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Health Care Management Review:

October/December 2005 - Volume 30 - Issue 4 - pp 361-371

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Improving Outpatient Health Care Quality: Understanding the Quality Dimensions

Ward, Keith F.; Rolland, Erik; Patterson, Raymond A.
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Author Information

Keith F. Ward, PhD, is Assistant Professor College of Business and Economics, Department of Management, Boise State University, ID. E-mail: kward@boisestate.edu. Erik Rolland, PhD, is Department Chair and Associate Professor, Department of Management-The Economic Approach, The A. Gary Anderson Graduate School of Management, University of California, Riverside. E-mail: erik.rolland@ucr.edu. Raymond A. Patterson, PhD, is Canada Research Chair and Associate Professor, Accounting & MIS, School of Business, The University of Alberta, Edmonton, AB, Canada. E-mail: ray.patterson@ualberta.ca.
Abstract

Abstract: Based on literature review, we derive a set of dimensions that influence patientperceived health care quality. Utilizing outpatient survey data from 222 different physicians, we identified six underlying quality factors and classified them according to the derived dimensions. These quality factors explain approximately 51 percent of the variation in overall patient-perceived health care quality. Although the Institute of Medicine's report, Crossing the Quality Chasm, acknowledged the tremendous advances in medical acumen in the past half-century, it also noted that this period experienced a substantial increase in patients' concerns over the quality of health care. These quality concerns were exacerbated by increases in the following: 1. the variety and complexity of potential treatments for diseases; 2. the number of societal members suffering from chronic conditions; and 3. the overall health care costs. As Washburn recently noted, despite these increases, the U.S. health care system has shown little change or willingness to acknowledge these heightened concerns over the quality of health care provided. Therefore, the need to study health care quality remains a vital issue for the medical community. Although thousands of studies have examined the efficacy of simple interventions (e.g., efficacy of new treatments), "the methods of evaluating complex interventions such as quality improvement interventions are less well described." This "complexity" of service quality in
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the health care delivery process is due to disagreement over how to properly evaluate quality. Specifically, disagreement exists regarding the appropriate dimensions for measuring quality, as well as which participants in the health care process should serve as the evaluators. Health care delivery quality is explored from the patient's perspective and is divided into four sections. The first section summarizes the debate over technical versus functional health care quality and the importance of the patient perspective. The second section examines prior health care research and identifies the major dimensions related to patient-perceived quality. The third section details an empirical analysis that identifies critical factors contributing to the patient-perceived quality dimensions. The conclusion discusses the findings as well as implications for managerial practice and suggestions for future research.
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THEORETICAL DEVELOPMENT
TECHNICAL AND FUNCTIONAL QUALITY

The paucity of descriptive literature on quality improvement methods may be due to the debate over whose opinion is most relevant-the provider or the patient-in regards to evaluating the health care provided. This debate was described as the difference between technical and functional quality. Technical health care quality (THQ) can be defined primarily as the degree of adherence to established technical norms and procedures, whereas functional health care quality (FHQ) is the manner in which the health care services are delivered. Due to training and experience, medical experts have been considered to be better equipped than patients to evaluate THQ. Indeed, the literature suggests that patients often cannot distinguish THQ from FHQ. This is not surprising given that research shows an interrelationship between THQ and FHQ However, it is clear that the patients' embedded participation in the health care process provides them with a unique vantage point from which to render an opinion regarding the overall delivery of health care quality-including perceptions of both THQ and FHQ. A patient's perceptions regarding the manner in which his or her care was provided can negatively impact the patient's overall perceptions of quality-even when an expert panel judges the diagnostic and treatment quality to be superior. In fact, FHQ may be more important to the patient's perspective on quality because THQ is considered satisfactory by patients in most cases. Therefore, the patient assumes that the majority of the providers are equal in technical proficiency. The patients' viewpoint is both valuable and unique, even while acknowledging that patients cannot perfectly judge the technical quality of the health care they receive. Although the works of the foundational researchers discussed above can be classified as encompassing either one or both of the health care quality constructs (THQ/FHQ), none completely capture our viewpoint that (1) THQ and FHQ are distinct concepts, (2) patient satisfaction is a distinctly different measurement of THQ/FHQ, and (3) the patient's view on both THQ and FHQ is relevant in determining the quality of health care delivery. Health care research and practice has long understood that health care quality consists of both clinical and nonclinical factors that cannot readily be separated. Clearly, the health care literature demonstrates a variety of approaches to defining quality, and it also demonstrates that there is no consensus regarding terms such as "overall quality," "technical (or clinical) quality," "patient satisfaction," and "perceived (or service) quality." The mainstream quality management literature and practice use the customer as the primary quality evaluator. Therefore, in the health care domain, total quality could be determined by the
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patient's observation and evaluation of THQ and FHQ. In line with this view, this article investigates the dimensions of patient-perceived quality in the context of the health care delivery process to help explain the variability in total patient-perceived quality.
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WHAT SHOULD BE MEASURED?

Seminal works published in the 1980s divided health care quality into three dimensions: structure, process, and outcome. Structure refers to organizational resource issues, such as the availability of the facilities, staff, equipment, and expertise to deliver care appropriately. Process measures what has been done for the patient, such as the medical tests conducted or the prescriptions issued. The outcome is defined as changes in the patient's health status that can be attributed to the particular medical care given. While this categorization represents a traditional health care organizational viewpoint by emphasizing THQ, it offers limited utility for addressing the patient's viewpoint. Although this categorization is frequently cited in the literature, until the SERVQUAL was imported from the business-marketing field, research on health care delivery model quality lacked focus. The SERVQUAL model was adapted to the health care setting and examined the patient's perceptions regarding the following: tangibles-the appearance of physical facilities, equipment, personnel, and communications materials; reliability-the ability to perform the promised service dependably and accurately; responsiveness-the willingness to help patients and provide prompt service; assurance-the knowledge and courtesy of personnel and their ability to convey trust and confidence; and empathy-the level of care and attention provided to individual patients. This model is quite pervasive in the health care literature; the National Library of Medicine's citation index service, MedLine, lists fifty-two health care articles that cite or use the SERVQUAL instrument). This version of the SERVQUAL model does represent an FHQ view. However, the SERVQUAL model does not include the patient's evaluation of the outcome-an item which is likely to impact the patient's overall perception of the quality of his or her interaction with the health care provider. In addition, this model has come under increased criticism in recent years, as it is not always robust when applied to a variety of health care settings. One model of the health care delivery process represented a more direct attempt to capture the patient's point of view. This model's four health care quality dimensions include the following: access-the timely availability of services when required; personnel-the total collection of individuals/groups involved in the delivery of care; outcome-the change in a patient's health status that may be attributed to the medical care provided based on accessible and usable data; and patient satisfaction-the extent to which patient expectations are met. This FHQ perspective includes patient satisfaction as a quality dimension. However, another model showed that satisfaction and perceived quality are end measures rather than components of quality. This point is supported by researchers who also conceptualize satisfaction as an antecedent to service quality. Service quality and patient satisfaction are believed to be separate and unique constructs. In 1997, a different conceptualization of Donabedian's framework was developed by dividing the single process dimension into three distinct process subcategories: physician processes, nurse processes, and support staff processes. This expansion recognizes that not all health care providers in one organization may be perceived as being the same in regards to the manner in which the care was delivered. However, the two concepts, FHQ and THQ, are combined, which diffuses the clarity of the patient's perspective. The models and frameworks cited provide a foundational representation of how health care
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quality has been conceptualized in the last quarter century. The challenge with these conceptualizations is that they represent two differing stakeholder viewpoints: organizational versus patient. While the organizational viewpoint received greater attention in the early literature, the patient viewpoint recognizes the growing need in the health care industry to respond to patient needs.
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DETERMINING APPROPRIATE DIMENSIONS

We propose four patient-perceived health care quality dimensions: access, outcome, interaction and communication, and tangibles, which are derived from the previous literature. Table 1 compares and contrasts several of the foundational studies that proposed unique dimensions. While some similarities between the studies can be noted in this table, each study represents a different approach/viewpoint to examining health care quality. The dimensions found in these foundational studies are mapped to common health care quality aspects (listed in the first column). The proposed dimensions (listed down the last column) are based on two criteria:

Table 1
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1. Does the proposed dimension capture a unique portion of the health care experience? 2. Does the sum of the proposed dimensions capture the totality of the patient-perceived health care delivery experience? The first quality dimension, access, is defined as giving patients timely and affordable access to medical care and includes items such as appointment scheduling, telephone and Web system capabilities, information on test results, and cost and insurance issues. This dimension is derived from previous research's dimension, access, and is also motivated by practice. The term "responsiveness" has also been used to refer to this dimension, a term which stems from the SERVQUAL instrument. The second quality dimension, outcome, is defined as positively impacting patient health as a function of the care given and includes items such as change in health status, and the patient's perspective on the referral process. While the act of giving a referral could be considered a process, it is also an outcome because the referral may conclude a patient's interaction with the health care provider for a particular medical problem, or to finalize a diagnosis. The outcome dimension is derived from previous research. The third quality dimension, Interaction and Communications, is defined as giving patients the experience of constantly courteous and caring treatment from office workers, providers, and other involved staff and includes items such as courtesy of front office/staff, courtesy of the provider, general willingness to help, empathy, and billing issues. This dimension includes written, verbal, and nonverbal communications. This dimension is derived from previous research as the structure dimension and the empathy and assurance dimensions. The fourth and final quality dimension, tangibles, is defined as providing the patient with the physical facilities, equipment, personnel, and credentials they expect from a health care provider and includes items such as convenience, impression and layout of facilities, availability of needed medical equipment and devices, as well as the credentials of providers and staff. This dimension is derived from the facilities, equipment, and physical plant
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elements of previous research's structure dimension, as well as from SERVQUAL's tangibles dimension. In proposing the above four dimensions of patient-perceived quality, we have attempted to logically integrate the previously proposed models. Specifically, we recognize the patient's unique perspective, and we recognize that patient satisfaction is not a separate dimension of quality but rather a resulting measure. Note that the diagnosis and treatment aspects as used in the past literature referenced in Table 1strictly addresses THQ as evaluated by experts. Thus, the diagnosis and treatment aspects are not included in our patient-perceived dimensions except as captured by the four proposed dimensions. By proposing this integrated view of quality dimensions from previous research, we hope to provide a clearer understanding of how patients perceive health care quality.
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HYPOTHESES

Patient perceptions are typically captured through various standardized survey instruments, often administered by private firms and consultants, as well as survey instruments proposed by public organizations such as CAHPS (by the Agency for Healthcare Research and Quality) and CAS (by the state of California). The data derived from these types of patient surveys are expected to yield factors that help explain patient-perceived quality. Each potential factor should logically fall under one of the four proposed patient-perceived quality dimensions. The dimensions can be thought of as broad categories of patient-perceived quality factors, whereas a factor is a specific combination of data from one or more survey questions. Therefore, any patient assessment instrument should yield factors related to specific quality dimensions, and these factors will explain a significant portion of overall patient-perceived quality. Formally, the hypotheses can be stated as follows: H1 One or more unique patient-perceived quality factors can be identified. H2 Given that one or more unique patient-perceived quality factors can be identified, these factors can be shown to belong to one of the four patient-perceived quality dimensions. H3 The unique patient-perceived quality factors identified through the pursuit of H1 combine to explain a significant portion of the variability in overall patient-perceived health care quality. The next section explains the data, methodologies, and the analyses that enable us to explore and test these hypotheses.
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METHODS
DATA COLLECTION

To pursue the above hypotheses, we acquired a large set of outpatient health care survey data. The data contain annual responses for a particular patient survey for the years 1995, 1996, 1997, 1998, 2000, 2001, and 2002. These data were collected from randomly selected outpatients in California who received treatment from primary care physicians during a prespecified six-week period each year. Valid patient responses (61,277) were obtained. Patients from 222 different doctors representing five medical practices distributed over twelve different clinics (or practice sites) were surveyed. The patient survey contained twenty-nine original questions. SeeFigure 1 for a list of the

survey questions relevant to this study and their descriptive statistics. The survey is representative of surveys used by many health care organizations, as the questions are standard for the industry.
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Figure 1
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METHODOLOGICAL SUMMARY

We have two goals in this section: first, we seek to identify any quality factors (as proposed in H1) latent in the data set by using factor analyses. Secondly, we will test how much of the variance in overall patient-perceived quality can be explained by the identified patientperceived quality factors (H3). To pursue the hypotheses, we chose to first perform an exploratory factor analysis to determine an initial identification of the factors in the data set. Evidence from the exploratory factor analysis suggested that a set of three to six factors was appropriate. To estimate the goodness of fit for the factor model, we performed confirmatory factor analyses. The confirmatory factor analysis assured us of the soundness of the six-factor model as the most statistically appropriate model, as well as a model that is the most logically explainable. This six-factor model was then used in a regression to estimate how much of the variation in overall patient-perceived quality these factors explained.
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FACTOR ANALYSIS

Using SPSS' factor analysis (Varimax rotation with Kaiser Normalization), the data contained in questions 7-12 and questions 14-25 suggest three to six latent factors. We choose to use six factors, even when three of their eigenvalues are less than one. There is some risk of "overfitting" the model when using these criteria in large data sets. Overfitting occurs when "a less complex model than the fitted one is sufficient to explain the variance" in the data. However, in our case, using a six-factor model is statistically justified (as described below) and logically most appropriate. A principal component analysis using listwise deletion was performed with results shown in Figure 2. We see that the first factor (1) is the provider (questions 16-23). The second (2) factor (questions 7 and 8) is scheduling, and the third (3) factor (questions 9 and 10) is waiting time. The fourth (4) factor is the referral factor (questions 24-25). The fifth (5) factor is staff (questions 11-12), and the sixth factor (6) is facility (questions 14-15).
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Figure 2
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In summary, the loadings on these six factors are very good, and the inter-item reliability is acceptable. However, the eigenvalues for factors 4, 5, and 6 are less than one, possibly due to having only two variables associated with each factor. A review of the eigenvalues and scree plot indicates one major factor, one moderate factor, and four minor factors. The same results were verified using another rotation method (Equamax). The six-factor model explains 84.3 percent of the total variance in the data. To test the robustness of the data set and the appropriateness of the six-factor model, we randomly divided the data into three subsets: A, B, and C. The factor analysis was run on the entire data set, as well as on the subsets A, B, and C using three, four, five, and six factors.

LISREL (v.8.53) was used to perform goodness of fit analyses. Using goodness of fit measures, such as RMSEA and others, the six-factor model was deemed most appropriate, given the overall goodness of fit measures for the six-factor model and the results of a confirmatory factor analysis (Figure 3). The findings for subsets A, B, and C are similar in all aspects to those resulting from the main data set, and the identical interpretable six-factor pattern exists in the main, A, B, and C data sets.

Figure 3
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These results comply with the recommended goodness of fit measures. Hence, we conclude that the goodness of fit measures are sufficient to confirm the six-factor model's validity for both the full data set as well as for each of the three subsets. Thus, we have positively confirmed H1 and found the existence of six patient-perceived quality factors. From the content of the questions that make up these six factors, we propose that these factors relate to the four patient-perceived quality dimensions as illustrated in Figure 4. The provider factor questions ask about the patient's experience with the doctor, which we classify as falling under the interaction and communication dimension. Questions regarding the provider appear to relate to both THQ and FHQ elements. The scheduling factor questions discuss the patient's ability to arrange a timely appointment, which we argue to fall under the access dimension. The waiting time factor questions ask about the length of time the patient spent waiting in the reception and exam areas on the day of the exam. We argue that this also falls under the access dimension. The referral factor questions ask about the acceptability and timeliness of any referral made. We argue that referral falls under the outcome dimension. The staff factor questions ask about the friendliness and courtesy shown to the patient by the receptionist and doctor's nurse, which we judge to fall under the interaction and communication dimension. The facility factor questions ask about the physical aspects of the offices and facilities, which fall under the tangibles dimension.
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Figure 4
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The factors, as verified, have reasonable inter-item reliability as shown in Figure 1. An interitem reliability measure above .8 is normally considered excellent, and we note that most of the standardized inter-item reliability is near or above that benchmark measure. Hence, proposing the mapping of the patient-perceived quality factors into the four patient-perceived quality dimensions as shown in Figure 4 not only makes logical sense, but there is also statistical support for this given the high inter-item reliability of the quality dimensions (range 0.746 to 0.944). Thus, H2 is supported. The exception is for the tangibles dimension, where the inter-item reliability is slightly less than the benchmark value of .8. It should be noted that the proposed quality dimensions potentially may include other quality factors; however, no other factors could be identified from our data set.
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EXPLANATION OF VARIANCE IN OVERALL PATIENT -PERCEIVED QUALITY

In the original data set, an overall and separate quality measure was included to assess the patient's perception of overall quality (question 6). Using this question, and the six confirmed quality factors from the factor analyses, we perform a multinomial logistic regression (using SPSS) to investigate how much of the overall variance in patient-perceived quality can be

explained by the six factors latent in the data set. While recent research is pointing out that the relationships between quality factors are often non linear, we use logistic regression to investigate a log-linear model only. The resulting pseudo R is .509. This measure indicates that 50.9 percent of the variation of global single-item patient-perceived quality is explained by the six factors outlined and confirmed above. We note that a regular linear regression yields an adjusted R of .49, which is in line with the result from multinomial regression. Thus, we positively confirm H3, which is the identified quality measures combine to explain a significant portion of the variability in overall patient-perceived health care quality. The predictive results of the multinomial logistic regression reveals an interesting observation (Figure 5). The predictive power of low overall perceived quality (a score of 1 or 2) is particularly poor, whereas the predictive power of higher overall perceived quality (3-5) is much better (88.5% for question 6 rated as "excellent"). This may lend credence to the notion that high patient-perceived quality and low patient-perceived quality should in fact be measured on two different scales. That is, the two ends of the overall patient-perceived quality scale cannot be effectively incorporated in a single regression model (similar to the argument of Scanlan ). Nevertheless, the overall correct prediction rate is at 72.5 percent, reflecting that most observations in this data set are toward the high end of the scale (the responses to question 6 are primarily 4s and 5s).
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Figure 5
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DISCUSSION AND CONCLUSIONS

In this article, we have examined the quality dimensions comprising patient-perceived quality in the outpatient setting. After analyzing a health care outpatient data set containing seven years of patient survey responses, six distinct quality factors emerged (provider, staff, scheduling, waiting time, facility, and referral) that are logically and statistically fitted into the four proposed health care quality dimensions (access, tangibles, interaction and communications, and outcome). Our study also shows that the factors contained in the data set explain 50.9 percent of the variability in patient-perceived quality using a global, singleitem measurement. We therefore conclude that we have explained a significant portion of overall patient-perceived quality, and as a result investments (or changes) in a health care delivery system can now be more readily tied to their impact on patient-perceived health care quality.
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THEORETICAL IMPLICATIONS

Our analysis showed that if patients are reporting high overall perceived quality, then we can readily understand the contributing factors. However, further studies are needed to explain the factors contributing to low overall perceived quality. This is an indication that high versus low quality may be better studied by using different scales. Dimensions are a useful tool for understanding and logically grouping the factors. Because the factors we have examined explain about 51 percent of the variance in overall patientperceived quality, future researchers should look for either new factors that apply to our proposed dimensions or determine if other potential dimensions with their associated factors

can be identified. There is an additional need in the research literature to recognize that different stakeholders in the health care industry have differing priorities in regards to evaluating the health care delivery experience. These differing priorities result in a plethora of assessment instruments and differing opinions on the changes needed in the health care system. A study examining the perspectives of the stakeholder might reveal that stakeholder values impact the questions asked and the dimensions evaluated in their assessment instruments. For example, governmental policy makers may be primarily interested in access and outcome dimensions, whereas medical directors, clinic and hospital managers, and independent physician association managers may be interested in all dimensions as each dimension impacts the total health care delivery experience. Finally, while we have attempted to consolidate the literature regarding the quality dimensions to better define and identify patient-perceived quality, future research should also seek a better understanding of how patient-perceived quality factors interact with organizational assets relevant to the stakeholder in question. Specifically, how do patients' interactions with some specific health care delivery system component impact their responses to specific assessment instrument questions (e.g., if the patient reports a poor communication experience, is he or she talking about a conversation with the doctor, the front desk receptionist, or the doctor's answering service?).
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MANAGERIAL IMPLICATIONS

When health care managers attempt to improve patient-perceived health care quality, they use their understanding of patients' quality concerns to do so. Thus, any process that seeks to improve the manager's understanding of these concerns should be welcomed. This article attempts to improve that understanding by extending the literature on health care quality dimensions. These dimensions were found in prior studies by researchers seeking to document how patients divide their perceptions of the health care delivery experience into logical groupings. The proposed set of patient health care quality dimensions-access, interaction and communication, tangibles, and outcome-was specifically chosen to ensure that it was distinct and sufficient to cover the totality of the patient's perception of their health care delivery experience. Therefore, any attempt made by the health care manager to improve patientperceived quality should be based on information that reflects the full spectrum of dimensions. For example, if anecdotal evidence suggests patients are perceiving poor overall quality with a specific health care unit and the health care delivery assessment instrument used by management is based solely on doctor-patient interactions (the interaction and communication dimension), it is likely that attempts to improve quality will fail if the patients' concerns lie with a cramped and cold waiting room (the tangibles dimension). In a similar manner, utilizing an instrument that contains the full spectrum of dimensions but does not contain a sufficient number of questions related to a factor may also spoil the health care manager's quality improvement attempts. For example, the access dimension contains both the scheduling and waiting time factors. If the health care organization's assessment instrument is imprecise in regards to these two factors, the health care manager might spend thousands of dollars on an automated scheduling system when perhaps an improved patient triage system would result in higher patient-perceived quality. Given these examples, it is evident that a health care manager relying on the results from a poorly designed instrument or one that fails to consider the organization's unique processes or

resources has little hope in improving patient-perceived health care delivery quality. Therefore, two issues arise for the health care manager when preparing to assess patientperceived health care quality. The first issue is whether the manager should use a generic "canned" survey for assessing patient-perceived quality (i.e., is it sufficient to reveal the full range of an organization's patient-perceived quality concerns?) Or would the organization be better served to have an assessment instrument designed specifically for its stakeholder context? An advantage of using a "canned" survey is the possibility of being able to benchmark to comparable institutions, but there is some question as to whether the results of a canned survey instrument offer sufficient organization-specific detail to suggest areas of needed change in an individual health care organization. The second issue is ascertaining whether a survey instrument specifically designed for the organization is designed appropriately (i.e., does it contain sufficient questions to examine each factor comprising the quality dimensions?) In either case, the greater the understanding the health care manager has regarding the patient-perceived quality process, the more likely he or she will be able to design effective quality improvement initiatives.
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LIMITATIONS

On the methodological side, our study uses various factor analyses that handle missing data by deleting records (listwise deletion). This causes a reduction in the resulting sample size and may not be the best method for handling missing data. No experiments were devised to test other methods for handling missing data, and it is conceivable that the results could be improved by such an investigation.
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CONCLUSION

This article brings additional understanding to the important topic of examining the totality of the health care delivery experience. It emphasizes the important role that patients' perceptions play in providing the health care manager with valuable insight into improving the patients' health care delivery experience. We believe that both academic researchers and practitioners will benefit significantly from the analysis in this article by enabling a greater understanding of the components of patient-perceived health care quality.
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REFERENCES

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Keywords: customer-orientation; service; statistical analysis; quality 2005 Lippincott Williams & Wilkins, Inc.