy‖ in Essentials of Healthcare
Marketing, Jones and Bartlett Publishers, Massachusetts, pp 213-239
Berman, Peter, A. K. Nandakumar, Jean-Jacques Frere, Hassan Salah, Maha
El-Adawy, Sameh El-Saharty and Nabil Nassar. August (1997): A
Reform Strategy for Primary Care in Egypt. Technical Report 9. Bethesda,
MD: Partnerships for Health Reform Project, Abt Associates Inc
Bertakis K. (1977), ―The communication of information from physician to patient:
A method for increasing patient retention and satisfaction‖, The Journal of
Family Practice, Vol. 5, No. 2, pp. 217-22
Bitner M.J. (1990) ―Evaluating service encounters: The effects of physical
surroundings and employee responses‖ Journal of Marketing, 54, April,
pp69-82
Bloemer Josee M.M. (1993) ‗Loyaliteit en tev redenheid: een studie naar de relatie
tussen merktrouv en consumentente vred en neia (Loyalty and
Satisfaction)‘ Maastricht University Press
Bolton Ruth N and James H Drew (1991a), ―A longitudinal analysis on the
164
impact of service changes on consumer attitudes‖, Journal of Marketing,
55, January, 1-9
Bolton Ruth N and James H Drew (1991b), ―A multistage model of customer
assessment of service quality and value‖ Journal of consumer research, 17,
March, pp375-84
Boulding, W; Kalra, A, Staelin, R and Zeithaml, V A (1993). ―A Dynamic
Process Model of Service Quality: From Expectations to Behavioral
Intentions,‖ Journal of Marketing Research, 30(February), 7-27.
Brady, M K, Cronin, J and Brand, R R (2002). ―Performance–Only
Measurement of Service Quality: A Replication and Extension,‖ Journal
of Business Research, 55(1), 17-31.
Brown, S.W. and Swartz, T.A. (1989), ―A Gap Analysis of Professional Service
Quality‖, Journal of Marketing, 53, April, pp 92-98
Burton K. E. and Wright V. (1980), ―The total solution for total hip replacement
surgery‖, Journal of Medical Engineering and Technology, 4, July, pp
183-5
Cadotte, H., Woodruff, R. and Jenkins, I.T. (1987), ―Expectations and Norms in
Models of Consumer Satisfaction‖, Journal of Marketing Research, 24,
August, pp.305—314.
Carman, J.M. (1990), ―Consumer Perceptions of Service Quality: an Assessment
of the SERVQUAL Dimensions‖, Journal of Retailing, 66, pp.33-55.
Carman, J.M. and Langeard, E. (1980), ―Growth Strategies of Service Firms‖,
Strategic Management Journal, 1, January-March, pp.7-22
Cartwright, A. (1986), ―A Depressing Pursuit of Quality‖, British Medical
Journal, 292, pp.1497
Churchill, G.A. and Carol Suprenant (1979), ―A paradigm for developing better
measures for marketing constructs‖, Journal of Marketing Research, 16,
February, pp 64-73
Churchill, G.A. and Carol Suprenant (1982), ―An investigation into the
determinants of consumer satisfaction‖ , Journal of marketing research,
14, November, pp 491-504
Cronin, J.J. Jr. and Taylor, S.A. (1992), ―Measuring Service Quality: a Re-
Examination and Extension‖, Journal of Marketing, 56, pp.55—68.
Cronin, J.J. Jr. and Taylor, S.A. (1994), ―SERVPERF vs SERVQUAL:
Reconciling performance based and Perceptions-Minus-Expectations
Measurement of Service Quality‖, Journal of Marketing, 56, pp.55—68
Dabholkar, P A, Shepherd, D C and Thorpe, D I (2000). ―A Comprehensive
Framework for Service Quality: An Investigation of Critical, Conceptual
and Measurement Issues through a Longitudinal Study,‖ Journal of
Retailing, 76(2), 139-73.
De Man, S., Gemmel, P., Vleric P. and Dierchx, R. (2002), "Patient's and
personnel's perceptions of service quality and patient satisfaction in
nuclear medicine", European Journal of Nuclear Medicine September,
Vol. 29, No. 9, pp. 1109-1117
Donabedian, A. (1992), ―Quality Assurance in Health Care: Consumers Role‖,
Quality in Health Care, 1, pp.247-25l.
Feletti G., Firman D. and Sanson-Fisher R. (1986), ―Patient‘s satisfaction with
primary care consultations‖, Journal of behavioural medicine, Vol. 9, No.
4, pp. 389-99
165
Finn, D W and Lamb, C W (1991). ―An Evaluation of the SERVQUAL Scale in a
Retailing Setting‖ in Holman, R and Solomon, M R (eds.), Advances in
Consumer Research, Provo, UT: Association for Consumer Research,480-
93
Folkes, V., Koletsky S. and Graham., J. (1987) ―A Field Study of Causal
Inferences and Consumer Reaction: the View from the Airport‖, Journal
of Consumer Research, 10, March, pp.534—539.
Furse David H., Michael R. Burcham, Robin L. Rose, and Richard W. Oliver
(1994): ―Leveraging the Value of Customer Satisfaction Information‖,
Journal of Healthcare Marketing, Fall , Vol. 14, No. 3, pp 16-20
Gazibarich, B. (1996), ―Quality of dietetics care: the missing customer‖,
Australian Journal of Nutrition and Dietetics, June, Vol. 53, Issue 2, p48-
52
Gotlieb, J B, Grewal, D and Brown, S W (1994). ―Consumer Satisfaction and
Perceived Quality: Complementary or Divergent Constructs,‖ Journal of
Applied Psychology, 79(6), 875-85.
Gronroos, C. (1980), ―Designing a Long-range Marketing Strategy for Services‖,
Long Range Planning, 13, April, pp.36-42
Gronroos, C. (1984) ―A Service Quality Model and its Marketing Implications‖,
European Journal of Marketing, 18, No.4, pp.36-44.
Grote, Kurt D, Newsman, John R. S., Sutaria, Saumya S. (2007): A better
hospital experience, The Mckinsey Quarterly, Health, November 2007
Gruca, Thomas S,, Loopo L, Rego, (2005). Customer satisfaction, cash flow and
shareholder value. /, Marketing 69(July) 115-130.
Gupta, Svinil and Zeithaml, Valarie (2006), ―Customer Metrics and Their
Impact on Financial Performance‖ MARKETING SCIENCE, Vol. 25, No.
6, November-December 2006, pp. 718-739
Hall, J.H. and Dornan, M.C. (1988), ―Meta Analysis of Satisfaction with Medical
Care: a Description of Research Domains and Analysis of Overall
Satisfaction levels‖, Social Science and Medicine, 27, No.6, pp.637-644.
Hallowell, Roger, (1996), The relationships of customer satisfaction, customer
loyalty, and profitability: An empirical study, Internatl J. Service Indust.
Management 7(4) 27-42
Hiidenhovi, H., Nojonen, K. and Laippala, P. (2001), “Development of a
patient-oriented instrument to measure service quality in outpatient
departments‖, Journal of Adanced Nursing, 34(5), pp696-705
Hiidenhovi, H., Nojonen, K. and Laippala, P. (2002), ―Measurement of
outpatient‘s views of service quality in a Finnish university hospital‖,
Journal of Advanced Nursing, 38(1), pp59-67
Hill, F.M. and McCrory, M.L. (1997), ―An attempt to measure service quality at
Belfast maternity hospital: Some methodological issues and results‖, Total
Quality Management, Oct, Volume 8, Issue 5
Howie, J.G.R., Morten, A.M.D., Heaney, D.J. and Hopton, J.L. (1991), ―Long
to Short Consultation Ratio: a Measure of Quality of Care for General
Practice‖, British Journal of General Practice, 41, pp. 48 -54
Hulka B.S., Kupper L.L., Cassel J.C. and Babineau (1975), ―Practice
characteristics and quality of primary medical care: The doctor patient
relationship:, Medical Care, Vol. 13, October, pp. 808 -20
166
Hulka B.S., Kupper L.L., Cassel J.C. and Thompson S.J., (1971), A method for
measuring physician‘s awareness of patients‘ concerns, HSMHA Health
reports, 86, August, 741-757
Hulka, B.S. and Stephen J. Zyzanski (1982), ―Validation of a Patient Satisfaction
Scale: Theory, Methods and Practice,‘ Medical Care, 20 (6), 649—53.
Hulka, B.S., Stephen J. Zyzanski, John C. Cassel, and Shirley Thompson
(1970), ―Scale for the Measurement of Attitudes Toward Physicians and
Primary Health Care,‖ Medical Care, 8 (5), 429—36.
Ittner, Christopher, David Larcker, (1998), Are non-financial measures leading
indicators of financial performance? An analysis of customer satisfaction,
Accounting Res. 36(3) 1-35.
Jacoby, Jacob and Jerry C. Olson (eds.) (1985): Perceived Quality: How
Consumers View Stores and Merchandise, Lexington, MA: Lexington
Books
Joby, J. (1992), ―Patient Satisfaction: the Impact of Past Experience‖, Journal of
Health Care Marketing, 12, No.3, pp.56-64
Katherine B.G. and Jan Hathcote (1994) Consumer expectations and perceptions
of service quality in retail apparel specialty stores, Journal of Service
Marketing, 8, (1), pp60-69
Kiam-Caudle P.R. and Marsh G.N., (1975), ―Patient satisfaction and reported
acceptance of advice in general practice‖, British Medical Journal,
February, pp. 262-4
Leblanc, C. and Nyugen, N. (1988), ―Customer Perceptions of Service Quality in
Financial Institutions‖, International Journal of Bank Marketing, 6, No.4,
pp 7 –18
Lebow, J.L. (1982), ―Consumer Satisfaction with Mental Health Treatment‖,
Psychological Bulletin, 91, March, pp 244 -259
Lehtinen, V. and Lehtinen, J.R. (1982), ―Service Quality: a Study of Quality
Dimensions‖, Working Paper, Helsinki Service Management Institute,
Finland.
Liang Matthew H and Karen E Cullen (1984), ―Evaluation of Outcomes in Total
Joint Arthroplasty for Rheumatoid Arthritis‖ Clinical Orthopaedics and
Related Research, 182, January – February, 41-5
Lovelock, C.H. (1981a), ―Towards a Classification of Services‖, In: Theoretical
Development in Marketing, (Eds) Lamb, C. and Dunne, P., Chicago,
American Marketing Association, pp.72-76.
Lovelock, C.H. (1983) ―Classifying Services to Gain Strategic Marketing
Insights‖, Journal of Marketing, 47, Summer pp.9-20.
MacGregor, Francis C (1981), ―Patient dissatisfaction with results of a
technically satisfactory surgery‖ Aesthetic Plastic Surgery, 5, January –
March , pp 7-32
Managed Care Weekly Digest (2003), ―JD Power: Customer Satisfaction in the
hospital Industry is Higher‖, July 14, 2003, pp 39-40
Mazis, Micheal B, Olli T Ahtola and R Eugene Klippel (1975), ―A comparison
of four multi-attribute models in prediction of consumer attitudes‘ Journal
of Consumer Research , 17, November, 460-9
MEMRAB International Research and Consultancy Group (2001), Egypt,
Summary of Demographics. Report,
Morrel, D.C., Evans, M.E., Morris, R.W. and Roland, M.D. (1986). ―The Five
167
Minute Consultation: Effect on Time Constraint on Clinical Content and
Patient Satisfaction‖, British Medical Journal, 292, pp. 870-873
Mowen, J.C., Licata, J.W. and McPhait, J. (1993), ―Waiting in the Emergency
Room: How to Improve Patient Satisfaction‖, Journal of Health Care
Marketing, Summer 1993, pp. 26 – 33
Murfin, David E., Bodo B Schlegelmilch, and Adamantios Diamantopoulos
(1995), ―Perceived Service Quality and Medical Outcome: an
interdisciplinary review and suggestions for future research‖, Journal of
Marketing Management, 11, pp 97-117
Nanadakumar, A.K., Peter Berman and Elaine Fleming. (April 1999). Findings
of the Egyptian Health Care Provider Survey. Technical Report 26.
Bethesda, MD: Partnerships for Health Reform Project, Abt Associates
Inc.
Nayyar, Praveen. (1995). Stock market reactions to customer service changes.
Strategic Management ]. 16(1) 39-53.
Nelson, Eugene, Ronald Rust, Anthony Zahorik, Robin Rose, Paul Batalden,
Beth Ann Siemanski. (1992). Do patient perceptions of quality relate to
hospital financial performance?, Health Care Marketing December 6-13.
Oliver, Richard L (1980), ―A Cognitive model of Antecedents and Consequences
of Satisfaction Decisions‖ Journal of Marketing Research, 17, Nov, pp
460-9
Parasuraman, A., Zeithami, V.A. and Berry L,L. (1985), ―A Conceptual Model
of Service Quality and Its Implications for Future Research‖, Journal of
Marketing, 49, Fall, pp.41-50.
Parasuraman, A., Zeithaml, VA. and Berry, L.L. (1988), ―SERVQUAL: a
Multiple Item Scale for Measuring Consumer Perceptions of Service
Quality‖, Journal of Retailing, 64, Spring, pp.26.-43
Parasuraman, A, Berry, L L and Zeithaml, V A (1990). ―Guidelines for
Conducting Service Quality Decrease,‖ Marketing Research, 2(4), 34-44.
Parasuraman, A., Zeithaml, VA. and Berry, L.L. (1991), ―Refinement and
Reassessment of the SERVQUAL Scale‖, Journal of Retailing, 67, 4,
Winter, pp.420-450.
Parasuraman, A, Zeithaml, V A and Berry, L L (1994). ―Reassessment of
Expectations as a Comparison Standard in Measuring Service Quality:
Implications for Further Research,‖ Journal of Marketing, 58(January),
111-24.
Paul, P David (2003), "What is the best approach for measuring service quality of
periodontists?", Clinical Research and Regulatory Affairs, Vol. 20, No.4,
pp 457-468
Peter, J P, Churchill, G A and Brown, T J (1993). ―Caution in the Use of
Difference Scores in Consumer Research,‖ Journal of Consumer
Research, 19(March), 655-62.
Peterson, R.A. and Wilson, W.R. (1992), “Measuring Customer Satisfaction: Fact
and Artefact‖, Journal of the Academy of Marketing Science, 20, Winter,
pp.61-71.
Phillips, L.W., Chang, D,R. and Buzzell, RD. (1983), ―Product Quality Cost
Position and Business Performance: a Test of Some Key Hypothesis‖,
Journal of Marketing, 47, Spring pp.26-43
Rajesh Iyer and James A. Muncy (2002), ―Who Do You Trust‖, Marketing
168
Health Services, Summer , 26-29
Rajuand P. S. and. Lonial S. C (2002): The impact of service quality and
marketing on financial performance in the hospital industry: an empirical
examination, Journal of Retailing and consumer services, vol. 9, no. 6, pp
335 -348
Rao AM and Kent B Monroe (1988), ―The moderator effect of prior knowledge
on cue utilization in product educations‖, Journal of Consumer Research,
15, pp 253-264
Rogers, Malcom P, Matthew H Liang, Robert Poss and Karen Cullen (1982),
―Adverse Psychological sequelae associated with total joint replacement
surgery‖, General Hospital Psychiatry, 4, July, 155-8
Ross Caroline K, Gayle Frommelt, Lisa Hazelwood and Rowland W Chang
(1987), ―The role of expectations in patient satisfaction with medical care‖
JHCM, Vol. 7, No 4, December, pp16-26
Rucci, Anthony, Steven Kirn, Richard Quirvn. (1998). The employee-customer-
profit chain at Sears. Harvard Bus. Rev. (Jan.-Feb.) 83-97
Rust, Roland, Anthony Zahorik, Timothy Keiningham. (1995). Return on
quality (ROQ): Making service quality financially accounTable,
Marketing 59(April) 58-70.
Ryter K (1997), ―Evaluating healthcare service quality: The moderator role of
knowledge‖ Journal of Consumer Satisfaction‖, Dissatisfaction and
Complaining behaviour, volume 10, pp 43-50
Savage. R. and Armstrong D. (1990), ―Effect of General Practitioners Consulting
Style on Patient Satisfaction — a Controlled Study‖, British Medical
Journal, 301, pp 968 -970
Sanjay K Jain and Garima Gupta (2004), Measuring Service Quality:
SERVQUAL vs. SERVPERF Scales, Vikalpa, Volume 29, No 2, April-
June
Schlegelmilch BB., Carman, J.M. and Moore, S.A. (1992), ―Choice and
Perceived Quality of Family Practitioners to the United States and the
United Kingdom‖, The Service Industries Journal, IZ No.2, pp.263—284
Schlegelmitch B Bodo, Carmen M James and Moore S Anne, ( 1992), ―Choice
and perceived quality of family practitioners in the united states and the
united kingdom‖, The service industries journal, volume 12, no. 2, April,
pp 263-284
Swan E John, Esse C Sawyer, Joseph G Van Matre and Gall W McGee,
―Deepening the Understanding of Hospital Patient Satisfaction: Fulfilment
and Equity Effects‖ Journal of Healthcare Marketing, Vol 5, No 3
(Summer 1985), pp 7-18
Swartz, TA and Brown, S.W. (1989), ―Consumer and Provider Expectations and
Experiences in Evaluating Professional Service Quality‖, Journal of the
Academy of Marketing Science, 17, No.2, pp.189 - l95
Teas, K R (1993). ―Expectations, Performance Evaluation, and Consumer‘s
Perceptions of Quality,‖ Journal of Marketing, 57(October), 18-34.
Teas, K R (1994). ―Expectations as a Comparison Standard in Measuring Service
Quality: An Assessment of Reassessment,‖ Journal of Marketing,
58(January), 132-39.
Walbridge, S.W. and Delene, L.M. (1993), ―Measuring Physician Attitudes of
Service Quality‖, Journal of Health Care Marketing, Winter, pp.6-15
169
Ware, H.E. Davies-Avery A.R. and Stewart, A.L. (1978). ―The Measurement
and Meaning of Patient Satisfaction‖, Health and Medical Care Services
Review 1, January-February pp.1-15.
Ware, John E and Allysot. R. Davies (1983), ―Defining and Measuring Patient
Satisfaction With Medical Care, Evaluation and Program Planning, 6,
247—63.
Ware, John E. and Mary K. Snyder (1975), ―Dimensions of Patient Attitudes
Regarding Doctors and Medical Care Services.‘ Medical Care 13, 669—
82.
Webb D (2000). ―Understanding Consumer Role and Its Importance in the
formation of Service Quality Expectations‖ The Service Industries
Journal, Jan, 20, (1) pp1-21
Webster C (1989), Can consumers be segmented on the basis of their service
quality expectations? Journal of Service Marketing, Vol. 3, No 2, Spring
1989
Westbrook, R. (1987), ―Product/Consumption Based Affective Responses‖,
Journal of Marketing Research, 24, August pp 258 – 270
Wikstrom, Solvig (1994), ―Managing Value‖, Constellation, paper presented at
QUIS conference
Wolf MH, Putnam SM, James SA and Stiles WB (1978), ―The medical
interview satisfaction scale: Development of a scale to measure patient
perceptions of physician behaviour‖, Journal of Behavioural Medicine,
Vol. 1, No.4, pp. 391-401
Woodruff Robert P, Ernest R Cadotte, and Roger L Jenkins (1983),
―Modelling consumer satisfaction process using experience-based norms‖
Journal of Marketing Research, 20, August, 296-304
Woodside Arch G, Lisa L Frey and Robert Timothy Daly (1989), ―Linking
service quality, consumer satisfaction and behavioural intention‖, Journal
of Healthcare Marketing, Vol 9, No 4, Dec 1989, pp 5-17
Wooley FR, Kane RL, Hughes CC and Wright DD (1978), ―The effect of
doctor-patient communication on satisfaction and outcome of care‖, Social
Science and Medicine, Vol. 12, pp. 123-8
Zeithaml, V.A., Berry L.L and Parasuraman, A. (1988), ―Communication and
Control Processes in the Delivery of Service Quality‖, Journal of
Marketing, 52, April, pp.358.
Zeithaml, V.A., Berry, L.L. and Parasuraman, A. (1993), ―:The Nature and
Determinants of Customer Expectations of Service‖, Journal of the
Academy of Marketing Science, 21, No.1, pp.1-12
Zyzanski, L.L., Hulka B.S. and Cassel J.C.,(1974). :Scale for measurement of
satisfaction with medical care: Modifications in content, format and
scoring‖, Medical Care, Vol. 12, July, pp. 611-20
2. Books
Benson, D.L. (1992), Measuring Outcome in Ambulatory Care. Chicago, IL:
American Hospital Publishing
Babbie E (1997), Survey Research Methods, 2nd ed, Wadsworth Publishing
Company, California
Babakus, E and Inhofe, M (1991). ―The Role of Expectations and Attribute
Importance in the Measurement of Service Quality‖ in Gilly M C (ed.),
170
Proceedings of the Summer Educator’s Conference, Chicago, IL:
American Marketing Association, 142-44.
Buzzell, Robert, Bradley Gale. (1987). The PIMS Principles. The Free Press,
New York
Cartwright, A. (1967), Patients and Their Doctors, London, Routledge and Kegan
Paul.
Cartwright, A. and Anderson, R. (1981), General Practice Revisited. A Second
Study of Patients and Their Doctors, London, Tavistock Centre for Health
Services Research.
Churchill, Gilbert. and Lacobucci, Dawn (2002) Marketing Research-
Methodological foundations. Eighth Edition. South-Western,
Cooper R Donald and Schindler S Pamela, (2001) Business Research Methods,
Seventh edition, McGraw-Hill / Irwin, New York
Engel, JF, Kollatt, DT and Blackwell RD. (1969) Consumer Behaviour. New
York, The Dryden Press.
Fisk, RE and Young, C.E. (1985), ―Disconfirmation of Equity Expectation:
Effects on Consumer Satisfaction with Services‖. In: Advances in
Consumer Research. JUI, (Eds) Hirschrnan, E.C. and Holbrook, MB., Ann
Arbor, Michigan, Association for Consumer Research pp.340-345.
Fitzsimmons, J. A. and R. S. Sullivans (1982), Service Operations Management,
New York: McGraw-Hill Book Company
Gronroos, C. (1982), Strategic Management and Marketing in the Service Sector,
Helsingors Swedish School of Economics and Business Administration.
Gronroos, C. (1983), ―Innovative Marketing Strategies and Organization
Structures for Service Firms‖. In: Emerging Perspectives on Service
Marketing, (Eds) Berry L., Schostack, G.L. and Upal, G.D., Chicago,
American Marketing Association, pp 9-21.
Hair, J. et al. (1998). Multivariate Data Analysis with Readings. Fourth Edition,
Prentice Hall, Englewood Cliffs, New Jersey 07632
Haywood-Framer J and F Staurt (1988): ―Measuring the Quality of Professional
Services‖ in The Management of Service Operations proceedings from the
Third Annual Conference of the UK Operations Management Association,
R Johnston, ed. London: University of Warwick
Howard, A. John & Sheth, Jadith N (1969), The Theory of Buyer Behaviour.
Wiley: New York.
Hussey J and Roger Hussey (1997), Business Research, a practical guide for
undergraduate and postgraduate students, Macmillan Press Ltd, London
Iacobucci, D, Grayson, K A and Ostrom, A L (1994). ―The Calculus of Service
Quality and Customer Satisfaction: Theoretical and Empirical
Differentiation and Integration,‖ in Swartz, T A; Bowen, D H and Brown,
S W (eds.), Advances in Services Marketing and Management, Greenwich,
CT: JAI Press,1-67.
Jowell, R. and Airey, C. (1990), British Social Attitudes: The 1987 Report,
Aldershot, Gower.
Kotler, Phillip and Gary Armsrtrong (1999). Principles of Marketing. 8th edition,
New Jersey: Prentice Hall Inc.
Kotler, Phillips (1988), Marketing Management Analysis, Planning,
Implementation and Control, 6th edition, Englewood Cliffs, NJ: Prentice-
Hall, Inc.
171
LoveLock, CH (1981b), ―Why Marketing Management Needs to be Different for
Services‖. In: Marketing of Services, (Eds) Donnelly, J. and George, W.,
Chicago, American Marketing Association, pp.5-9.
Malhotra, K Naresh (1999), Marketing Research-An applied orientation. Third
Edition. Prentice Hall, Inc. New Jersey
Mostyn, B. (1985), ―The Content Analysis of Qualitative Research Data: A
Dynamic Approach‖ in Brenner, Michael, Brown, Jennifer and Canter,
David (eds) The Research Interviews, Uses ad Approaches, London:
Academic Press, pp115-46
Nelson, E.C., Splain, M.E., Batalden, P.B. et al. (1998), Measuring Clinical
outcomes at the frontline, in C. Caldwel (ed.) The handbook for managing
change in healthcare. Milwaukee, WI: ASQ Quality Press
Nicosia, Francesco(1966) Consumer Decision Processes: Marketing and
Advertising Implications. Prentice-Hall, Englewood Cliffs, NJ
Parasuraman, A., Zeithaml, VA. and Berry, L.L. (1990), Delivering Service
Quality: Balancing Consumer Perceptions and Expectations, New York,
The Free Press
Polyani M (1983), The Tacit Dimension, Mass Peterson Smith
Sasser, W. Earl, Jr, R. Paul Olsen, and D. Daryl Wyckoff (1987), Management
of Service Operations: Text, Cases and Readings. Boston: Allyn and
Bacon, Inc.
Sekran U. (2000), Research Methods for Business, USA, John Wiley & Sons, Inc.
Silvermann, David (1993), Interpreting Qualitative Data: Methods for Analyzing
Talk, Text and Interaction ,London, Sage
Smith Ruth A and Michael J Houston (1983), "Script based evaluations of
satisfaction with services" in Emerging Perspectives on Services
Marketing, Leonard Berry et al., eds., Chicago: American Marketing
Association
Spreng, R A and Singh, A K (1993). ―An Empirical Assessment of the
SERVQUAL Scale and the Relationship between Service Quality and
Satisfaction,‖ in Peter, D W, Cravens, R and Dickson (eds.), Enhancing
Knowledge Development in Marketing, Chicago, IL: American Marketing
Association, 1-6.
Tabachnick, Barbara. and Fidell, Linda (2001). Using Multivariate statistics. 4th
edition, Allyn and Bacor, 2001
Walburg J., (2006), "The Outcome Quadrant" in Performance Management in
healthcare improvement patient outcomes: an integrated approach,
Walburg, J., Bevan H., Wilderspin J. and Lemmens K. eds, Routledge,
New York
Ware JE and Davies-Avery A and Stewart AL (1977), The measurement and
meaning of patient satisfaction: A review of the literature, P-6036, Santa
Monica, California: Rand Collection
Ware, John E and W. Russell Wright (1976), ‗Development and Validation of
Scales to measure patient satisfaction with Healthcare Services: Volume 1
of a final report. Part B: Results Regarding Scales Constructed From the
Patient Satisfaction Questionnaire and Measures of Other Health Care
Perceptions.‘ Springfield, VA: National Technical Information Services
(NTIS No. PH 288 330)
Zeithaml, V.A., and Bitner M.J. (2000), Service Marketing: Integrating Customer
172
Focus Across Firms, McGraw Hill Companies, USA
Zeithaml, V.A., Parasuraman, A. and Berry L.L. (1990), Balancing Consumer
Perceptions and Expectations, The Free Press, New York
3. Online References
Altera Corporation, 2006: http://www.altera.com/end-
markets/medical/overview/med-overview.html
Bakr, A (2008), ―Government re-examines health insurance”, Business
Information Center, American Chamber of Commerce
http://www.amcham.org.eg/publications/businessmonthly/November
%2006/indepth(governmentreexamineshealthinsurance).asp
Cranberry Corporations: http://bpo.cranberryindia.com/bpo.htm
David Silverstein (2006) Healthcare Costs – The Real Story:
http://www.leadershipandbusiness.com/2006/03/healthcare_cost.html
EMRO (eastern Mediterranean regional health systems observatory (2008) in
―Health Systems Profile: Egypt‖, World Health organization Publications,
2006
http://gis.emro.who.int/HealthSystemObservatory/PDF/Egypt/Full%20Pro
file.pdf
Espicom Business Intelligence, May 31st, 2007
https://www.espicom.com/Prodcat.nsf/Search/00000546?OpenDocument
PriceWaterhouseCoopers (1998), ―Healthcast 2010, Smaller World, Bigger
Expectations‖
http://www.pwchealth.com/articles.shtml#HealthCast%202010
PriceWaterhouseCoopers, 2006:
http://pwc.com/us/eng/about/ind/healthcare/rising.html
SIS 2007
http://www.sis.gov.eg/En/Pub/yearbook/book2007/110105000000000015.htm
173
APPENDIX A:
EGYPT: SOCIO ECONOMIC CLASSIFICATION
Class Average Monthly HH Education Profession
Income in LE
A-B A: $1500+/month Holders of Members of the top general management (managers, directors,
B: $800-1499/month university degrees at senior executives)
least Businessmen/ merchants (employers with more than 5 persons)
Senior government officials
Professionals (requiring qualifications of degree standard, e.g.
doctors, accountants, architects, lawyers) running their own business,
or as employees
University teachers (professors, senior lecturers)
C1 C1: $300-799/month Varies between Middle management (including junior executives, senior
holders of diplomas supervisors, etc.)
(minimum) to Professionals (requiring qualifications of degree standards) working
holders of university as employees but with less than 5 years experience
degrees Senior technicians and professionals without university education of
a degree standard
Middle government officials (section heads, senior supervisors, etc)
High school teachers
Self-employed or employers with 2-5 persons in small business
(grocers, small shop owners, transport, etc.) in main urban areas
C2 C2: $150-299/month Holders of technical Small shop owners with no employees mainly in rural areas
diplomas, or Junior government employees
completed middle Junior office employees in the private sector (clerks, typists, office
education assistants, bookkeepers, etc.)
I
Production supervisors and foremen
Primary education teachers
Paramedical staff (without university degree, e.g. nurses, lab
assistants, etc.)
Artisans and technicians (including surveyors, draughtsmen, etc.)
Farmers (large and middle scale)
Skilled manual employees
Skilled manual employees (who had some apprenticeship technical
course, etc.)
Drivers
Class Average Monthly HH Education Profession

Income in LE
D-E D/E: Less than Mostly illiterate, or Skilled workers
$150/month with informal Semi-skilled and unskilled manual workers
education, or Drivers
primary education Small scale farmers and fishermen
maximum Junior office employees
Servants/ messengers
Street vendors
Shop employees
Assistant technicians
Unemployed
Source: MEMRB Research Agency
II
This socioeconomic classification is based on a combination of 5 factors (profession, education, income and household size, area of
residence, and properties and household appliances). A minimum level in each factor is necessary to be eligible for each class. That is why
we find certain overlaps among the different classes. For example, we find ‗junior office employees‘ in both C and DE class groups, as the
final classification of each household will depend on the other criteria.
Although income is an indicator of the economic class, yet size of family must be taken into consideration (in addition to the other criteria),
because a 7-8 member family with a monthly income of LE 1500, does not have the same standard of living that a 3 member family of the
same income has.
Education can‘t be the sole indicator of socioeconomic class because many of the technicians have higher incomes than university
graduates, and some of the rich merchants are illiterates.
Profession can‘t be the sole indicator of socioeconomic class, since some of the professions that were previously of high standing and high
pay, are no longer so due to the unsTable economic situation of the country.
Area of residence: The proprietor of this classification, Middle East Marketing Research Bureau, has a record of all cities and districts in
Egypt, along with their classification. For example, some districts in Cairo, such as Maadi, Zamalek, and parts of Heliopolis are classified as
'A class' residential areas, while other areas are DE class areas.
Properties and household appliances: In most cases, ‗A‘ have their houses fully equipped. ‗B‘s may have most of what a regular household
would need, for example, a colored TV set, a washing machine, and maybe a VCR player. However, ‗C‘s would have most of the electronic
equipment missing from the house, and ‗DE‘s would probably have at most a TV set and a regular tape recorder set.
III
APPENDIX B
Questionnaire
This questionnaire deals with your experiences as a consumer of healthcare

services. It aims to evaluate your experience with the last encounter you had
with a specific hospital as well as what you would expect from your service
provider as an excellent hospital and the importance of each part of the hospital
encounter to you. There are no right or wrong answers, all we are interested in
are the numbers that strongly shows your expectations, perceptions and
importance with of the services offered.
Guide to Answering
S D = Strongly Disagree
D = Disagree
N = Neutral
A = Agree
SA = Strongly Agree
IV
A) Perceptions
The following statements deals with your feelings about hospital XYZ that you
have chosen to base your opinions upon for hospital service. Please show the
extent to which you think this institution possesses the features described in
each statement. Do this by using the scale presented below. If you strongly
disagree that an institutions possesses this feature, circle a one. If your feelings
are not strong, circle one of the numbers between one and five to reflect the
actual strengths of your feelings. If you strongly agree that the hospital
possesses this feature, circle a five.
S D D N A SA
1. Hospital XYZ has the most technologically 1 2 3 4 5
advanced equipment
2. The physical facilities (buildings, 1 2 3 4 5
landscape, physical layout) at Hospital XYZ
Premises//Employees
is visually impressive
3. Employees at Hospital XYZ are extremely 1 2 3 4 5
neat appearing
4. Materials associated with the service 1 2 3 4 5
clearly contain all the necessary information
at Hospital XYZ
5. Doctors in Hospital XYZ are always on 1 2 3 4 5
time
6. Patients of Hospital XYZ feel extremely 1 2 3 4 5
7. Doctors in Hospital XYZ have very high 1 2 3 4 5
level of knowledge required to answer my
questions satisfactorily
8. Excellent hospitals have an experienced 1 2 3 4 5
doctor who is aware of my case available at
all times of my hospital stay
9. Doctors in Hospital XYZ hear very 1 2 3 4 5
carefully what I have to say
10. Doctors in Hospital XYZ are extremely 1 2 3 4 5
careful in explaining what I am expected to
do in words understand
11. Doctors in Hospital XYZ spend enough 1 2 3 4 5
Doctors Medical Service
time with me
12. Doctors in Hospital XYZ examine me very 1 2 3 4 5
carefully before deciding what is wrong
with me
13. Doctors in Hospital XYZ treat me with 1 2 3 4 5
respect
14. Where my medical care is concerned, 1 2 3 4 5
doctors in Hospital XYZ discuss all
V
decisions with me
15. Doctors in Hospital XYZ have excellent 1 2 3 4 5
reputations
16. Doctors in excellent hospitals are 1 2 3 4 5
17. Doctors in excellent hospitals are 1 2 3 4 5
degrees
18. Doctors in Hospital XYZ never order never 1 2 3 4 5
order any unnecessary diagnostic medical
procedures
19. Laboratory and X-ray technicians in 1 2 3 4 5
hospital XYZ have high technical skills
required to perform the service
20. Lab tests and X-rays in Hospital XYZ are 1 2 3 4 5
Diagnostics
always done right the first time

21. Lab tests and X-rays in Hospital XYZ are 1 2 3 4 5
always provided at the time they are
promised
22. Nurses in Hospital XYZ have high 1 2 3 4 5
personal hygiene (body and mouth odor,
nails, cleanliness of uniforms etc)
23. Nurses in Hospital XYZ have level of 1 2 3 4 5
knowledge & skill needed to perform the
service very well
24. Nurses in Hospital XYZ perform the 1 2 3 4 5
service required (tests, procedures,
medication dispensing) at exactly the right
time
25. Nurses in Hospital XYZ are consistently 1 2 3 4 5
courteous
Nursing Medical Service
26. Nurses in Hospital XYZ always 1 2 3 4 5

communicate in accepTable language
27. Nurses in Hospital XYZ always respond in 1 2 3 4 5
a reasonable length of time
28. Nurses in Hospital XYZ give me personal 1 2 3 4 5
attention
29. Nurses in Hospital XYZ understand my 1 2 3 4 5
specific needs
30. In Hospital XYZ, appointments are made 1 2 3 4 5
easily
Admission
31. Admission personnel in Hospital XYZ 1 2 3 4 5

provide clear information (e.g. directions,
schedules)
VI
32. Admission personnel in Hospital XYZ are 1 2 3 4 5
consistently courteous
33. Meals in Hospital XYZ are always served at 1 2 3 4 5
the right temperature
34. Meals in Hospital XYZ have excellent 1 2 3 4 5
quality
35. Meals in excellent hospitals should be 1 2 3 4 5
Meals
carefully prepared to suite the case of each

individual patient
36. Rooms in Hospital XYZ are visually 1 2 3 4 5
appealing
37. Rooms and baths in Hospital XYZ are kept 1 2 3 4 5
very clean
Rooms
38. Housekeeping staff in Hospital XYZ are 1 2 3 4 5

consistency courteous
39. Business office personnel in Hospital XYZ 1 2 3 4 5
Discharge
answer questions (e.g. billing, insurance)

very adequately
40. Business personnel in Hospital XYZ are 1 2 3 4 5
B) Expectations
The following statements deal with your opinions of hospital service. Please
show the extent to which you think institutions offering medical service should
possess the features described in each statement. Do this by using the scale
presented. If you strongly disagree that an institution should possess a feature,
circle a one. If your feelings are not strong, circle one of the numbers between
one and five to reflect the actual strengths of your feelings. If you strongly
agree that an institution should possess this feature, circle a five.
S D D N A SA
1. Excellent hospitals should have the most 1 2 3 4 5
2. The physical facilities (buildings, 1 2 3 4 5
landscape, physical layout) at excellent
Premises/Employees
hospitals should be visually impressive

3. Employees at Excellent hospitals should be 1 2 3 4 5
4. Materials associated with the service 1 2 3 4 5
should clearly contain all the necessary
information at excellent hospitals
5. Doctors in excellent hospitals should 1 2 3 4 5
always on time
Medical
Doctors
6. Patients of excellent hospitals should feel 1 2 3 4 5

service
extremely safe in their transactions

7. Doctors in excellent hospitals should have 1 2 3 4 5
VII
very high level of knowledge required to
answer patient's questions satisfactorily
8. Excellent hospitals should have an 1 2 3 4 5
experienced doctor who is aware of the
patient's case available at all times of my
hospital stay
9. Doctors in excellent hospitals should hear 1 2 3 4 5
very carefully what the patient has to say
10. Doctors in excellent hospitals should be 1 2 3 4 5
extremely careful in explaining what the
patient is expected to do in words she
understands
11. Doctors in excellent hospitals should spend 1 2 3 4 5
enough time with the patient
examine the patient very carefully before
deciding what is wrong with me
always treat the patient with respect
14. Where the patient's medical care is 1 2 3 4 5
concerned, doctors in excellent hospitals
should discuss all decisions with the her
15. Doctors in excellent hospitals should have 1 2 3 4 5
excellent reputations
degrees
18. Doctors in excellent hospitals should never 1 2 3 4 5
order any unnecessary diagnostic medical
procedures
19. Laboratory and X-ray technicians in 1 2 3 4 5
excellent hospitals should have high
technical skills required to perform the
service
20. Lab tests and X-rays in excellent hospitals 1 2 3 4 5
Diagnostics
should always done right the first time

21. Lab tests and X-rays in excellent hospitals 1 2 3 4 5
should always provided at the time they are
promised
22. Nurses in excellent hospitals should have 1 2 3 4 5
high personal hygiene (body and mouth
odor, nails, cleanliness of uniforms etc)
Nursing
Service
23. Nurses in excellent hospitals should have 1 2 3 4 5

level of knowledge & skill needed to
perform the service very well
VIII
24. Nurses in excellent hospitals should 1 2 3 4 5
perform the service required (tests,
procedures, medication dispensing) at
25. Nurses in excellent hospitals should be 1 2 3 4 5
26. Nurses in excellent hospitals should always 1 2 3 4 5
communicate in acceptable language with
patients
27. Nurses in excellent hospitals should always 1 2 3 4 5
respond in a reasonable length of time
28. Nurses in excellent hospitals should give 1 2 3 4 5
patients personal attention
29. Nurses in excellent hospitals should 1 2 3 4 5
understand the specific needs of their
patients
30. In excellent hospitals, appointments should 1 2 3 4 5
be made easily
31. Admission personnel in excellent hospitals 1 2 3 4 5
should provide clear information (e.g.
admission
directions, schedules etc) to patients

32. Admission personnel in excellent hospitals 1 2 3 4 5
should be consistently courteous and helpful
to patients
33. Meals in excellent hospitals should always 1 2 3 4 5
served at the right temperature
34. Meals in excellent hospitals should be of 1 2 3 4 5
excellent quality
35. Meals in excellent hospitals should be 1 2 3 4 5
meals
carefully prepared to suite the case of each

individual patient
36. Rooms in excellent hospitals should be 1 2 3 4 5
visually appealing
37. Rooms and baths in excellent hospitals 1 2 3 4 5
should be kept very clean
rooms
38. Housekeeping staff in excellent hospitals 1 2 3 4 5

should consistently be courteous
39. Business office personnel in excellent 1 2 3 4 5
discharge

40. Business personnel in excellent hospitals 1 2 3 4 5
should consistently be courteous to patients
IX
C) Importance
The following section lists the eight features concerning hospitals and services
they are offering. We would like to know how important each feature is to our
patients when they evaluate a Hospital's service quality. Please allocate a total
of 100 points among the eight features according to how important each feature
is to you. The more important the feature, the more points you should allocate
to it. Please ensure that the sum of points you allocate to the eight features add
up to 100.
41. Least Not Neutral Imp Most
Imp Imp Imp
42. Hospital Premises and
Employees
43. Medical Doctors
44. Diagnostic Services
45. Nursing Care
46. Admission Personnel
47. Meals
48. Housekeeping
49. Discharge Services
D) For Overall Hospital Assessment

The following section deals with your feelings about the overall service
quality, your degree of satisfaction and intention to return to the hospital that
provided the service. Please show the extent to which you think this institution
possesses the features described in each statement. Do this by using the scale
presented below. As in the previous, If you strongly agree that an institutions
possesses a feature, circle a one. If your feelings are not strong, circle one of
the numbers between one and five to reflect the actual strengths of your
feelings. If you strongly agree that an institution possess this feature, circle a
five.
S D D N A SA
50. Overall, I am satisfied with hospital 1 2 3 4 5
service provided
51. I should definitely choose this hospital 1 2 3 4 5
again if I need it
52. I should never recommend this hospital 1 2 3 4 5
to a friend or relative
53. I got excellent value of my money for 1 2 3 4 5
hospital services rendered
54. I left the hospital without any hospital- 1 2 3 4 5
caused problems for me
55. I left the hospital without any hospital- 1 2 3 4 5
caused problems for my baby
X
E) Demographic Characteristics
The following set of questions relate to your personal characteristics. All
information should be kept in strict confidentiality. Please respond by circling
the number you think best reflects your personal characteristics:
56. Age: 59. Education:
0-25 Diploma / Middle
26-35 Education
36-45 College / University
More than 45 Graduate Education
57. Occupation: 60. Income level:
> 15, 000 +/month
58. Geographic Location: 9,000 to 15,000
4,000 to 9,000 / month
2000 to 4,5000 / month
Less than 2,000 / month
XI
APPENDIX C
RESULTS OF PILOT STUDY
The following Tables summarize the results obtained for each construct in the
pilot study performed:
Table A1: Demonstrates Frequency of Responses of the Results for the

Construct "Premises and Employees" in the Pilot Study
Perceptions Expectations
SD D N A SA SD D N A SA
1 2 3 4 5 1 2 3 4 5
Q1 2 2 0 4 2 0 0 0 2 8
Q2 2 0 3 4 1 0 0 2 3 5
Q3 1 1 1 4 3 0 0 0 1 9
Q4 0 5 5 0 0 0 0 3 3 4
Q5* 0 0 0 2 0 0 0 0 0 2
Q5 showed non-response in 8 out of 10 patients (80%)

Construct "Doctors Service" in the Pilot Study
1 2 3 4 5 1 2 3 4 5
Q6 1 1 2 2 4 0 0 0 1 9
Q7 0 3 2 1 4 0 0 1 2 7
Q8 1 1 2 2 4 0 0 1 2 7
Q9 0 3 2 1 4 0 0 1 2 7
Q10 1 0 4 3 2 0 0 0 3 7
Q11 0 3 2 4 1 0 0 0 3 7
Q12 1 0 5 3 1 0 0 1 3 6
Q13 0 1 3 3 3 0 0 0 3 7
Q14 0 0 1 4 5 0 0 0 1 9
Q15 0 0 6 3 1 0 0 1 3 6
Q16* 0 0 0 0 0 0 0 0 0 0
Q17 0 0 3 2 5 0 0 1 1 8
Q18 0 0 2 3 5 0 0 2 3 5
Q19 0 0 2 3 5 0 0 2 1 7
*Q16 showed non-response in 10 out of 10 patients (100%)
XII
Construct "Diagnostics Service" in the Pilot Study
1 2 3 4 5 1 2 3 4 5
Q20 0 1 4 2 3 0 0 2 3 5
Q21 0 2 4 4 0 0 0 0 4 6
Q22 0 2 5 2 1 0 0 1 6 3
Q23 0 3 3 3 1 0 0 1 6 3
Q24* 0 0 0 1 0 0 0 0 0 1
Q24 showed non-response in 9 out of 10 patients (90%)

Construct "Nursing Service" in the Pilot Study
1 2 3 4 5 1 2 3 4 5
Q25 1 1 4 0 0 0 0 0 3 7
Q26 1 2 4 3 0 0 0 0 4 6
Q27 0 2 2 4 2 0 0 1 1 8
Q28 0 4 1 3 2 0 0 1 1 8
Q29 0 3 2 3 2 0 0 0 3 7
Q30 0 2 4 2 2 0 0 0 3 7
Q31 0 1 5 3 1 0 0 2 2 6
Q32 0 2 4 2 2 0 0 2 1 7

Construct "Admission Services" in the Pilot Study
1 2 3 4 5 1 2 3 4 5
Q33 0 1 3 3 3 0 0 0 5 5
Q34 0 3 4 1 2 0 0 0 5 5
Q35 0 1 3 6 0 0 0 0 7 3

Construct "Meals" in the Pilot Study
1 2 3 4 5 1 2 3 4 5
Q36 0 2 3 4 1 0 0 0 7 3
Q37 0 3 3 3 1 0 0 0 7 3
Q38 1 1 1 5 2 0 0 0 4 6
XIII
Construct "Rooms and Housekeeping" in the Pilot Study
1 2 3 4 5 1 2 3 4 5
Q39 1 0 2 1 5 0 0 1 5 4
Q40 1 1 1 2 5 0 0 3 4 3
Q41 0 0 1 9 0 0 0 3 4 3

Construct "Discharge Services" in the Pilot Study
1 2 3 4 5 1 2 3 4 5
Q42 0 1 4 5 0 0 0 1 5 4
Q43 0 0 5 5 0 0 0 0 7 3
XIV
APPENDIX D
RESULTS OF QUANTITATIVE SURVEY
1. Testing the SERQUAL Method for assessing service quality:

difference between expected and perceived service quality, all variables with
loading less than 0.5 were eliminated, and repeated the factor analysis process.
The results were as follows: Determinate = 1.228E-04is > 0.00001, means that
there is no bivariate correlation > 0.8 in the correlation matrix. This proves the
absence of multi-collinearity.
Table A9: KMO and Bartlett's Test for SERVQUAL Method

Df 780
Sig. .000
analysis technique. Bartlett‘s measure tested the null hypothesis that the
original correlation matrix is an identity matrix. In order to be able to use
Bartlett test of sphericity should be significant <0.05.
Table A10: Demonstrating Total Variance Explained for SERVQUAL Method

Initial Eigen values Extraction Sums Rotation Sums of
of Squared Loadings Squared Loadings
component Total % of Cumulative Total % of Cumulative Total % of Cumulative
1 6.382 15.956 15.956 6.382 15.956 15.956 2.511 6.277 6.277
2 2.498 6.246 22.201 2.498 6.246 22.201 2.236 5.591 11.868
3 1.726 4.315 26.516 1.726 4.315 26.516 2.059 5.147 17.015
4 1.558 3.895 30.411 1.558 3.895 30.411 1.889 4.723 21.738
5 1.504 3.760 34.172 1.504 3.760 34.172 1.751 4.379 26.117
6 1.427 3.567 37.739 1.427 3.567 37.739 1.709 4.272 30.389
7 1.378 3.444 41.183 1.378 3.444 41.183 1.635 4.089 34.477
8 1.313 3.282 44.465 1.313 3.282 44.465 1.619 4.047 38.525
9 1.270 3.174 47.639 1.270 3.174 47.639 1.598 3.994 42.519
10 1.177 2.942 50.581 1.177 2.942 50.581 1.568 3.921 46.439
11 1.102 2.756 53.337 1.102 2.756 53.337 1.440 3.599 50.039
12 1.086 2.715 56.052 1.086 2.715 56.052 1.428 3.571 53.610
13 1.053 2.633 58.685 1.053 2.633 58.685 1.392 3.479 57.089
14 1.009 2.522 61.207 1.009 2.522 61.207 1.363 3.407 60.496
15 .954 2.384 63.591 .954 2.384 63.591 1.238 3.095 63.591
16 .900 2.249 65.840
17 .874 2.184 68.024
18 .836 2.089 70.113
19 .812 2.030 72.143
20 .779 1.948 74.091
21 .747 1.869 75.960
22 .731 1.827 77.787
23 .710 1.776 79.563
24 .656 1.640 81.203
25 .630 1.574 82.778
26 .605 1.513 84.291
27 .581 1.451 85.742
XV
28 .565 1.413 87.156
29 .540 1.351 88.507
30 .533 1.332 89.839
31 .502 1.256 91.095
32 .487 1.218 92.313
33 .470 1.174 93.487
34 .440 1.099 94.586
35 .419 1.048 95.635
36 .415 1.037 96.672
37 .369 .921 97.593
38 .339 .848 98.442
39 .316 .790 99.231
40 .307 .769 100.000
*Extraction Method: Principal Component Analysis.
They explained almost 64 % only of the variance. The rest could not be
explained by the variables included in the analysis.
Table A11: Demonstrating Rotated Component Matrix for SERVQUAL

Method
Component
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
P-E33 .717
P-E35 .674
P-E34 .666
P-E2 .723
P-E5 .512
P-E17 .735
P-E15 .656
P-E16 .615
P-E38 .766
P-E36 .748
P-E37 .548
P-E39 .833
P-E40 .757
P-E32 .673
P-E30 .533
P-E4 .696
P-E8 .635
P-E3 .530
P-E13 .744
P-E14 .566
P-E21 .739
P-E18 .608
P-E28 .762
P-E29 .749
P-E7 .787
P-E20 .574
P-E10 .710
P-E24 .667
P-E25 .795
P-E12 .694
P-E27 .790
* Extraction Method: Principal Component Analysis. Rotation Method: Varimax with Kaiser
Normalization. Rotation converged in 23 iterations.
As can be seen in the above results, the rotation converged in 23 iterations that
were not consistent with the framework the researchers had formulated in the
XVI
2. Testing the WEIGHTED SERVQUAL for assessing service quality

Factor analysis was perfromed using all 40 variables representing the weighted
SERVQUAL method for measurement of service quality [W*(P-E)], all
variables with loading less than 0.5 were eliminated, and repeated the factor
analysis process. The results were as follow: Determinate = 1.167E-04is >
0.00001, means that there is no bivariate correlation > 0.8 in the correlation
matrix. This proves the absence of multi-collinearity.
Table A12: Demonstrating KMO and Bartlett's Test for WEIGHTED
SERVQUAL Method
Df 780
Sig. .000
Table A13: Demonstrating Total Variance Explained for WEIGHTED

SERVQUAL Method
Initial Extraction Sums Rotation Sums
Eigen values of Squared Loadings of Squared Loadings
1 6.323 15.807 15.807 6.323 15.807 15.807 2.308 5.770 5.770
2 2.585 6.463 22.270 2.585 6.463 22.270 1.924 4.809 10.579
3 1.734 4.335 26.605 1.734 4.335 26.605 1.883 4.708 15.287
4 1.579 3.948 30.553 1.579 3.948 30.553 1.779 4.447 19.734
5 1.506 3.764 34.317 1.506 3.764 34.317 1.707 4.266 24.000
6 1.454 3.636 37.953 1.454 3.636 37.953 1.623 4.056 28.057
7 1.439 3.599 41.551 1.439 3.599 41.551 1.619 4.047 32.104
8 1.298 3.245 44.797 1.298 3.245 44.797 1.592 3.981 36.085
9 1.248 3.121 47.917 1.248 3.121 47.917 1.587 3.967 40.052
10 1.175 2.936 50.854 1.175 2.936 50.854 1.579 3.947 43.998
11 1.146 2.866 53.720 1.146 2.866 53.720 1.555 3.887 47.885
12 1.069 2.673 56.393 1.069 2.673 56.393 1.437 3.592 51.478
13 1.016 2.541 58.934 1.016 2.541 58.934 1.409 3.522 55.000
14 .984 2.460 61.395 .984 2.460 61.395 1.261 3.152 58.152
15 .940 2.350 63.745 .940 2.350 63.745 1.243 3.107 61.258
16 .902 2.255 66.000 .902 2.255 66.000 1.230 3.075 64.333
17 .876 2.190 68.190 .876 2.190 68.190 1.199 2.998 67.331
18 .824 2.060 70.250 .824 2.060 70.250 1.168 2.919 70.250
19 .789 1.972 72.223
20 .761 1.904 74.126
21 .726 1.816 75.942
22 .719 1.797 77.739
23 .690 1.726 79.465
24 .651 1.628 81.093
25 .620 1.550 82.642
26 .611 1.527 84.170
27 .590 1.475 85.645
XVII
28 .582 1.454 87.099
29 .551 1.378 88.477
30 .525 1.311 89.788
31 .519 1.297 91.085
32 .487 1.217 92.302
33 .473 1.181 93.483
34 .452 1.129 94.613
35 .421 1.052 95.664
36 .410 1.026 96.690
37 .371 .926 97.617
38 .351 .877 98.493
39 .322 .805 99.298
40 .281 .702 100.000
* Extraction Method: Principal Component Analysis.
Table A14: Demonstrating Rotated Component Matrix for WEIGHTED
SERVQUAL Method
Component
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
P_E33D6 .778
P_E34D6 .713
P_E35D6 .665
P_E1D1 .767
P_E2D1 .710
P_E4D1 .622
P_E38D7 .780
P_E36D7 .751
P_E37D7 .640
P_E39D8 .875
P_E40D8 .815
P_E16D2 .830
P_E17D2 .656
P_E30D5 .695
P_E31D5 .664
P_E15D2 .623
P_E11D2 .600
P_E13D2 .725
P_E14D2 .673
P_E9D2 .651
P_E12D2 .608
P_E21D3 .785
P_E18D3 .614
P_E29D4 .763
P_E28D4 .744
P_E25D4 .778
P_E26D4 .609
P_E20D3 .847
P_E7D2 .508
P_E27D4 .839
P_E8D2 .803
P_E24D4 .809
P_E3D1 .864
P_E10D2 .779
Rotation Method: Varimax with Kaiser Normalization. Rotation converged in 21 iterations.
XVIII
3. Testing the SERPERF Method for assessing service quality:

Perceived service quality (P), all variables with loading less than 0.5 were
eliminated, and repeated the factor analysis process. The results were as
follow: Determinate = 6.568 E-06 is > 0.00001, means that there is no
bivariate correlation > 0.8 in the correlation matrix. This proves the absence of
multi-collinearity.
Table A15: Demonstrating KMO and Bartlett's Test for SERVPERF Method
Df 780
Sig. .000
Table A16: Demonstrating Total Variance Explained for SERVPERF Method

Initial Extraction Sums Rotation Sums
Eigenvalues of Squared Loadings of Squared Loadings
1 8.595 21.487 21.487 8.595 21.487 21.487 2.468 6.171 6.171
2 2.603 6.506 27.994 2.603 6.506 27.994 2.173 5.433 11.604
3 1.593 3.983 31.977 1.593 3.983 31.977 1.927 4.819 16.423
4 1.518 3.794 35.771 1.518 3.794 35.771 1.823 4.558 20.981
5 1.346 3.365 39.136 1.346 3.365 39.136 1.737 4.344 25.324
6 1.272 3.181 42.317 1.272 3.181 42.317 1.729 4.324 29.648
7 1.205 3.012 45.330 1.205 3.012 45.330 1.534 3.836 33.483
8 1.185 2.962 48.291 1.185 2.962 48.291 1.520 3.800 37.284
9 1.127 2.818 51.109 1.127 2.818 51.109 1.454 3.636 40.920
10 1.093 2.733 53.843 1.093 2.733 53.843 1.437 3.592 44.512
11 1.084 2.710 56.553 1.084 2.710 56.553 1.362 3.404 47.916
12 1.052 2.630 59.183 1.052 2.630 59.183 1.359 3.399 51.315
13 .972 2.429 61.612 .972 2.429 61.612 1.311 3.278 54.593
14 .946 2.365 63.976 .946 2.365 63.976 1.309 3.273 57.866
15 .932 2.331 66.307 .932 2.331 66.307 1.302 3.256 61.122
16 .876 2.190 68.498 .876 2.190 68.498 1.290 3.224 64.346
17 .831 2.079 70.576 .831 2.079 70.576 1.267 3.169 67.515
18 .803 2.007 72.583 .803 2.007 72.583 1.223 3.057 70.572
19 .772 1.931 74.514 .772 1.931 74.514 1.185 2.963 73.535
20 .752 1.881 76.394 .752 1.881 76.394 1.144 2.860 76.394
21 .698 1.744 78.139
22 .667 1.666 79.805
23 .645 1.612 81.417
24 .614 1.535 82.952
25 .600 1.499 84.451
26 .560 1.400 85.850
XIX
27 .550 1.376 87.226
28 .530 1.325 88.551
29 .501 1.252 89.803
30 .488 1.219 91.022
31 .468 1.171 92.193
32 .458 1.146 93.338
33 .429 1.073 94.412
34 .389 .973 95.385
35 .374 .934 96.319
36 .363 .906 97.225
37 .328 .821 98.046
38 .296 .741 98.787
39 .261 .652 99.439
40 .224 .561 100.000
Table A17: Demonstrating Rotated Component Matrix for SERVPERF
Method
Component
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
A18 .689
A30 .660
A20 .655
A1 .615
A33 .725
A34 .659
A35 .627
A15 .716
A16 .704
A17 .658
A40 .814
A39 .791
A2 .747
A5 .544
A38 .762
A36 .681
A37 .505
A24 .786
A28 .780
A29 .672
A4 .833
A3 .509
A14 .777
A12 .788
A23 .751
A27 .565
A26 .851
A7 .769
A32 .713
A13 .870
A21 .859
A31 .805
A11 .744
A10 .839
XX
*Extraction Method: Principal Component Analysis. Rotation Method: Varimax with Kaiser
Normalization. a Rotation converged in 28 iterations.
XXI

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Development of a Model for Healthcare Service

To obtain the degree of Doctor of Business Administration

Dr Ingy Mohamed Fikry Farid

MD, MPhil, MBA, MSc

Maastricht School of Management

I.M.F. Farid, Development of a Model for Healthcare Service Quality: An

Key words: Service Quality/Healthcare Marketing/Developing Countries/ Egypt/

Cover: Ingy Mohamed Fikry Farid

© 2008 by I.M.F. Farid, Maastricht School of Management. All rights reserved. No

Prof. Dr. Jan Walburg

Prof. Dr. Ahmed Taher

CS/D Confirmation Satisfaction/Disconfirmation

1.1 Significance of the Problem and Choice of topic

1.2 Statement of the Problem

1.3 Objective(s) of the Study

1.4: Research Questions

1.5 Research Methodology

1.6 Scope of the Research

1.9 Organization of the Research

The success of a service organization lies centrally within the boundaries of

2.1: Healthcare Sector Worldwide

2.2: Consumer Satisfaction Literature

2.3: Consumer Satisfaction and Service Quality Literature

Patient satisfaction reigns supreme in healthcare marketing, and satisfaction

2.6: Linking Service Quality, Patient Satisfaction and Behavioural Intentions to

2.7 Effect of Consumer Demographics on Service Quality Expectations and

2.8 Egyptian Healthcare Systems

2.8.1 Structure of the Egyptian Healthcare System

2.8.2 Stakeholders in Healthcare System in Egypt

2.8.2.2 Medical Stakeholders

2.8.3 Healthcare Finances in Egypt

2.8.4 Health Services Positive Indicators

2.8.6 Health Sector National Reform Program

2.9 Linking between Service Quality, Outcome, and Financial Performance

2.10 Service Quality: Implementation of a Consumer-Focused Culture

Source: Brown and Swartz, 1989

G) Access (Availability): The ease of

Source: Joby, 1992, Walbridge and Delene, 1993and Carman, 1990

Source: Woodside et al., 1989

Total health 30 - - 192 -

Table 2.7: Sources of finance, by percent (1990-2004)

Central 28.98% 35% 29% -

Source: EMRO, 2006

Public and central hospitals (Number) 169 381

Rural hospitals (Number) 39 931

Rural health units (Number) 1880 4500

Beds (in thousand) 84.4 185

Number of doctors (in thousand) 52.3 164

Number of nursing categories (in thousand) 60.3 206

Number of population per bed 499 393

Number of population per doctor 805 440

Number of population per nurse 698 353

Medicine self-sufficiency ratio (%) 73.6 93.3

Source: (SIS, 2007)

Expectations Use Occasion

Source: Cadotte et al., 1987

Source: Gronroos, 1984

Word-of-Mouth Personal Past

Source: Parasuraman et al., 1990

Perceived Control Gap 3

Path 1: Path linking Satisfaction and purchase intentions

Source: Cronin & Taylor, 1992

(A) (N) Nursing (F) Food (H)

Overall Satisfaction with