A case study of travancore medical college hospital kerala, india

Critically evaluate service quality as a determinant factor

for patient satisfaction in gaining patient loyalty.

A case study of Travancore Medical College Hospital Kerala, India.

BY

ANEESH POOCHAPANDIYIL VELAYUDHAN PRASANNAN

SUPERVISOR : MR. CILLIERS DIEDERICKS

WALES ID : 1092227390326

KCB ID : 15040

Submitted in fulfilment of the requirements of the Taught Masters Dissertation to the
University of Wales, for the degree of Masters in Business Administration (MBA).

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DECLARATION

This research work is purely the author’s own effort where the ideas of other

scholars and authors are referenced using the Harvard Referencing style. It has not

been previously accepted in substance in any degree and in not being concurrently

submitted in candidature in any degree

This dissertation is the result of my own investigation, except where otherwise

state, where correction services have been used, the extent and nature of the

correction is clearly marked in footnote(s). The ethical issues have been kept into

consideration during the preparation of this report and the responses of the

individuals to the research survey are kept confidential.

I hereby give consent for my work, if accepted to be available for

photocopying and for inter-library loan, and for the title and summary to be made

available to outside organizations.

Signed ……………………………………………………….. (Candidate)

Date: 14/02/2012

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Table of contents Page No.

1. Introduction 1
1.1 Research background 2
1.2 Research Aim 4
1.3 Objectives 4
1.4 Rationale for choosing the research topic 5
1.5 Company profile 6
1.6 Conclusion 7
2. Literature review 7
2.1 Introduction 7
2.2 Aims and objectives 7
2.3 Literature Review 8
2.4 Service Quality Conceptualization 8
2.5 Dimensions of service quality 11
2.6 Measuring Service quality 12
2.6.1. Gap Model 13
2.6.2 SERVQUAL Model 15
2.6.2.1 Advantage of SERVQUAL Model 18
2.6.2.2 Criticism of SERVQUAL Model 18
2.6.3 SERVPERF Model 20
2.7 .Patient satisfaction 20
2.8. Patient satisfaction and its dimensions 23
2.9 .Theories of customer satisfaction 24
2.10. Measure of customer satisfaction 24
2.11. Patient Loyalty 25
2.12 Importance of custom loyalty 26
2.13 Measurement of patient loyalty 27
2.14 Service quality and customer satisfaction relationship. 29
2.15 Service quality and customer loyalty relationship 29
2.16 Customer satisfaction and customer loyalty relationship 29
2.18 Conclusion 30

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3. Research Methodology
3.1 Introduction 31
3.2 Aims and objectives 31
3.3 Research Methodology 31
3.4 Research Design 32
3.4.1 Exploratory Research 33
3.4.2 Descriptive research 33
3.4.3 Explanatory research 33
3.4.4 Justification for research design 33
3.5 Research Philosophy 34
3.5.1 Epistemology 34
3.5.2 Positivism 34
3.5.3 Realism 34
3.5.4 Interpretivism 35
3.5.5 Ontology 35
3.5.5.1 Subjectivism 35
3.5.5.2 Objectivism 35
3.5.6 Axiology 35
3.5.7 Justification of research philosophy 36
3.6 Research approach 36
3.6.1 Justification of research approach 37
3.7 Research Strategy 38
3.7.1Quantitative data 38
3.7.2 Qualitative data 38
3.7.3 Justification of research strategy 38
3.8 Source of data 38
3.8.1 Primary data 39
3.8.2 Justification of primary data 40
3.8.3 Secondary data 40
3.8.4 Types of secondary data 41
3.8.5 Justification of secondary data 41

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3.9 Sampling 42

3.9.1 Probability sampling or Representative sampling 42
3.9.2 Non Probability Sampling or judgemental sampling 42
3.9.3 Justification of sampling 42
3.10 Conclusion 42

4. Research findings and Analysis
4.1 Introduction 43
4.2 Aim and Objective 43
4.3 Analysis of primary data 44
4.4 Comparing primary data with secondary data 65
4.5 Conclusion 67

5. Conclusion and Recommendation
5.1 Introduction 69
5.2 Aim and Objective 69
5.2.1 Achievement of objective 1 69
5.2.3Achievement of objective 3 72
5.3Conclusion 73
5.4Research limitation 73
5.5Recommendations 74
5.5.1 Recommendation 1 74
5.5.8 Recommendation8 84
6. Reflective summary 85

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7 Reference 86

8 .LIST OF FIGURES

1. Fig 2.1 Gap Model 14
2. Fig 2.2 Measurement of patient loyalty 27
3. Fig 2.3 Patient loyalty and service quality model 28
4. Fig 2.4 The relationship between service quality,
Customer satisfaction and customer loyalty. 30

5. Fig 3.1 Research onion 32
6. Fig 3.2 Source of Data 39
7.Fig 3.3 Primary data 40
8.Fig 3.4 Secondary data 41

9. List of Tables
1. Table 2.1 22 Items of SERVQUAL instruments 17
2. Table 2.2 Customer Benefits 26
3. Table 3.1 Types of Research Design 33
4. Table 3.2 Research Approach 37
5.Table 4.22 Patient satisfactory 65
6. Table 5.1 Gantt Chart of ERP 76
7. Table 5.2 Gantt Chart of recruitment of HR trainers 79
8. Table 5.3 Gantt chart of CCTV 81
9.Table 5.4 Gantt chart of purchase of medicines 83

9.List of Charts

1. Chart 4.1 Distribution of sample size according to age and sex 44
2. Chart 4.2 The reason for choosing hospital 45
3. Chart 4.3 The receptionist was friendly and courteous 46
4. Chart 4.4 The staff respects the patient with respect ,dignity and were
Courteous in the hospital 47
5. Chart 4.5 There is a lot of paper work for admission 48

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6. Chart 4.6 The service cost for hospital is affordable. 49
7. Chart 4.7 All the staffs were in correct uniform 50
8. Chart 4.8 Hospital is visually attractive 51
9. Chart 4.9 Hospital is a convenient location 52

10 Chart 4.10 Hospital has good directional science 53

11. Chart 4.11 Hospital provides services at allocated time 54

12. Chart 4.12 Hospital department is working effectively 55

13 Chart 4.13 You felt ease during your appointment 56

14 Chart 4.14 Doctors listen carefully and adhered to your needs 57

15 Chart 4.15 Hospital addresses the patient complaint quickly 58

16 Chart 4.16 Do you think staff responded immediately 59

17 Chart 4.17 Hospital employee are sympathetic and re assuring 60

18 Chart 4.18 Hospital doctor prescribes affordable medicine 61

19 Chart 4.19 Average waiting time in the hospital 62

20 Chart 4.20 Charges of TMC hospital is affordable 63

21 Chart 4.21 Recommending hospital to the friends and relatives 64

10. 1 Appendix 1 92

2. appendix 2

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Chapter 1

Introduction
1 Introduction

All business organisations including health care organisation are interested in
achieving long term financial success (Al Hawary et al., 2011). Healthcare is one of
the most important elements of life and people always demand a better quality of
health to have a healthy life. This patient centric approach and consumer satisfaction
became the fundamental requirement for healthcare providers (Desai, 2011).In the
recent years the number of private and public hospitals had been increased
tremendously. In order to gain competitive advantages in the health care industry
and improve the operative efficiency the hospitals have adopted quality improvement
measures (Yasin et al., 2011) . Likewise Bullet (1996) had identified service quality
as a corporate market strategy and financial performance driver and had stated that
the hospitals can achieve competitive advantage and operational efficiency by
adopting service quality as a strategic tool. According to Shaktivel et.al (2005)
customer satisfaction is one of the critical factors that judges the service quality
delivered to the customers (Shaktivel et.al (2005); cited by Ooi et al., 2011).Impact of
patient satisfaction in choosing hospitals are important. Research had shown that
there are links between patient satisfaction and healthcare quality (Kessler & Mylod,
2011). Woodruff in 1997 had pointed out that service providers consider customer
loyalty as a competitive advantage. Many researches had proved that enhanced
customer loyalty increase profitability of the organisation (Woodruff (1997); cited by
Wang & Wu, 2012). On the other hand Strasser et.al in 1995 had stated that
negative word of mouth can cause hospitals a revenue loss of 6000$ to 400,000 $
(Naidu, 2009).With the increasing no of private and public hospitals the completion to
be the top health care provider is intense. The private hospitals compete with each
other to provide the best healthcare. According to Lim and Tag (2000) the public
awareness and rising literacy rate in the population made healthcare providers to
provide high quality treatment to the patient. Every patient have expectations what
their health care centre is going to provide them .Every healthcare centres should

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give attention to reduce the gap between what patients actually expects and the
service that is actually delivered. (Lim and Tag (2000); cited by Suki et al., 2011). In
this research the author will be evaluating service quality as a determinant factor for
patient satisfaction in gaining patient loyalty.

First of all the author begins with the research background then the author had
discussed about research aims and objectives then the author had talked about
about the reason for choosing this research topic, the company’s background and
finally will conclude by summarizing the entire research research.

1.1 Research background

India has been witnessing increasing demand for quality healthcare after
globalization. Urbanization had improved quality of life which in turn had demanded
quality health care. Service quality has been chosen as an important element by
consumers for selecting hospitals (Dr.Vanniarajan & Arun, 2010).India has now
become a medical hub and the patients from the Western countries and other parts
of Asia and Africa use undergo treatment due to due to low cost and high quality
treatment. According to KGMP report of 2011 the healthcare industry in India will
grow from USD 79 Billion in 2012 to 280 Billion in 2020 (KMPG, 2012).Eventhoug
the health care spending in India is significantly low as compared to the developed
countries and other emerging countries. The average CAGR for the healthcare
industry in the next 10 years is 21%. . In India more than 50 percent of healthcare
expenditure comes from the individual against the state level government
contribution of less than 30 percent (Padma et al., 2010) .According to the WHO
health statistics 2010 private sector contributes approximately 75 % of the health
sector. The key factors for the growth of healthcare sector are Increase in
population, rising disposable income of the population, rising literacy rate,
demographic changes by 2026 there will be an increase in geriatric population from
current 96 million to 126 million which means that there will be an increased
dependence on hospitals, increase in lifestyle related diseases like cardiovascular
disease, diabetes. The health care industry in India is also facing many challenges
like lack of manpower and infrastructure. The healthcare infrastructure in India lags
behind the global average .India has only .6 doctors per 1000 population against the
global average of 1.3 it is evident from this finding that there is a gap of man power.

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The no of bed available per the 1000 population is only 1.27 which is less than the
global average of 2.6%.However in the last decade there was an increase
participation of private sector in the healthcare industry. In the coming years the
healthcare sector will be facing stiff competition due to increased no of private
hospitals and because of the government policies allowing 100 % FDI in hospital
sector .In order to have a competitive advantage in this highly competitive
environment the hospitals should improve their quality standards in lieu with their
counterparts. Hospitals should implement healthcare accreditations like JCI (Padma
et al., 2010).

Despite of the growth of the healthcare industry the hospitals and other health
care organisations are struggling to deliver quality healthcare in this competitive
environment (Avgar et al., 2011).The service delivery system in the recent years
have been restructured and is now patient centric (Desai, 2011).Moreover the
studies done by Sahay (2008) shows that there is a need for improvement for
customer service (Padma et al., 2009). In recent years concern for service quality
had gained unprecedented levels. Service quality had now become an important
distinguishing factor between services to gain competitive advantage (Rashid &
Jusoff, 2009). According to Taner and Antony (2006) health care service has a
unique position among other service due to its very nature of highly involved risk.
This makes measuring service quality and patient satisfaction in healthcare setting
more important and more complex (Taner & Antony, 2006; cited by Rashid & Jusoff,
2009)

According to Kotler in 1998 customer loyalty is an indispensable tool for profit and
non profit organisation to sustain competitive advantage and to enhance business or
service measures (Chahal, 2008). The research done by many researchers like
Berry et .al (1989) had emphasised the fact that “good service quality leads to the
retention of customers and attraction of new ones, reduced cost ,enhanced
corporate image, positive word of recommendation increases profitability of an
organisation”. Service quality has become an important element in selecting
hospitals by people (Berry et .al (1989) ;Reichheld and Sasser (1990);Rust and
Zahorik (1993) ;Cronin et.al (2000);Kang and James (2004) ;Yoon and Suh
(2004); cited by Dr.Vanniarajan & Arun, 2010).According to Analeeb (1998) was in
the point of view that hospitals who don’t give importance to customer satisfaction

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may be inviting extinction. Service quality are of great importance for the service
marketers because they are under the direct control of the service providers and its
consequence may improve service satisfaction and it will influence the buyers
behavioural intention which will lead to use the service again .This will ultimately lead
to customer loyalty (Padma et al., 2010).By doing this research the author can find
the gaps in the service provided by the hospital and can recommend the hospital to
reduce the gap between the customers expectation and the actual service delivered
so that they can increase patient satisfaction and gain patient loyalty .

1.2 Research Aim

Critically evaluate service quality as a determinant factor for patient satisfaction in
gaining patient loyalty. A case study of Travancore Medical College Hospital Kerala,
India.

1.3 Objectives

1. To review literature on service quality, patient satisfaction and patient loyalty.
2. To investigate the current service quality measures adopted by Travancore
Medical College Hospital
3. To evaluate the service quality offered by Travancore Medical College
Hospital and its effect on patient satisfaction in gaining patient loyalty.
4. To recommend Travancore Medical College Hospital to improve the service
quality so that they can increase patient satisfaction and gain patient loyalty.

1.4 Rationale for choosing the research topic

Service quality is an important determinant to appraise the triumph of any entity as
success in meeting the client’s expectation is the definitive objective of business.
Customer contentment has been considered as significant success factor in today’s
spirited business milieu, as they facilitate in retaining customers and maintaining
market share. It is also not different in case of hospital. It is one of the imperative
benchmark used to measure the patient satisfaction in gaining fidelity towards the
hospital. Because the totality of services rendered by the hospital to its patients is
the input en route for the patients and the contentment derived is the output.

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Escalating customer satisfaction is vital for customer allegiance. Service providers
should always manage to improve customer satisfaction it is one of the factor by
which the patient measures the quality of the medical services offered. Hence an
attempt has been done to articulate to evaluate service quality as a determinant
factor for patient satisfaction in gaining patient loyalty, for which a case study was
done in Travancore Medical College Hospital, one of the leading private sector
hospitals in Kerala, India.

1.5 Company Profile

Travancore Medical College Hospital Kerala, India. The TMCH consists of 800
bedded multi speciality hospital with state of the art facilities. It is a unit of Quilon
medical trust started with the view to promote medical education and health care to
the minorities of the society with the motto “service with love”. The hospital has a
highly qualified doctor, dedicated nursing staff and a technically sound paramedical
staff. The hospital has unique facilities like 15 bedded medical ICU unit, 15 bedded
emergency ICU unit, 6 bedded neuro ICU unit. There are about 10 operation
theatres in the hospital along with other laboratory units such as biochemistry It is
one of the premier medical facility for trauma, emergency, critical care and
ambulatory care. TMCH is one of the reputed medical emergency care centres in the
south Kerala region, and receives most complicated referral cases from many other
hospitals. The administration and medical team are highly qualified based on
education training. The hospital is equipped with the most advanced high technology
instruments to provide the best treatment available. The hospital has a dedicated
highly experienced nursing staff to avoid mal practice. They have a medical college
and a nursing college attached to the hospital .TMCH is the leading medical
education provider in Kerala. They admit nearly 100 students each year. The
hospitals have the best infrastructure available and the best available medical
teachers in India. The hospital has 22 department with the most experienced and
eminent doctor of Kerala. As a part of the social commitment the hospital was
providing free treatment for the patients hospitalised in the ward. The hospital also
has satellite centres in the interior parts of the kerala where there are no hospitals
and the patients around that place fully depend on these hospitals. As a part of the
professional development in career the hospital proves continuing medical education

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programmes on regular basis so that all the doctors in the hospital can participate
and be updated (Travancore medical college, 2012).

1.6 Conclusion

The author had divided the dissertation into 5 chapters. In Chapter 1 the author
gives a brief overview of the entire research which includes the research aim and
objective a brief back ground of the health care industry and the hospital selected .
In Chapter 2 the author critically reviews all available literature which are in the forms
of journals, books, website and newspaper which forms the secondary data. In
Chapter 3 the author forms a framework for the primary analysis .The author then
discuss about the various methods adopted in research which include research
strategy, research approach, research philosophy, sample size and the sampling
method used. In Chapter 4 The author will be analysing the primary data,
questionnaire that were distributed to the patients of the TMC hospital and then the
author will be comparing the findings with the secondary research. In Chapter 5 the
author draws a conclusion from the primary and secondary research and the author
put forwards some suggestions that can improve the service quality standards of
TMCH to improve patient satisfaction so gain patient loyalty.

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Chapter 2

Literature Review
2 .1 Introduction

In the present chapter author reviews the literature related to Service Quality,
Patient satisfaction and Patient loyalty get a deep insight and understanding of these
topics and to form the basis of future primary research .All the data’s that we collect
both the primary and the secondary should be compared so that the researcher can
draw conclusions from it and suggest recommendation for improving the present
situation. The author can suggest good recommendation’s only if the author has
done a strong secondary research. So the author had made use of all the available
data to frame a strong foundation for the research.

First of all the author begins the chapter by restating the aim’s and objective
and then begins reviewing the literature by discussing about the conceptualization of
service quality then about the dimensions of service quality. The author had also
discussed the different models of service quality used to measure them.

The author then had focused on patient satisfaction its dimensions and theories.
The discussion then moves on to patient loyalty, importance of patient loyalty and
measurement of patient loyalty. Finally the chapter had concluded by discussing the
relationship between service quality and customer loyalty, relationship between
customer loyalty and customer satisfaction and the relationship between customer
satisfaction and customer loyalty.

2.2 Aim and objective

India.


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quality so that they can increase patient satisfaction and gain patient loyalty

2.3 Literature Review

In the last few decades the hospitals are thriving to provide the highest possible
service quality to its patients at a lowest possible cost. Morris and Bell (1995) had
stated that the issue of defining, measuring and monitoring the quality of healthcare
had been addressed from ancient times (Morris and Bell,1995; cited by Sivakumar &
Srinivasan, 2010).According to Youseff et.al (1996) all hospitals in healthcare sector
provides same type of service but different quality of service (Youseff et.al, 1996
cited by; Suki et al., 2011). According to Berry et al (1988) with the constant increase
in customer and increasing competition service quality is the key factor that major
service companies have (Berry et.al, 1988 ; cited by Sainy, 2010).It is easy to see
that with the rising income of people and literacy rate of people they demand high
quality healthcare.. In a patients view point service quality is ultimately how they
judge the service they had encountered in the hospital which includes the interaction
with the doctors , nurses the staffs of the hospital outcome of the service. There fore
service quality of hospitals can be the key deciding factor for the selection of
hospitals

2.4 Service Quality Conceptualization

First of all there are different concepts for service quality to begin with initially
Takeuchi and Quelch (1983) had assessed the service quality of healthcare by six
dimensions namely reliability, service quality, prestige, durability, punctuality and
ease of use (Takeuchi and Quelch, 1983; cited by Dr.Vanniarajan & Arun, 2010),
Gravin (1984) had established 5 categories or approaches to the concept of quality
namely transcendent based on degree of excellence, product based which involves
measurable characteristics of products, User based which involves meeting the
needs of the user, manufacturing based on the conformance with design or

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specification and finally value based which involves how much of something is
related to price (Gravin ,1984; cited byAl Hawary et al., 2011).

Similarly Gonroos (1984) had stated “that the perceived service quality is an
evaluation process where the customer compares his expectation with the service
that he had received ’’. He had proposed that there are two types of service quality
the functional ‘’service quality’’ and ‘’technical service quality’’. The functional service
quality is that the manner in which serve quality is delivered and technical service
quality is what actually the customer received from the service ( Gonroos 1984;cited
by Alrubaiee & Feras, 2011). Later in 1990 Gonoroos had added image of service
providers as a third dimension which acted as a filter in consumers perception of
quality (Padma et al., 2009).However Lehitmere and Jukka (1985) had presented a
holistic view to measure, monitor and operational customer perception of service
quality in health care organisation (Lehitmere and Jukka,1985; cited by
Dr.Vanniarajan & Arun, 2010).

Bopp (1986) had developed a “medical service quality active satisfaction model”.
The mode evaluates the service quality in consumption stage of patients purchase
cycle”. The finding of the study revealed that the factors that that played a role in
patient evaluation include expressive caring, expressive professionalism and
expressive competence of the service interaction. The study results emphasised that
staff’s with expressive caring, professionalism and physicians expressive caring has
a significant effect on patient satisfaction. (Bopp, 1986; cited by Sivakumar &
Srinivasan, 2010)

According to Parasuraman (1988) “service quality is defined as a global
judgement or attitude, relating to overall superiority of the service’’ (Parasuraman
1988; cited by Blery et al., 2011).John (1987) had developed an instrument to
measure the construct the “perceived service quality”. The findings of the study were
encouraging for other researchers by revealing that the measure of perceived
service quality is a multi dimensional construct containing variables namely
competence, credibility, reliability, security, courtesy, communicativeness,
understanding, availability, responsiveness, physical environment. This is in
consistent with generic dimensions of service quality which was later proposed by
Parasuraman et.al (1990).

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Woodside et.al (1989) had defined service quality in healthcare as the gap
between patient expectation and perception (Woodside et.al,1989;cited by Wu,
2011). Similarly Bower et .al in 1994 had studied 5 common attributes of quality
from SERVAQUAL model, of this caring and communication were found to be
important and three of the generic SERVAQUAL dimension were related to patient
satisfaction: empathy, responsiveness and reliability (Bower et .al ,1994; cited by
Dr.Vanniarajan & Arun, 2010)

Zeithmal and Bitner (1996) was in the point of view that service quality lies in
providing excellent or superior service than the customers expectation.(Zeithmal and
Bitner 1996 ;cited by Alrubaiee & Feras, 2011).Other researchers like Lytle and
Mokva (1992) argues that service quality satisfy the need of patient and patient
evaluates the service quality on the basis of service output, service process and
physical environment (Lytle and Mokva ,1992; Wu, 2011).

According to Zeithaml et.al (1990) there are 5 different gaps in service quality.

a) “Word of mouth”
b) “Personal needs”
c) “Previous experience”
d) “Service product content”
e) “External communication of service providers with customers”

The customer expectation is influenced by the first 3 factors and quality
perception is formed by the fourth factor.

According to Maxell (1992) healthcare Service quality has 6 dimensions
namely accessibility, acceptability, appropriateness, equity, effectiveness and
efficiency which the patient considers important. The study done by Bell et.al (1993)
resulted in identifying dimensions similar to Maxell except they added the dimension
Privacy (Bell et.al 1993; cited by Sivakumar & Srinivasan, 2010).

A study conducted by Fitzsimmons and Fitzsimmons (2000) included price as it
is a service winner. They had defined price in terms of monetary and non monetary
and then added the dimension of time. Monetary price is the sum of the expense the
customer had incurred to get the service. The non monetary price includes any
perceived sacrifice like the time spent, the inconvenience and physiological cost like

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perception of risky anxiety (Fitzsimmons and Fitzsimmons, 2000; cited by Al Hawary
et al., 2011).

Walter (2001) had judged the quality of service in health care organisation by
“reliability, availability, credibility, security, competence of staff, understanding of
customer needs, responsiveness to customers, courtesy of staff, comfort of
surroundings, communication with participants and associated goods provided with
the service”. (Walter, 2001; cited by Dr.Vanniarajan & Arun, 2010).

The researchers started evaluating behavioural intentions like word of mouth as
service quality dimensions. Similarly researchers like Yavas .et.al (2004) and
Swanson and Davis (2003) had done research to prove that word of mouth have
effect on service quality. (Yavas .et.al, 2004; Swanson and Davis, 2003; cited by
Urban, 2010). Likewise Sweetney et.al (2008), Dean and Lang (2008) and Murray in
(1991) stated that word of mouth often lead to repurchase behaviour (Sweetney
et.al,2008; Dean and Lang ,2008; Murray,1991;cited by Urban, 2010)

Vasso Eiriz and Jose Antonio Figueirideo (2005) had developed a frame work for
the evaluation of healthcare based on the relationship between customers and
providers. They had considered four quality items namely customer service, cost,
location and competence of the staff. They were in the point of view that service
quality of hospitals should not be judged alone on patient’s evaluation. (Vasso Eiriz,
Jose Antonio Figueirideo (2005); cited by Al Hawary et al., 2011).

2.5 Dimensions of Service Quality

Pollack,B.,L.(2008) had stated that “service quality is an multi dimensional construct
“.Brandy and Cronin (2001) had stated that the advanced “hierarchical
conceptualization model of service quality consist of 3 dimensions namely outcome
quality, physical quality and interaction quality”. “Outcome quality refers to the
patient’s assessment of the main service offered to them”. “The interaction quality
refers to the customer’s assessment of service delivery and physical quality refers to
the customer’s evaluation of the tangible aspects of the service”. Lehtinin and
Lehtinin (1991) had stated that there are “three dimensions for service quality
namely physical quality, interactive quality and corporate quality”. (Alrubaiee &
Feras, 2011).

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The most popular conceptualization of “Service Quality”, “SERVQUAL model is
based on 5 dimensions which are illustrated in the diagram below namely (Markovic
& Raspor, 2010)

1. “Tangibles”
Include physical facility equipment and staffs
2. “Reliability”
Includes ability to provide promised service accurately
3. “Responsiveness”,
Includes willingness to provide prompt services and help customers
4. “Assurance”
Includes knowledge and courtesy of employees to promote trust and
confidence.

5. “Empathy”.

Includes care and attention the organisation provides to the customer

Responsiveness, Empathy and Assurance represents the interactive quality
Sower, V. (2011)

According to Bakar et.al (2008) the dimensions of service quality in healthcare
quality can be studied in a two way approach. It was been divided in to clinical
quality and service quality. Clinical quality involves surgical skills, sufficient drugs
and logistics which help in better outcome. The service quality includes patient
experience namely waiting time, hospital comfort, support from the providers,
physical environment, appointment and visits (Bakar et.al 2008; cited by Atinga et
al., 2011).

2.6 Measuring service quality

Most of the methods developed in the past two decades belong to a user based
paradigm and employ questionnaire to collect the data, some. (Sliwa & O’Kane,
2011).The different methods for collecting service quality data are described below.

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2.6.1 Gap model

Parasuraman et.al (1985) developed a gap model to measure the attributes of
service quality. This initial gap model which included following determinants of
service quality.

However according to Parasuraman et.al (1988) service quality cannot be
conceptualised or evaluated by the traditional method used for evaluating the goods
quality because of its nature of “intangibility, heterogeneity and inseparability”.
Moreover Service quality can be defined as the function difference between
customer expectation and perception of service performance. This results in a gap
between the expectation and perception. Hence the model is also referred to as Gap
model which is illustrated in the fig 2.2 (Parasuraman et.al, 1988; cited by Nassab et
al., 2011). Consumer expectation described as what the consumers want and these
they are formed from marketing, word of mouth, prior experience and personal
needs. Consumer perceptions are formed when they are experienced during the
interactions with the organisation. “Five main Gaps are identified that occur during
the service process”. Four of these gaps occur during service provision and are
influenced by the management and provider (Alin et al., 2009)

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Fig 2.1 Gap Model

(Alin et al., 2009)

a) “Gap 1 Difference between consumer expectation and management
perception of consumer expectation.”
b) “Gap 2 Difference between management perception of consumer expectation
and service quality specification”.
c) “Gap3 Difference between service quality specification and service quality
actually delivered”.
d) “Gap 4. Difference between service delivered and what is communicated
about the service to consumers”.
e) “Gap 5. It is the difference between consumer expectation and consumer
perception of service delivery which is caused by the combined influence of
Gap 1 to 4”.

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Gap 1 which is shown in fig 2.2 will arise when the management lacks to
understand the customers expectation which were formed as a result of marketing,
word of mouth, previous experience. Gap 2 shown in fig 2.2 will arise when the
management fails to achieve the target level of perception of the patient and
transform them to the workable level. Gap 3 as illustrated in fig 2.3 arises when the
actual service delivery standard set by the management will not meet expectation.
Gap 4 as shown in fig 2.2 arises when usually the organisation exaggerates what will
be provided to the customers rather than the real fact it will lead to increase in
customer expectation .Gap 5 as shown in fig 2.2 arises from the difference between
customer expectations and actually the customer receives

2.6.2 SERVQUAL MODEL

The SERVQUAL method developed by Parashuraman et.al (1988) is the most
popular method to access customer satisfaction in service industry. It measures the
quality by comparing the customer’s perception of a quality of a service experienced
and what that customer expected for the service (Parashuraman et. al (1988);cited
by Lonial et al., 2010).

The SERVQUAL method was used in various settings like banks, hotels , dental
clinic, insurance companies, healthcare organisation , telecommunication, hospitals
hotels and fast food chain. Kaul (2005) had said that SERVAQUAL scale was
extensively used in India to measure quality of services provided by retail stores.
Deshpande (2006) had said that SERVQUAL SCALE is used in Hospitals.
Sivakumar and Srinivas (2003) had stated that SERVQUAL was extensively used in
hotels and Jain and Gupta ( 2004) had said that SERVQUAL model was used in fast
food chain (Kaul (2005); Deshpande (2006); Sivakumar and Srinivas (2003); Jain
and Gupta ( 2004); cited by Mengi, 2009).

SERVQUAL Model developed by Parasuraman et.al in 1988 is one of the main
tool for service quality (Parasuraman et.al in 1988; cited by Mengi, 2009). The
SERVQUAL scale has a multi dimensional approach for measuring perception of
service quality. The three dimensions that are relevant for health care are assurance,
empathy and responsiveness (Karl et al., 2010). Assurance refers to customer’s

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perception of trust how they feel with the employee or employees providing care.
According to Lee and Lin (2008) reduced patient trust in care givers can lead to post
discharge non compliance which causes slow or incomplete recovery. Empathy
refers to the level of care and individual attention that is provided to each patient.
(Lee and Lin, 2008; cited by Karl et al., 2010). Likewise Spigelman and Sensor
(2008) had argued that patients are looking for personalised care. According to
Anderson et.al (2004), Anderson et.al (2006), Roszak (2007) had stated that the
responsiveness or waiting time is an additional customer care quality factor that is
critical for the customer perception in healthcare (Anderson et.al (2004), Anderson
et.al (2006), Roszak (2007) ;cited by Karl et al., 2010).

SERVQUAL instrument has been designed to be applied on a variety of service
settings. SERVQUAL is used as a diagnostic technique for uncovering quality
strength and weakness. SERVQUAL instrument has a variety of potential application
and is widely used for assessing the consumer expectation and perception of
Service Quality. It also point out problems that require managerial attention
(Yesilada, 2009).

This model contains 22 items illustrated in the table 2.1 for accessing customer
perception and expectation regarding the quality of service. SERVQUAL is a
diagnostic technique used to uncover the quality strength and weakness

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Table 2.1 ,22 item of SERVQUAL Instrument

(Joanna lee, 2011)

The SERVQUAL scale has 22 questions which is used to measure the “5
dimensions” of the “service quality” namely “Reliability”, “Tangibility”, “Security”,
“Empathy” and “Responsibility” .These questions are scored in “LIKERT scale” from
1 to 5 .They are marked from “strongly agree to strongly disagree ” (Nair et al.,
2010).

The results of perception and expectation are compared to each question and the
difference between perception and expectation gives the final score The negative
results reveal that perceptions are below the expectation and there is an
unsatisfactory service experience for the client. The positive result shows that there
is a satisfactory service experience for the client.

According to Parasuraman et al in (1988) SERVQUAL is a concise scale with
good reliability and validity. Zeithaml (1987) SERVQUAL involves perceived quality
which is customer’s judgement about an entity’s overall excellence (Parasuraman et
al ,1988, Zeithaml ,1987; cited by Yesilada, 2009).

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According to researchers like Bahia and Natel (2000), Sachdev and Verma
(2004) and Chiu (2002) SERVAQUAL is the best known leading instrument used by
managers of different industrial, commercial and non profit setting (Bahia and Natel
2000 ,Sachdev and Verma ,2004 ,Chiu,2002 ; cited by Urban, 2010).

Likewise Sureshchandra et.al (2003) had identified 5 factors for service quality
from customers perspective which includes core services or service product, Human
element of service delivery, systemization of service delivery, tangibles of service,
social responsibility (Akbar & Parvez, 2009).According to Taner and Antony (2006)
SERVQUAL and Service quality gap model are the widely accepted tool in health
care setting (Taner and Antony (2006); cited by Jane Li & Ying Huang, 2011).

2.6.2.1 Advantages of SERVQUAL

According to Rohini and Mahadevappa (2006) the advantages of SERVQUAL
include (Rohini and Mahadevappa ,2006;cited by Padma et al., 2009).

1. The SERVQUAL instrument is used as a standard instrument for accessing
different dimension of Service Quality
2. The SERVQUAL instrument has shown its credibility for a number of service
situations
3. The SERVQUAL instrument has been reliable
4. The SERVQUAL instrument has a limited number of items so it can be easily
filled by customers and employers.

2.6.2.2 Criticism of SERVQUAL Model

SERVQUAL model has also drawn many criticisms, Cronin and Taylor (1992) and
Oliver (1993) had criticized SERVQUAL model for using attitudinal model in place of
disconfirmation model(Taylor (1992),Oliver (1993);cited by Padma et al.,
2009).Cronin and Taylor (1992) and Boulding et.al in (1993) had criticized
SERVQUAL model for conceptualization for service quality as gap between
perception and expectation(Cronin and Taylor (1992) , Boulding et.al in
(1993);Padma et al., 2009). Cronin and Taylor (1992) and Richard Allaway (1993)
had criticized for focusing only on functional quality rather than technical quality.
Babakus and Boller (1991) and Carman (1990) had criticises SERVQUAL for
number and structure and dimension, polarity of the scale and variance extracted in

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explaining service quality. Caraman had also criticised SERVQUAL for Item
composition, Ambiguity and usage of expectations battery, Moment of truth (Padma
et al., 2009).Sureshchandra et.al (2001) had criticised SERVQUAL for exclusion of
crucial factors such as core service, image, value, physical ambience, service
encounters. Caruana et,al (2000) had criticised it for the order effect of expectations
and perceptions (Sureshchandra et.al ,2001, Caruana et,al ,2000; cited by Padma
et al., 2009).According to Tan and Pawitra (2001) had argued that there is some
limitation to SERVQUAL method. They said that SERVQUAL assumes a linear
relationship between customer satisfactions and service attributes which can’t be
true at all the situations (Tan and Pawitra, 2001; cited by Yesilada, 2009).

SERVQUAL method was criticized for its applicability in other service industry.
Developing a list of service dimension required for an industry requires determining
factors that are required by the customers in that industry. As a result of criticism,
alternative measures of service quality for specific setting were developed. Knutson
et.al (1991) had developed LODGSERV a model used to measure the quality of
lodging industry. The model contains 5 original SERVQUAL dimensions and 26
items. Getty and Thompson (1994) introduced another specific model for hotel
setting called LODGQUAL model which has 3 dimensions namely tangible, reliability
and contact (Knutson et.al (1991), Getty and Thompson (1994); cited by Markovic &
Raspor, 2010).

In 1999 Wong Ooi Mei et.al developed a HOLSERV model which includes 27
items grouped in 5 original SERVQUAL dimensions. Steven Knutson and Patton
(1995) had developed DINESERV for measuring the service quality in restaurants. In
2000 O’Neil et.al had developed DIVEPERF model to measure the perception of
diving services.

Sower (2001) had developed eight dimension of Hospital service quality. It
includes respect and caring, the way in which the hospital staff interacts with the
patients. Effectiveness and continuity, transition from unit to unit or hospital to home
handling .Appropriateness, include the physical facility and staff professionalism
.Information, keeping patient and family members informed about the procedures.
Efficiency includes billing procedure. Meals include quality and efficiency of the meal

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service. The first impression includes the first contact with the hospital and Staff
diversity, Sower, V. (2011).

In (2003) Kahn had introduced ECOSERV it was used to utilize the service quality
expectation in ecotourism it uses 30 items and dimensions of SERVQUAL
Kahn,2003; cited by Markovic & Raspor, 2010).Kettinger and Lee (1994) had
identified 4 dimension in a study of information system quality and did not have a
tangible dimension. Cronin and Taylor (1992) had developed one factor
measurement instrument instead of 5 factor proposed by Parasuraman et.al (1988)
(Cronin and Taylor (1992), Kettinger and Lee (1994); cited by Akbar & Parvez,
2009). Ramsaran –Fowdar R. ( 2008) had proposed a modified SERVQUAL scale
for private healthcare PRIVHEALTHQUAL two more dimensions were added namely
core medical services and information dissemination (Ramsaran –Fowdar
R,(2008);Alrubaiee & Feras, 2011).

2.6.3 SERVPERF Model

Cronin and Taylor (1992) had argued “that performance is the measure that best
explains the customer’s perception of customer’s expectation so expectation should
not be included in the service quality measurement instrument”. They formed a
performance only scale called SERVPERF model (Cronin and Taylor (1992); cited
by Blery et al., 2011). Beside theoretical argument they provided empirical evidence
that SERVPF model is superior over SERVQUAL across 4 industries namely Bank,
Pest control, Dry clean and Fast food. SERVPERF model uses 22 questions and 5
dimensions of SERVEQUAL model but does not include expectation. Mazis et al,
Cronin and Taylor was on the point of view that because of its unweighted
measurement of performance it is a better method of measuring service quality. A
higher perceived performance implies higher service quality (Blery et al., 2011).

2.7 Patient satisfaction

Anderson and Suvillian (1993) had stated that increasing customer satisfaction is
vital for customer loyalty. According to Bolton (1998) service providers always seeks

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to manage and increase customer satisfaction (Wu & Wang, 2012).Patient
satisfaction is an important factor as it measures the quality of the medical service
offered. Customer satisfaction also gives the information of the provider’s success in
meeting the client’s expectation as they are the ultimate authority (Habbel, 2011).
According to Dimitriades in (2006) stated that satisfied customers tends to be less
influenced by competitors less price sensitive and they stay loyal longer. Customer
satisfaction has been considered as critical success factor in today’s competitive
business environment as they helps in retaining customers and maintaining market
share (Dimitriades, 2006;cited by Ooi et al., 2011)

According to Ware et.al in 1983, Moret et.al (2008) and Donahue et.al (2008)
patient satisfaction in medical care is an multi dimensional concept with dimensions
that corresponds to major characteristics of providers and services (Ware et.al in
1983, Moret et.al, 2008 and Donahue et.al, 2008; cited by Alhashem et al., 2011).
Likewise Donabedian (1980) had stated that informal assessment of satisfaction has
an important role in physician client interaction, since it can be used continuously by
the practitioner to monitor and guide that interaction and in the end how successful
the interaction was (Donabedian 1980; cited by Habbel, 2011).

However client satisfaction has some limitation as a measure of quality. Patients
generally have an incomplete understanding of the medical treatment in hospital.
Moreover the patient sometimes demand and expect thing that would be wrong for
the practitioner because they may be professionally or socially forbidden (Habbel,
2011).

Donabedian (1980) was in the point of view that these limitations will not lower the
validity of patient satisfaction as a measure of quality, but they are the best
representation of certain components of definition of quality, namely, client
expectation and valuation (Habbel, 2011).Mano and Oliver (1993) and Westbrook in
(1987) had stated that satisfaction is both cognitive and an affective evaluation of
service experience.

Armstrong and Kotler (1996) interpreted satisfaction as a feeling which results
from a process of evaluation what has been received against what was expected
including the purchase decision and needs and wants associated with the purchase
(Akbar & Armstrong and Kotler ,1996;cited by Parvez, 2009).Oliver (1997) is

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defined “customer satisfaction” as a “consumer’s fulfilment response”. (Oliver 1997;
cited by Wittmer et al., 2011). Kane et.al (1997) had said that customer satisfaction
is a complex concept that includes cognitive and affective components. He was of
the view that satisfaction is an “attitude response to value judgement that patients
make about their clinical encounter” (Kane et.al, 1997; cited by Alrubaiee & Feras,
2011).

Some researchers like Hogg and Gabbott (1998) had suggested that customer
satisfaction is an antecedent for service quality. Likewise Bitner (1990),Bolton and
Drew (1991), Parasuraman et.al (1988) was in the point of view that accumulation of
a satisfaction and dissatisfaction creates an overall assessment of service quality.
Eventhought satisfaction and service quality are considered to be two different
construct they are related (Sivakumar & Srinivasan, 2010).

In (1998) Gabbott & Hogg had acknowledged the work of Bitner and
Hubbert (1995) which distinguishes the different hierarchical level of satisfaction
which is related to quality judgement (Sivakumar & Srinivasan, 2010).

According to Moordian and Oliver (1997) satisfied customers can increase
the profitability by providing new referral through positive word of mouth. Brahme
2000-2001 was in the point of view that these satisfied customers act as unpaid
ambassadors of the service providers business (Moordian and Oliver,1997;cited by
Sivakumar & Srinivasan, 2010).Johnson et.al (2006) had described the basic
concept of satisfaction into transaction specific and cumulative. Transaction specific
is customer’s transient evaluation of a particular product or service experience and in
the other hand Cumulative satisfaction is the total consumption experience of the
product to the date (Johnson et.al 2006; cited byTuu & Olsen, 2012).

According to Hesselink and Wiele satisfaction is a positive affective state
resulting from the appraisal of all aspects of party’s working relationship with each
other (Akbar & Parvez, 2009).Zeithaml and Bitner (2003) had said that satisfaction is
customer’s evaluation of a product or a service in terms of whether that product or
service had met their needs and expectation. They had also said that “customer
satisfaction is a boarder concept.” (Zeithaml and Bitner ,2003; Akbar & Parvez,
2009).Pakdil and Harwood (2005) had said that “satisfaction is the most important
quality dimension and key success indicator in healthcare”. Zineldin in 2006 had

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defined satisfaction as ‘’an emotional response’’ (Pakdil and Harwood 2005; cited
byAlrubaiee & Feras, 2011). Piporas et.al (2008) had said that patient expectation
and perception are not simply related because medical or health service is not
technically comprehensive. So patient will not have a clear idea of expectation in the
clinical setting (Piporas et.al, 2008; cited by Alrubaiee & Feras, 2011).

Jackson et.al in 2001 (Alrubaiee & Feras, 2011) had stated that after
clinical visit the “patient satisfaction” is strongly influenced by the communication
between patient and doctor. Patient age and functional status also influences
“patient satisfaction”. According to them patient satisfaction can be used for four
purposes

a) “Compare different healthcare programmes”.
b) “To evaluate quality of care”.
c) “To identify the aspect of service needed”.
d) “To assist the organization to identify consumers”.

Parasuraman et al (1994) was in the point of view that greater
customer satisfaction will lead to positive customer behaviour such as repeated
purchases, positive word of mouth communication which will lead to increased
market share and increased profit margin of the company (Parasuraman et al, 1994;
Sainy, 2010).

2.8 Patient satisfaction and its Dimensions

According to Conway and Willcock (1997) cure is the fundamental expectation in
health care service. Linde- Peltz (1982) was in the point of view that patient
satisfaction is an evaluation of health care dimension. Tucker and Adams in (2001)
had stated that patient satisfaction is predicted by factors relating to caring, empathy,
reliability and responsiveness (Naidu, 2009).

Ware et.al (1978) had identified the factors such as physicians conduct, service
availability, continuity, confidence, efficiency and outcome. Fowdar (2005) had
included core service, customization, professional credibility, competence and

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communication. Woodside et .al in (1989) had included admission, discharge,
nursing care, food housing keeping and technical services (Naidu, 2009).

2.9 Theories of customer satisfaction

According to Expectancy-Disconfirmation theory by Oliver (1980)
customer purchases products and services with pre purchase expectation of
anticipated performance. Once the product or service is used the outcome is
compared against the expectation. When outcome matches expectation confirmation
occurs. Disconfirmation occurs when there is a difference between outcome and
expectation .Satisfaction is caused by confirmation or positive disconfirmation of
expectation and dissatisfaction is caused by negative disconfirmation of consumer
expectation (Oliver, 1980; cited byPadma et al., 2010).

According to Personal Control Theory proposed by Rotter (1969) satisfaction
with one’s life experience or job is related to person’s perception of psychological
covariance between their actions and desired outcomes (Rotter, 1969; cited by
Padma et al., 2010).

According to Boulding et.al (1993) and Oliver (1993), in transaction specific model
customer relation has been modelled as function of psychological constructs such as
attitude, expectation and disconfirmation. Whereas Gustaffson and Johnson (2004)
had proposed cumulative satisfaction model in which the benefit is derived from the
product or service attributes form the primary antecedent to satisfaction (Boulding
et.al, 1993, Oliver, 1993 Gustaffson and Johnson, 2004; cited byPadma et al., 2010).

2.10 Measuring customer satisfaction

Measuring customer satisfaction is an extremely difficult challenge given to the
changing healthcare industry. Evenhaim (2000) had said that measuring customer
satisfaction is important for programme planning, identifying patient concern, quality
improvement as well as customer relationship management and strategic planning
initiatives. Ford et.al (1997) had said that healthcare staff should measure patient
satisfaction in order to identify the patient related service problems and come with
solutions to improve patient satisfaction.

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According to Ford et.al (1997), the commonly used qualitative and
qualitative instruments to measure satisfaction may vary substantially in cost,
accuracy, generalizability and convenience. (York & McCarthy, 2011).

2.11Patient Loyalty

According to Woodruff (1997) customer loyalty is considered as an important
source of competitive advantage (Woodruff, 1997; cited by Wang & Wu,
2012).Patient loyalty is the surrogate of customer satisfaction and service quality
measures as understanding these measures are the first step in improving a patient
provider relationship. Customer loyalty can be described as customer’s willingness to
continue to do business with a firm over long term by purchasing and using its goods
and services repeatedly and recommending the firms product and services to friends
and relatives. It is more expensive to win a new customer than retaining an existing
customer. The net return of investment for company would be higher on retention
strategies than investing in attracting new customers (Blery et al., 2011).

John and Sasser defined “customer loyalty” as the “feeling of attachment
to or affection for the company’s people, product or service” (Blery et al., 2011).
According to Hallowell,R (1996) “customer loyalty” can be defined as “attitude
loyalty” and “behavioural loyalty” . “Attitude loyalty is customer’s affection for the
product or service willingness to recommend the service and behavioural loyalty is
the customer’s intention to repurchase” (Hallowell,R ,1996; Blery et al., 2011).

According to Pearson (1996) “customer loyalty is a mindset of
customers who hold a favourable attitude to the company, shows intention to
repurchase the products and recommend the product service to others”. Oliver
(1981) had argued that customer first becomes loyal in a cognitive sense when the
consumer belief in one brand and is preferred than its alternatives because of the
knowledge or information of the brand attributes. The second stage is affective
loyalty where the consumer develops a liking and good attitude for the brand based
on cumulative satisfying usage occasionally. At the third stage is Conative loyalty
where the customer is committed to rebuying the same product it is due to

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behavioural intention. This leads to action loyalty where the consumer exhibits
consistent repurchase behaviour (Oliver, 1981; cited by Sainy, 2010).

2.12 Importance of Customer Loyalty.

Reichheld (1996) and Soderland M (1998) was on the view that high level of
customer loyalty increases a firms profit through different ways like lower marketing
cost, ability to charge a premium price, increased customer referral and lower
operating cost (Reichheld, 1996,Soderland M,1998;cited by Sainy, 2010).It is more
expensive for the organisations to attract to customers. Research done by Peterson
and Barnes (1995) shows that long term relationship of both customers and the firm
should have mutual benefits (Peterson and Barnes, 1995; cited by Blery et al.,
2011). The customer benefits according to the researchers are presented in the
Table below:

Table 2.2 Customer benefits

Barlow, 1992 Social benefit associated with personal
recognition from employees
Barnes, 1994 Social Benefits include familiarity, personal
recognition, social support
Bitner, 1995 Confidence benefits, faith in the
trustworthiness of the service provider.
Shetha & Parvitar, reduction of choices by engaging in an ongoing
1995 loyalty programme by the marketers
Berry, 1995 Risk reduction
Kemperer,1987 Economic advantage like treatment benefits
Peterson,1995 Special pricing consideration
Rosenblatt,1977 Freedom from having to make decision.
Zeithmal,1981 Providers gain knowledge of consumers taste
and this ensures better treatment.

Author (2012)

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2.13 Measurement of Patient loyalty

According to Peltier et.al (1999) patient loyalty can be measured by
(Peltier et.al (1999); cited by Chahal, 2008) . The figure below shows the 3
factors lead to patient loyalty

a) “Using provider again for same treatment” (UPAS),
b) “Using same provider for different treatment” (UPAD),
c) “Referring providers for others” (RPO).

Figure 2.2 Measurement of patient Loyalty

(Chahal, 2008)

a) “Using provider again for same treatment (UPAS)
Using the provider again for the same treatment
expresses the willingness of reusing the same healthcare
provider for previously received service. The level of
patient satisfaction and perceived service quality
influenced the patient’s willingness to reuse the same
healthcare facility

b) “Using same provider for different treatment (UPAD)

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Visiting the same unit for different treatment is considered
to be the second long term measure of patient loyalty

c) Referring providers for others (RPO)
This is the strongest measure of patient loyalty as they
are associated with positive referral from existing patients
and it is based on their personal experience .

The patient loyalty concept used above fig 2.2 signify the perception of care
received by patient during their hospital care, the perceived care received by the
staff later on as well as the overall impression and intention to recommend the
facility. In other words the patient develops loyalty towards a hospital is based upon
the interpersonal experience that they had during the interaction with the doctor,
nursing staff and the operation quality of the hospital. According to Ostwald et.al
(1998) the patient uses the associated facility and human factor to gauge the quality
of hospital service and influence of customer satisfaction. The fig 2.3 below reflects
that the physician performance, nursing performance, operational performance and
overall service quality supplement the patient loyalty to measure to have a better
insight of process (Ostwald et.al (1998); cited by Chahal, 2008)

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Figure 2.3 Patient loyalty and service quality model

(Chahal, 2008)

2.14 Service Quality and Customer Satisfaction relationship

Sureshchandra et.al (2003) had identified that a strong relationship
exist between “service quality” and “customer satisfaction” while emphasizing that
“these two are made of different conceptual constructs in customer’s point of view”.
(Sureshchandra et.al, 2003; cited by Akbar & Parvez, 2009)

Spreng and Mckoy (1996) had said that “service quality leads to
customer satisfaction”. Thus the researcher can argue “that perceived service quality
has a positive effect on Customer satisfaction”. (Spreng and Mckoy,1996;cited by
Akbar & Parvez, 2009)

2.15 Service quality and customer loyalty relationship

Boulding et.al (1993) had conducted various “research on the relationship
between service quality and customer loyalty”. Boulding et.al in 1993 had done a
research on “elements of repurchasing as well as willingness to recommend “and his
study was able to establish a “positive relation between service quality and
repurchase intention and willingness to recommend”. Thus the researcher can argue
that there is a positive relation between service quality and customer loyalty since

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repurchase intention and recommendations forms the basis of customer loyalty.
(Akbar & Parvez, 2009)

2.16 Customer satisfaction and Customer loyalty relationship

Numerous studies done by various researchers like Andreson & Suvllivan
in 1993, Bolton& Drew 1991, Fronell in 1992 had found a “positive correlation
between customer satisfaction and customer loyalty”. Similarly studies in service
sector by Anderson & Suvillian 1993,Bansal & Taylor in 1999 ,Cronin & Taylor in
2000 had also “empirically validated the relationship between customer satisfaction
and customer loyalty”. Hart and Johnson in 1999 had stated that “true customer
loyalty is total satisfaction”. Thus the researcher can argue that customer satisfaction
has a positive effect on customer loyalty. (Akbar & Parvez, 2009)

2.17 Relation between service quality and patient satisfaction

Relationship Between Service Quality, Customer Satisfaction & Customer Loyalty

Figure 2.4 (Mengi, 2009)

Thus the researcher can argue that Service quality is a focussed evaluation
of “customer’s perspective of reliability, responsiveness, assurance, empathy and
tangibles”. “Customer satisfaction is influenced by perceived service quality, product
quality, price along with personal and situational factors”. The customer loyalty is
influenced by both service quality and customer satisfaction. The fig 2.4 shows the

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relation between “the customer perception of service quality, customer satisfaction
and customer loyalty” and their interrelationship.

2.18 Conclusion

Service quality is an important determinant factor that is considered in meeting the
client’s expectation. Service quality is of prime importance because it is in the hand
of the service providers. Studies have been shown that service quality plays an
important role in customer satisfaction and there is a relation between customer
satisfaction service quality and patient loyalty each customer has their own
perceived perceptions for service quality. In healthcare sector the perceptions of the
patients will always cannot be taken in to account as they lacks the knowledge of
the technical aspects of the hospital.

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Chapter 3

Research Methodology
3.1Introduction

The author begins the chapter by restating the research aims and
objectives then the author discusses about the research philosophy, then he talks
about research strategy research approach and about data collection and then
moves on to discusses about the sample size of the research the sampling
technique to be adopted and finally concludes the chapter

3.2 Aim and objective

India.

quality so that they can increase patient satisfaction and gain patient loyalty

3.3 Research Methodology

According to Burns (1997) research can be defined as a systematic investigation
to find a solution for a problem (Burn,1997: cited by Kumar, 2011). Saunders et.al
(2007) stated that “research process is a series of linked stages and gives the
appearance of being organized in a linear manner” (Saunders et al., 2007).
Dr.C.Rajendra Kumar (2008) was on the point of view that “research methodology is
a way to systematically solve the research problem” (Kumar, 2008).

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3.4 Research Design

“Research Design” is the general plan how research will be done. Saunders
et.al in 2007 had classified the research in to six stages and labelled them as
research onion in fig 3.1. They had divided research into philosophies, approach,
strategy, choices, time horizon, technique and procedure. Saunders “research onion
is the way of exhibits the issue underlying your choice of data collection method or
methods and peeled away the outer two layers the research philosophy and
research choice.” (Saunders et al., 2009). “Research Philosophies”, “Research” and
“time horizon” guide the researcher to “desired process of Research Design”.
“Research Philosophies” and “Research Design” helps to answer the “research
question”. “Research Strategy” depends upon “research topic”, “data collection”,
“analysis” and “time factors”. “Research design” can be classified as “Exploratory”,
“Descriptive” and “Explanatory”.

Figure 3.1 Research onion

(Saunders et al., 2009)

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3.4.1 Exploratory research

It is an attempt to have an develop an initial understanding of the new
phenomenon (Babbie, 2010).The difference between the different research is given
in table 3.1.

3.4.2Descriptive Research

It is the precise measurement and reporting of characteristics of some
population or phenomenon .It also involves analysing the existing data (Babbie,
2010) .The

3.4.3Explanatory Research

It is a study which involves establishing a cause effect relationship between
different aspects of phenomenon under study (Babbie, 2010).

Types of Research Design

Table 3.1 (Saunders et al., 2009)

3.4.4 Justification for this research design

The researcher had used “explanatory design” to because the researcher is trying to
trying to find the relationship between the different aspects of phenomenon of study.

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3.5 Research Philosophy”

“Research Philosophy contains important assumptions, in which research will be
conducted”. It forms the basics of research strategy and is influenced by practical
consideration.

3.5.1Epistemology

In this the researcher has a role of a scientist and resources are selected objectively.
Epistemology refers to the nature of the knowledge in the way we conceive our
surrounding Epistemology is of three types Positivism, Realism, Interpretism.

3.5.2 Positivism

If we intent to adopt an approach similar to natural scientist then our approach is
positivist. In positivism theory is explored to develop a hypothesis. It’s a value free
research observations which are quantifiable and statistical analysis can be carried
out (Wilson, 2010). If we are following a positive approach for our study then we
believe that we are independent of our research and is truly objective. Positivists are
in the point of view that the research should be done in a scientific manner. It is an
empirical research which is done under strict guidelines of polices by trained
scientist. The research is usually carried out in a deductive approach moving from

theory to observation. In general positivist wants their findings to be applicable to the
whole of the population (Wilson, 2010).

3.5.3 Realism

It is a scientific approach to the development of knowledge which is similar to
positivism

Realism is truth and is divided in to

1. Direct realism In direct realism researcher does just observations and
recording of what we experience through our senses.
2. Critical realism the researcher sees the entire research as a part of bigger
picture..

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Critical realism the researcher can experience the world in two
ways. First one is the thing by itself and the sensation it conveys and the second
is the mental processing that goes on sometimes after sensation meets our
senses. On the other hand Direct realism says that only first step is enough
(Saunders et al., 2009).

3.5.4 Interpretivism

In this research the researcher take an active role in carrying out research. This type
of research the emphasises the need for conducting research on people rather than
on objects. The researcher looks in to a particular subject in depth. The purpose of
the research is not to generalise but to actively engage in high level of participation
and interactions (Wilson, 2010).

Interpretivism comes from two intellectual traditions

1. Phenomenology: - We can make sense about the world around us.
2. Symbolic Interactions: - We are continuously Interpreting other actions and
making new meaning by combining our views and their action (Saunders et
al., 2009).

3.5.5 Ontology

It deals with that which is at least in principle that can be categorised. Ontology is
that which can be rationally understood or at least partially (Poli, 2010).Ontology is
concerned with the nature of reality (Saunders et al., 2009).

It is divided into subjectivism and objectivism

3.5.5.1 Subjectivism

In subjectivism here is a continuous interaction with constantly changing world

3.5.5.2 Objectivism

In objectivism everything has its own identity

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3.5.6 Axiology

Axiology is that which studies the judgement of the value. It is a more credible form
of research. Philosophy is based on the value of researches with respect to data
collected. if we want our research to be credible we have to uphold our values in
each stage of research process. (Saunders et al., 2009).

3.5.7Justification of research philosophy

The researcher had adopted positivist approach because it does not emphasise on
human interest and aims to analyse quantitative data in a statistical analysis.

3.6 Research Approach

According to Saunders in 2007 there are “two approaches deductive and
inductive”.

In deductive approach a hypothesis are developed and research strategy is
designed to test the hypothesis. Table 3.2 shows that deductive approach is a highly
structured approach. In this the researcher is independent of what is being
researched. In deductive approach it explains the relationship between different
variables. There is a collection of quantitative data.

While in “inductive approach” “data are collected and theory is developed as a result
of data analysis” (Saunders et al., 2009). Table 3.2 shows that inductive approach
involves understanding the human attach to the event. There is a collection of
qualitative data. The researcher is the part of the research process.

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Research Approach

Table 3.2 (Saunders et al., 2009)

3.6.1 Justification Of research approach

The researcher will be adopting a deductive approach because of the
Positivist research philosophy. It also relies on prior conceptual and theoretical
framework covered by a large number of quantitative data. It also tests the existing
theory where the findings can be generalised.

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3.7 Research strategy.

Is study method used to gather the data which can be divided in to:-

3.7.1Quantitative data

It emphasizes the production of generalized and precise statistical finding.
Qualitative Data is used when we want to verify whether a cause produces an effect
(Rubin & Babbie, 2011).

3.7.2 Qualitative data

The first challenge faced by the researchers is to select the best qualitative
method to answer the research question. The qualitative method had developed
from a philosophical perspective each of which had developed the influence of
associated methodology (Issel, 2009). In qualitative data we are we get the inner
meanings of humans through observation which are intended to gen theoretical
observation and are not easily reduced to numbers. (Rubin & Babbie, 2011).

3.7.3 Justification of Research Strategy

The researcher had chosen quantitative research strategy. The researcher will
be using questionnaires .The researcher will be testing the hypothesis and the theory
with data. Qualitative researchers consider prime importance to state hypothesis and
test the hypothesis with the data to see if they are supported.

3.8 Source of Data

We can divide the data as archival data or secondary data which already exist
in some forms e.g. pay rolls and Primary data which have to be collected in the due
course of the research (Burt et al., 2009)

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Fig 3.2 Source of data

(Burt et al., 2009).

3.8.1 Primary Data

“Primary Data” are those data fig 3.3 which have do be collected in the due
course of research. They can be collected by different ways by observation,
questionnaire, personal interview, telephonic interview. Primary data can be
collected either by quantitative research or qualitative research.

Quantitative technique includes survey, observation and experiments
and Qualitative technique includes in depth interview, Projective technique and focus
group. (Wiid & Diggines, 2009).It is illustrated in the diagram below.

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Fig 3.3 Primary Data

(Wiid & Diggines, 2009)

3.8.2 Justification of “Primary Data”

The research will be carried out by distributing questionnaire. They will be
formulated in a semi structured method so that the respondent can give more
information.

3.8.3 Secondary Data

Secondary Data are those which already exists that had been gathered for a
previous studies (Churchill Jr & Iacobucci, 2010).

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3.8.4 Types of Secondary Data.

“Secondary data” can be classified in to several types most important one
is internal data those found within an organisation .External data can be again
divided into that are regularly published and we get the information for free for
example, census report, statics and that are published by different commercial
organisations and sells the information eg AC Neilson (Churchill Jr & Iacobucci,
2010).

Figure 3.4 Secondary Data

(Churchill Jr & Iacobucci, 2010)

3.8.5 Justification for secondary Data

Secondary data will be collected from the
Hospitals website since the website will be biased the researcher will also collect
data from government statistics, newspaper articles, journals and books.

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3.9 Sampling

“Sample is a subset of a population” (Lohr, 2010). “Sampling techniques” are of two
types :-

3.9.1Probability Sampling or Representative sampling

With “probability sample the chance, or probability, of each case being
selected from the population is known and is usually equal for all cases”. (Saunders
et al., 2009).

3.9.2 Non Probability Sampling or Judgemental Sampling

For a “non Probability sampling the probability of each case
being selected for total population is not known and it is impossible to answer the
research question or address the research objectives that require statistical
interference about the characters of the population” (Saunders et al., 2009).

3.9.3 Justification of sampling

The researcher will be using probability sampling. The researcher had used simple
random sampling the research. The researcher will be distributing 500
questionnaires to the patient of the hospital.

3.10 Conclusion

This chapter discusses about the primary research of the research method. The
author had adopted explanatory research as research design in the light of this he
had adopted deductive approach and positivism as research philosophy. Books
journals and the hospital website will be used for secondary research and primary
data will be collected by distributing questionnaires to 500 patients. Simple random
sampling of Probability sampling will be uses as sampling technique.

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A case study of travancore medical college hospital kerala, india

A case study of travancore medical college hospital kerala, india

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