A study of service quality assessment for patients case of ahi evran university training and research hospital emergency services

doi: 10.26579/jocrebe-7.2.26
Journal of Current Researches
on Business and Economics
(JoCReBE)
ISSN: 2547-9628
www.stracademy.org/jocrebe
A Study of Service Quality Assessment for Patients: Case of Ahi
Evran University Training and Research Hospital Emergency
Services
Neşe ACAR1, Ayşegül TURAN2 & Bülent ÇİZMECİ3
Keywords
Service Quality,
Patient
Satisfaction, Health
Care, Servqual.
Abstract
It is aimed that the measuring of level of patient’s expectation from health
services and the realization of these expectations. In this direction, expectations
and perceptions are measured of a sample group of 501 people who are treated
in public hospital emergency room. Variables are dimensioned and Servqual
method is used. While the patient’s perceptions are higher than their
expectations in responsiveness and confidence factors, perceptions and
expectations of patients are very close for empathy factor. In order to determine
the differences in perception of the patient's t-test are performed. The result of
multivariate analysis of variance showed significant differences in terms of age,
income, educational status.
1. Introduction
Healthy generations, advances in science and technology, healthy workforce and
economic benefits and many positive developments are possible with raising the
level quality of health services. When hospital services are considered as
hospitalized, policlinic and emergency, patients are firstly consulted to emergency
or policlinics. It can be seen that, when the patients need again examination,
treatment and diagnosis services, the experiences of patients satisfied are effective
for consulting these services. Therefore, detecting how the perception of the
offered services and the level of satisfied is important for patients and healthcare
personalities.
2. Health Care
Healthcare is a service which is offered by private and public organizations in
order to protect to individual health, diagnose, treatment and rehabilitation
(Harcar 1991:38). The purpose of marketing health is to meet patient expectations
within the framework of scientific norms by providing diagnosis and treatment. In
the healthcare market, inability to predict to demand, the application of some
1 Corresponding Author. Yrd. Doç. Dr., Nevşehir Hacı Bektaş Veli Üniversitesi, Türkiye,
neseacar@nevsehir.edu.tr
2 Nevşehir Hacı Bektaş Veli Üniversitesi, Türkiye, Aysegul.Turan2@saglik.gov.tr
3 Nevşehir Hacı Bektaş Veli Üniversitesi, Türkiye, bulent.cizmeci@yahoo.com
Year: 2017
Volume: 7
Issue: 2

408 Acar, N., Turan, A. & Çizmeci, B. (2017). A Study of Service Quality Assessment for
Patients: Case of Ahi Evran University Training and Research Hospital Emergency
Services
procedures of Health Ministry in the entering of the healthcare market, having
insufficient information by consumers about the health care market, lack of equal
quality of service delivery of healthcare providers, having a number of external
factors affecting health services market, not delay to the demand of healthcare
services, the difficulties of calculation of health care cost, civil organizations in
these areas, are some features that is separated from others (Kurtulmuş,1998,44-
60).
Marketing approach in the provision of healthcare services has not been accepted
morally for a long time, after the eighty years it has begun to take a place. In the
past years, the marketing concept with the same advertising was seen but
nowadays it takes the form patient focused health care delivery. Patients are
expected to meet their needs in terms of the clinical and services. A satisfied
person means a loyal customer. Even in his entourage who recommended the
company will have contributed to the positive publicity (Corbin, 2001: 181).
Marketing mix in the healthcare service is consist of traditional marketing mix
components in addition to the components such as participants(peoples), physical
environment and process management (Tengilimoğlu 2000: 190).
The product of range is very wide in the health sector. Besides the diagnostic,
treatment, preventive and rehabilitative basic health services, the products is used
for assistive service such as cleaning, beverage, hospitality, patient safety and the
provision of these services. (Erin 2006: 34). Consumers are insensitive against to
price due to the reasons of being mandatory requirement of healthcare, doctor
direction related to services and paying the cost by the insurance.(Erin 2006: 49).
Health business can make pricing in four ways according to laws, rules and
regulations, demand cost and competition (Erin 2006: 50). There are two means of
access to health services. These; the distance between the patient and health care
provider and the procedures such as patient registration, admission and discharge
(Öztürk, 2007: 28).
In order to be aware of the health services by target market, purchasing and
adoption, the announcement these services via various communication channels
located between healthcare promotion activities (Erin 2006: 58). In the promotion
of health services public relations activities can be seen in the foreground.
Furthermore, programs to inform the public made by the staff of health
institutions can be considered as indirect advertising. At the same time, the unit of
patients' rights, public education (schools at upper secondary level, Koran courses,
and stands established in the universities, workers in factories etc.) made
structure in the city is located between the communication activities. Thanks to
this training, it is trying to create demand making the promotion of health services.
Furthermore patients hospitalized in the clinics, there is an obligation to give
training about patient rights. Patient rights training officers of this unit while
training at the same time evaluating the satisfaction of patients and their
suggestions and can also contribute to determine new strategies to provide
healthcare services.
It includes contributors to the production of services in marketing activities and
consumers (Tengilimoğlu, 2000: 197). Employees of health care establishments

Journal of Current Researches on Business and Economics, 2017, 7 (2), 407-420. 409
with patient’s attitudes and behaviours are caused consumers to reach some
conclusions about health business (Erdem, 2007: 45). Therefore, the patient rights
unit training officers are periodically training to hospital staff about interpersonal
relations.
Physical conditions of health institutions (lighting, ventilation, decoration, etc.) are
among the factors that impact on the satisfaction of patients and their relatives
(Öztürk, 2007: 40). Patient rights unit is according to the principle of each patient
has the right to be examined in clean and secure, it leads to the improvement of the
physical conditions of the hospital. Fluctuations in demand can be experienced in
health care. Patient rights units provide training in order to get this situation under
control and patients are introduced about appointment system and encouraged.
3. Patient Satisfaction
One of the factors that health authorities should pay attention to when considering
marketing is the patient satisfaction (Churchill, Surprenant 1982, 491; John, 1992,
56). Consumer satisfaction a post-purchase one that reflects how satisfied the
consumer is from the service after experiencing the service. (Bearden, Teel, 1983,
27; Churchill, Suprenant, 1982, 503). Patients are the focus of marketing health
care services. The aim of the patient-oriented marketing approach is to meet and
satisfy the expectations and needs of existing and potential patients better than the
competition, and to improve the level of satisfaction by providing more qualified
services and to make life permanent. (Tengilimoglu, 2000: 103).
Social benefit and profitability are two important purposes of health enterprises
Profitability are possible by increasing patient demands. The first goal of the
healthcare enterprises should be to best meet the patient expectations because the
patient can receive the request through the same operation again and by
recommending it to others. Patient satisfaction consists of many factors such as
staff qualifications, physical conditions of the hospital, ease of access to the service,
reliability of the analyses and examinations, employee attitudes and credibility,
and one or more of these negative experiences may affect the evaluation of other
factors. For this reason, services provided by health institutions should be of high
quality. A patient who is satisfied with the service he has received is a loyal
customer and he always chooses the same hospital when he is in need (Gülmez,
2005: 148).
4. Service Quality
Quality is an area of uncertainty and complexity in terms of understanding,
implementation and supervision. For this reason it is sometimes difficult for
businesses to establish the features of the services offered at the same level.
(Öztürk, 2003). In Turkey, the concept of quality in health has begun to be used for
the first time with the Health Transformation Program of the Ministry of Health in
2003. The quality of service perceived in health can be explained by the
satisfaction level of the patient. A satisfactory patient is continuous, profitable and
relatively low cost (Bust, 1995). In health services quality can be expressed in
three parts as technical, interpersonal communication and comfort direction. The
technical aspect indicates how well medical science and information are applied in
the diagnosis and treatment of health problems. The communication aspect

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between the persons includes the benevolence, friendly approach and features of
the persons present during the presentation of the health service, while the
comfort aspect includes the facilities offered by the hospital (Donabedian 1997;
Varinli, Çakır, 2004: 34). Many methods are used to measure the quality of service.
In this study, the servqual model was used.
5. Servqual Service Quality Model
Quality has dimensions that are not easily understood and easily distinguishable
from each other (Parasuraman, Berry & Zeithalm, 1985). Since the quality of
service is difficult, until 1980s there are not many studies related to the subject. In
our country, it is seen that these works started from 1990's years. (Nakip, Varinli,
Güllü, 2006: 374). There are definitions by many authors, institutions and
organizations regarding the quality of service. It is seen that the service provided
at the centres of these definitions is conformity to certain specifications, satisfying
consumers, meeting expected needs, and so on. (Güllü ve Şahin, 2015:37-57).
Studied by Parasuraman, Zeithaml and Berry has modelled many studies on the
measurement of service quality. According to the authors, since the quality of
service is evaluated by consumers, the expectations and perception levels of
consumers should be determined. In addition, service quality assessment is a
comparison of consumers' expectations and perceptions, and evaluation is based
on various service quality dimensions. The quality of service components
identified by the authors as ten dimensions subsequently reduced to five
dimensions. These dimensions; physical features, confidence (Realibility),
responsiveness, trust and empathy (Parasuraman etc, 1988, 1991).
Servqual service quality dimensions include physical characteristics (facilities and
equipments that owner of the business or enterprises), reliability (performance
consistency and reliability, faultless billing as well as complete service in the first
place, keeping records in place and completing specified services at specified
times) (Service management employees have the necessary knowledge, skills and
equipment, honesty, credibility and prestige, customer gentlemanliness, self-care
competence), empathy Service management employees do not show individual
interest and sensitivity to customers, and behave with diligence) (Parasuraman,
1991: 420).
6. The Importance of Research
The diagnosis, diagnosis and treatment services of the patients who have health
problems and are referred to the hospital are first met by emergency services
according to the conditions of their diseases. The purpose of the research
determining the factors affect the satisfaction level of patients entered emergency
and it is to determine the quality of service components that affect the satisfaction
of patients. Service quality dimensions are determined based on the servqual and
its effects on patient satisfaction score of this size were examined. The results
obtained through the detection of patient expectations are considered to be a
resource for the planning of appropriate health services. Although there are many
studies in health and other institutions relevant for measuring the quality of
services performed in hospital emergency service work are seen in a limited way

(Saat 1999; Lee 2000; Jain vd. 2004; Öziç 2007; Rahman vd, 2007; Mohammad
2007; Erdem 2007; Filiz vd. 2010; Kuzu 2010; Yalkın 2010; Harput 2014, Papatya
vd. 2012; Gülmez 2005, Güllü & Şahin 2015, Nakip vd. 2006).
This study has tried to determine the impact on patients' who receive a service
from the emergency, quality of service and customer satisfaction ratings.
7. Methods
In this research, literature is reviewed and the theoretical framework has been
established. The servqual scale developed by Parasuraman, Zeithaml and Berry for
measuring the service quality is widely used for the application and the survey
method was used for primary data. The questionnaire has been created by
adapting the SERVQUAL scale survey of patient satisfaction with the Ministry of
Health and survey questions was applied to the patients who applied to the
emergency department for the time period between 1 October 2015 and 31
January 2016.There are 25 separate questions related to expectations and
perception in the questionnaire, participants who were asked to evaluate items
based on five-point Likert scale. The respondents were requested to reply these
items according to five-level Likert type scale (1=Strongly disagree, 2=Disagree,
3=Neither disagree nor agree, 4=Agree and 5=Strongly agree). Also includes
questions to determine the demographic characteristics. The main mass of this
study is consisted of patients who were admitted to the emergency room between
the dates of 1 October 2015 and 31 January 2016. Nowadays, the number of
patients who were admitted to the emergency room is 70 312, in determining the
sample size of five percent confidence level has decided that sample size is enough
occurrence from 501 person (Kurtuluş, 2006: 192). Reliability value of the
questions related to perception is 0.929 and the reliability of the questions related
to the expected value is 0.926.
8. Research Model and Hypotheses
Graphic 1: Research Model
H1: Expected service affects the perceived service quality.
H2: Perceived service quality affects patient satisfaction.
9. Results
According to results, 61,9% female, 88,2% married, 56,3% graduated from a
University, 36-45 age group is 53,1%, %35,7% officer and 2.001-3.000 TL income
group is 34,7% (Table: 1).

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Table 1: Demographic Characteristics of the Participants
Age Frequency % Profession Frequency %
18-25 36 7,2 Student 5 1,0
26-35 108 21,6 Officer 179 35,7
36-45 266 53,1 Retired 154 30,7
46 + 91 18,2 Worker 27 5,4
Gender Frequency % Housewife 16 3,2
Mail 191 38,1 Other 120 24,0
Femail 310 61,9 Income Frequency %
Education Frequency % 1000-2000 144 28,7
Primary Education 17 3,4 2001-3000 174 34,7
High School 192 38,3 3001-4000 160 31,9
University 282 56,3 4001-5000 4 ,8
Graduate 10 2,0 5001+ 19 3,8
Marital Status Frequency %
Married 442 88,2
Single 59 11,8
Total 501 100 Total 501 100
9.1. Assessment of Service Quality Expectations-Perception at the Emergency
Participants' perceptions of service quality related to the 25 variables, SERVQUAL
analysis was applied. In Table 2, factors are given to the difference between
perception and expectation levels. The physical properties of size, it is observed
that services of person’s expectations are higher than the perceptions. Patients and
relatives to sign router shows that how important it is already the most important
indicator of a higher rise of the difference in this variable (placing in accordance
with the direction signs). Eventually, in an emergency situation that people in the
current psychological consequences router marks may be more useful. In the
dimension of reliability; it was determined that expectations were higher than
perceptions. Understanding the patients' expectations by examining the reliability
of expressing variable is important of the management strategies. In the
responsiveness size, it is observed that except this variable (doctors to provide
information about the disease to patients and relatives) the perception is higher
than expectations. The information given by the doctor of the current status of
these patients is not fully understood or said that it caused them to leave more
time. Jargon words especially used by doctors can turn into situations that are
difficult to understand for emergency patients. In this regard, doctors may be
appropriate to use phrases that patients can understand.
The size of confidence; "that there were no problems while getting service" and
“the problems to be resolved shortly” outside of these variables perception has
increased more than expectations. The appearance of high expectations on these
variables, the service provided by the condition of the patient and elapsed time
during the resolution of the problem by offering a service may be caused by
different evaluation. The services to be satisfactory, the service will have
properties preferable and the quality of services may be recommended to the
others is variable in services are expected to rise more than the perception of the
patients were satisfied and they will prefer to be thought of in the same hospital
when they have health problems again and or will suggest it to other patients.

Table 2: Reviews of Patient’s Expectation and Perception
perception expectation difference
PHYSICAL PROPERTIES 2,98 3,22 -0,24
Be comfortable Registration/reception and
waiting area
3,17 3,35 -0,18
Place the router signboards in a proper way 2,86 3,23 -0,37
Be clear 2,86 3,05 -0,19
Be sufficient Heating, cooling, lighting and
ventilation systems
3,08 3,24 -0,16
To be included in applications for the
disabled
2,96 3,21 -0,25
CONFIDENCE 2,49 3,41 -0,92
The execution of the service in a reliable and
accurate way
2,47 3,40 -0,93
Accurate diagnosis and treatment of
physicians
2,49 3,40 -0,91
Not keep you waiting for the results of tests
and analysis and be reliable
2,51 3,40 -0,90
Accurately keeping records 2,49 3,41 -0,92
The hardware is sufficient (necessary
supplies and equipment)
2,49 3,42 -0,92
Sufficient number of personnel 2,49 3,41 -0,92
RESPONSIVENESS 3,36 3,20 0,16
Polite and courteous staff against patients 3,36 3,05 0,31
Informing patients their relatives about the
disease by doctors
3,53 3,67 -0,14
Proper orientation of patients by staff 3,36 3,06 0,31
Without waiting for more to be examined 3,18 3,02 0,16
TRUST 3,49 3,33 0,16
There were no problems while getting
services
3,41 3,43 -0,02
The problems to be resolved shortly 3,49 3,50 0,00
The services to be satisfactory 3,53 3,29 0,24
The characteristics of the service is to be
preferred again
3,52 3,31 0,21
Being in nature of service can be
recommended to others
3,50 3,13 0,37
EMPATHY 2,66 2,65 0,01
Individual attention according to the needs
of the patients
2,65 2,57 0,08
Staff make patients feel special 2,67 2,69 -0,03
Employees keep the interests of patients
above everything else
2,63 2,71 -0,08
Employees do their best for their patients 2,67 2,70 -0,03
24 hours emergency service to serve
effectively
2,67 2,58 0,09
When it comes to empathy, the perception and the expectation seems to be close.
Individual attention shown for the needs of the patients, a 24-hour emergency
service in effective service delivery variables and the perception has increased to
slightly more than expectations. Given the state of emergency services, in other

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expressions, the expectation has increased to more than perception, and also the
condition of the patient, intensive work environment and by providing services
according to patients whether they are sufficient and can be said to be a little
difficult to give the necessary importance. On the same period of the study, due to
seasonal reasons, especially when there is intense corresponds to the patient.
According to the general assessment of the perceptions and expectations where
the study was made of the patients are satisfied with the service that they received
and they will be able to recommend it to others. Expectations were high for
variables that especially suggested strengthening emergency services in terms of
physical properties, studies on the improvement of working conditions and the
number of staff by management.
9.2. Perception Differences of Service Quality According to Demographic
Characteristics of Patients
According to the five factors identified in order to assess whether perceptions
differ in the demographic characteristics of patients with T - tests and multivariate
analysis of variance was applied.
The results of the t-test analysis showed that there is a difference in perception
with regard to the gender of the patient. Table 3 is a detection level of service
quality according to the size of the patient.
Table 3: T-Test Results on the Patient Perception of Service Quality
(Factors)
Responders
T-Value Significance
Male Female
Physical features 2,9937 2,9787 ,183 ,000
Confidence 2,1230 2,7151 -6,056 ,000
Trust 3,1927 3,6729 -5,328 ,000
Empathy 2,5497 2,7252 -1,924 ,018
As a result of the analysis it is seen that the size of the difference in the levels of
detection about physical features, reliability, confidence and empathy. Women are
more solution-oriented therefore it considered to have the highest confidence in
the average size. Physical characteristics dimensions, the ladies of the average of
male participants are expected to be high, because such as cleanliness, comfort of
the waiting room, ladies in high expectations and more rigorous than men. When
considered in terms of averages, perceptions of female participants in all aspects
except the physical properties were higher than men. The maximum difference
between the average of male and female participants is reliability of size. The
reason for this female patients in these issues of service delivering respect of
physicians in the diagnosis and treatment, the accuracy of tests and analysis,
accurate record keeping and the technical background to be adequate can be
evaluated as more reliable than men.
Patients, levels of detection dependent on the dimensions of service quality
containing five factors and taking demographic characteristics as independent
variables, multivariate analysis of variance was performed. There was a significant
difference with regard to age, income, educational status. Patients of the detection
level are set according to the service quality dimensions in table 4.

Table 4: According To the Age Level of Patients That Factors Perception Differences
Shown
Factors
Age
F Significance
18-25 26-35 36-45 46 +
physical features 2,89 2,84 2,87 3,52 14,950 ,000
responsiveness 3,08 2,19 3,56 4,26 143,741 ,000
empathy 2,78 2,33 2,74 2,73 4,980 ,002
Hotelling'sTraceValue: 1,403 F: 45,983p: ,000
According to patient’s age, factors demonstrate significant differences in
perceptions of physical characteristics, responsiveness and empathy. Age as of the
biggest difference is seen that the responsiveness size. According to this table,
staffs is polite and respectful towards patients, physicians informed their patients,
staff directed patients appropriately and more on whether waiting for the medical
examination can be said to be a difference of dissidence between the age groups.
When looking at the averages of the patients in the age group 46 and above, the
mean values are higher.46 year’s later participants are able to perceive a higher
quality of service delivery to their benchmark by the hospital conditions they live
in the past.
Table 5: According to the Income Levels of Patients That Factors Perception Differences
Shown
Factors
Income-Revenue
F Significance
1.000-
2.000
2.001-
3.000
3.001-
4.000
4.001-
5.000
5.001+
physical
features
3,13 3,29 2,48 4,40 2,98 25,948 ,000
Reliability 3,19 2,18 2,14 3,50 2,70 27,721 ,000
responsiveness 4,27 2,85 3,09 3,75 3,28 65,990 ,000
Confidence 4,17 3,72 2,61 3,65 3,46 80,112 ,000
Empathy 3,04 2,63 2,30 3,50 2,83 12,717 ,000
Hotelling'sTraceValue:1,670 F: 40,963 p: ,000
Revenues in all sizes of patients’ perceptions as factors show significant
differences. Revenue size is the biggest difference as confidence, the highest
average is 1,000 - 2,000 TL income level and it is observed that the lowest average
is belonging to participant’s income 3.001 - 4.000 TL. Participants with medium
income levels, they do not find the services satisfactory, they won't choose again or
recommend, patients in the process of service received may think the solutions
will take time. When looking at averages 1,000 to 2,000 TL incomes between the
groups of patients in the mean values are higher. Due to the living conditions of
low-income respondents said that their expectations are low.

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Table 6: According To the Educational Status of Patients That Factors Perception
Differences Shown
Factors
(Educational Status)
F Sig.
Primary Ed. High S. University Graduate
Physical features 2,99 3,13 2,84 3,96 8,218 ,000
Reliability 2,60 2,99 2,13 2,60 26,867 ,000
Responsiveness 3,47 4,30 2,70 3,47 220,575 ,000
Confidence 3,43 3,85 3,23 3,80 16,432 ,000
Empathy 2,78 2,89 2,48 3,24 8,055 ,000
Hotelling's Trace: 1,831 F: 60,004 p: ,000
Factors of patient perceptions have significant differences by education level in all
sizes. In the case of education, it is observed that the biggest difference in
responsiveness dimension. High school graduate participants, staff attitude
towards patients, information and the routing issues that have a positive view, it
was concluded that the university graduates have higher expectations. Other
demographic characteristics are also believed to be effective in this regard.
10. Conclusion
In the study, prepared by Parasuraman service quality factor is taken as 5
components. These are physical features, confidence, trust, responsiveness and
empathy. Expectations of patients according to their physical characteristics and
reliability factors were higher than perceptions. Especially concerning variable
direction signs, it seems to be more in difference between perception and
expectation. In this regard, it is important to be placed in a way that people can
take care of the incoming emergencies direction signs. Enthusiasm and confidence
factor in the perception of the patients was higher than expected, the empathy
factor according to the perceptions and expectations of the patients were close to
each other. According to the general assessment of their perceptions and
expectations of patients are satisfied with the service they received from the
emergency room where the study was conducted and concluded they can
recommend to others. Expectations were high for variables that the administration
should strengthen the emergency services in terms of particular physical
properties and issues such as number of personnel and the improvement of
working conditions should be given.
According to the five factors identified in order to assess whether perceptions
differ in the demographic characteristics of patients with T-tests and multivariate
analysis of variance (MANOVA) was applied. The results of the t-test analysis
showed that there is a difference in perception with regard to the gender of the
patient. In terms of averages, the perception of women in all aspects except the
physical properties was higher than those of men.
As a result of multivariate analysis of variance, there was a significant difference
with regard to the age, income, educational status. Patients' perceptions of factors
by age, perceptions of physical characteristics, responsiveness, shows significant
differences in empathy. Responsiveness size 46 and above age group the difference
is even greater. The biggest difference comes in sizes as confidence was higher in
group revenues between 1.000-2.000 TL. According to the education level factors

of the patients showed significant differences in the perception of all sizes.
According to the state of education, the biggest difference was seen in patients
with an average size of enthusiasm who graduated from high school.
The quality of service is not only the responsibility of health manager’s interests
and it is also a component associated with the expectations and requirements of
the patients in this direction. So expectations of the service providers (hospital
administrators) service recipients (patients) accurately perceived and they are
required to provide services in this direction. In other words, patients and hospital
executives said compliance is the issue of expectations and perceptions. Subject to
compliance expectations and perceptions of patients and hospital executives.
The results of the study, it includes only assessments of patients who receive
treatment in the emergency room of a public hospital in Kırşehir. Therefore, it is
not possible to generalize the results of the research. In the next study it will be
done in different samples and provinces and the comparison of results will be able
to present useful information.
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