Understanding hospital quality: Empirical insights from patients’ perspectives in the growing hospital sector

Abstract

Background: The rapid expansion of the hospital sector in Indonesia, fueled by the National Health Insurance Program (JKN), emphasizes the need for improved service quality. Understanding patient perceptions of hospital service quality is crucial for enhancing satisfaction and optimizing healthcare delivery.

Purpose: This study aims to evaluate hospital service quality from the patient’s perspective, focusing on empathy, safety, tangibility, perceived quality, and patient expectations. It also investigates the moderating role of patient expectations on the relationship between perceived service quality and satisfaction.

Research Design: A quantitative approach using structural equation modeling (SEM) was employed, with confirmatory factor analysis (CFA) to assess construct validity.

Study Sample: 355 hospital patients from Jakarta, Indonesia, were surveyed using a 7-point Likert scale.

Results: Empathy significantly enhanced perceived service quality, while safety and tangibility had negligible effects. Perceived quality was a key driver of patient satisfaction. Additionally, patient expectations moderated the relationship between perceived service quality and satisfaction, with low expectations leading to greater satisfaction at moderate service levels.

Conclusions: The study underscores empathy’s critical role in improving perceived quality and satisfaction. It highlights the importance of managing patient expectations and fostering empathy in healthcare settings to boost patient satisfaction.

Keywords

hospital quality servqual perceived quality patients’ satisfaction

Introduction

According to data sourced from the Indonesia Ministry of Health through their report, the landscape of the healthcare sector in Indonesia is expected to undergo substantial expansion, with projections indicating a consistent growth trajectory in the number of hospitals. Specifically, statistical analyses reveal an average annual growth rate of 5.2% since the year 2012. Notably, within this overarching trend, private hospitals have exhibited an even more robust growth rate, averaging 7% annually over the same period.¹ This observed pattern underscores a notable intensification of competition within the hospital sector, signifying the imperative for healthcare institutions to strategically position themselves to attain and sustain competitive advantages. As the market becomes increasingly dynamic and competitive, the ability of hospitals to secure competitive edges becomes paramount in safeguarding their market positions and ensuring long-term viability and success within the evolving healthcare landscape.²

The healthcare sector, essential to human well-being, parallels consumer-driven sectors in prioritizing customer satisfaction. Patients seeking care in hospitals anticipate quality service, akin to consumers seeking satisfaction from products. Attaining customer satisfaction in healthcare can yield competitive advantages like repeat patronage, pricing flexibility, crisis resilience, and positive referrals. Previous research, exemplified by Saini and Matta,³ underscores the importance of service quality dimensions in influencing patients’ intention to revisit, indicating its crucial role in driving satisfaction. Putri, Farida⁴ further also accentuate the positive impact of patient satisfaction on repeat visits, emphasizing the role of customer satisfaction in fostering loyalty. Furthermore, Kang, Cho⁵ advocated for improving responsiveness and empathy to enhance customer satisfaction, aligning with the notion that service quality is essential in meeting patient expectations. In the setting of service quality in the hospital setting, there are two concept, that are patient perceptions of service quality and its direct influence of satisfaction.⁴ Additionally, bolded by Kang, Cho,⁵ service quality as the gap between expectations and perception, stressing the importance of meeting patient expectations. Collectively, the findings from Saini and Matta,³ Putri, Farida,⁴ and Kang, Cho⁵ highlight the critical role of service quality in enhancing patient satisfaction, encouraging repeat visits, and generating positive referrals, thereby emphasizing the significance of customer satisfaction in the hospital sector.

The widespread adoption of the SERVQUAL model across diverse industries underscores its efficacy in gauging perceived quality and customer satisfaction. Studies such as that by Abu‐El Samen, Akroush⁶ were discussing the five dimensions proposed by Parasuraman, Zeithaml⁷ affirm its relevance in assessing service quality. Moreover, some previous researchers emphasize its importance in tailoring marketing strategies to meet consumer needs and the effectiveness in evaluating after-sales service.⁸ In terms of healthcare sector, A’aqoulah, Kuyini⁹ further concerning to discusses proactive measures for improving service quality. Those some collective evidence highlights the SERVQUAL model’s utility across diverse service contexts, serving as a valuable instrument for organizations to enhance customer satisfaction and loyalty. As businesses adapt to evolving customer preferences, the model’s multidimensional approach enables targeted improvements, ensuring alignment with customer expectations and fostering long-term loyalty.

Various studies have applied the SERVQUAL model to gauge service quality and patient satisfaction within healthcare contexts. For instance, Aand Iyer¹⁰ delved into the SERVQUAL model’s applicability in assessing the perceptual gap between patient expectations and actual experiences in hospitals situated in Tier II cities of India. Similarly, Gholami, Kavosi¹¹ showcased the SERVQUAL model’s effectiveness in evaluating service quality in Iranian healthcare settings. However, prevailing research predominantly hones in on singular domains, such as patient expectations, often overlooking the potential synergy between these elements. This study endeavors to bridge this gap by integrating the SERVQUAL model with patient expectations, aiming to construct a more holistic framework for discerning perceived quality in healthcare organizations. The overarching objective is to cultivate insights that can inform strategies geared towards enhancing patient satisfaction and optimizing healthcare service delivery.

Indonesia’s healthcare system combines elements of the Beveridge and Bismarck models, with universal health coverage under the National Health Insurance (NHI) program, or Jaminan Kesehatan Nasional (JKN) in Indonesian and a robust private healthcare sector. The JKN has expanded access to essential services, but disparities remain, particularly in rural areas due to geographic and socioeconomic challenges.¹² Private healthcare providers complement public services, playing a significant role in urban areas and key healthcare initiatives like immunizations.¹³ Decentralization has improved local governance but has also widened regional disparities in healthcare resources and workforce distribution.¹⁴ Digital health innovations offer potential solutions to bridge these gaps, yet their effectiveness depends on equitable implementation and outreach.¹⁵

Hospitals in Jakarta, Indonesia, face significant challenges in delivering quality healthcare services. Public hospitals are overwhelmed by long wait times, high patient volumes, and limited resources, compounded by inadequate ambulance services in the face of severe traffic congestion.¹⁶ The COVID-19 pandemic has further highlighted the vulnerabilities in public health surveillance systems and laboratory capacities, which have contributed to higher mortality rates.¹⁷ In contrast, private hospitals, although able to offer higher-quality services, face their own set of issues, including high operational costs that restrict accessibility, as well as elevated employee turnover rates that negatively impact service delivery^18,19

This study aims to evaluate patient satisfaction using the hospital quality framework based on the SERVQUAL model, focusing on empathy, safety, tangibility, perceived quality, and patient expectations. By examining these dimensions, the study remains relevant, as it is anticipated to contribute insights into hospital quality from the perspective of patient perceptions. Furthermore, the study’s implications are expected to provide a clearer understanding of patient expectations regarding healthcare services in developing countries, particularly as their health sectors continue to advance and develop infrastructure.

Literature review and hypotheses development

Expectation confirmation model

The integration of the Expectation Confirmation Model (ECM) with the SERVQUAL framework and patient expectations represents a significant advancement in comprehending perceived quality within hospital sector contexts. Studies on the ECM have shown positive relationships between confirmation and post-adoption expectations across various domains.²⁰ Additionally, empirical research has revealed that the confirmation of expectations influences perceived usefulness, which in turn impacts satisfaction levels.²¹ In the context of healthcare services, studies have explored the gap between patients’ expectations and perceptions based on the SERVQUAL model, highlighting the importance of aligning service delivery with patient expectations.⁹ Furthermore, the ECM has been utilized to predict and explain continuance intentions in various settings, emphasizing the role of satisfaction, confirmation of expectations, and perceived usefulness.²² The ECM, with its focus on post-acceptance satisfaction and confirmation of beliefs, provides a valuable framework for understanding patient satisfaction and service quality in healthcare settings.²³ By integrating the ECM with the SERVQUAL framework and patient expectations, healthcare providers can gain insights into enhancing service quality, improving patient satisfaction, and fostering long-term patient-provider relationships.

Oliver²⁴ offered valuable insights into the cognitive processes underlying satisfaction judgments. The study explores how individuals form their satisfaction judgments through cognitive evaluations and examines the subsequent impact of these judgments on behaviors and decisions. Oliver’s work is particularly pertinent in understanding how patients within healthcare settings formulate satisfaction judgments, especially regarding service quality, patient experiences, and expectation confirmation. By considering the cognitive dimensions of satisfaction decisions, healthcare providers can gain deeper insights into the dynamics of patient satisfaction and better tailor their services to effectively meet expectations.²³ Integrating this cognitive model with the Expectation Confirmation Model (ECM) within the SERVQUAL framework presents a holistic approach to evaluating and enhancing service quality and patient satisfaction in the hospital sector.

Although both SERVQUAL and HEALTHQUAL are used to assess service quality, SERVQUAL stands out due to its wider applicability across different industries, not just healthcare, which makes it a more flexible tool for evaluating service quality.^23,25 This flexibility enables organizations across different industries to use the same reliable framework, ensuring consistent quality measurement. Moreover, SERVQUAL’s thorough gap analysis approach efficiently uncovers differences between customer expectations and perceptions, offering valuable insights that assist organizations in pinpointing areas for improvement.^26,27 The model’s well-established framework, encompassing dimensions like tangibility, reliability, responsiveness, assurance, and empathy, allows for a thorough evaluation of service quality.^9,28 Its widespread acceptance in both academic research and practical applications further validates its reliability and effectiveness in service quality assessments.²³ Finally, SERVQUAL’s strong emphasis on understanding and meeting customer expectations ensures that organizations can better align their services with customer needs, making it a powerful tool for improving customer satisfaction and loyalty.^9,26

Empathy and patients’ perceived service quality

The crucial role of empathy in healthcare service quality and patient satisfaction is well-documented in existing literature.²⁹ Empathy in healthcare is defined as the ability of healthcare providers to understand, share, and respond to the emotional experiences and perspectives of their patients.³⁰ Empathy emphasizes personalized care and attention in service delivery, crucial for understanding and addressing customer needs.³¹ Studies consistently highlight its positive impact, showing that higher levels of physician empathy lead to increased patient satisfaction and better health outcomes, while reducing medical errors.³² Patients’ perception of empathy significantly influences their satisfaction with healthcare encounters.²⁹

Additionally, empathy’s effects are observed across various medical specialties, fostering better communication, stronger doctor-patient relationships, and improved understanding of patient needs.³³ Recent research explores empathy’s role in emerging healthcare delivery models, like telemedicine, underscoring its ongoing relevance.^34,35 Beyond physicians, empathy also impacts nurses and general practitioners, correlating with higher patient satisfaction, job satisfaction, and reduced burnout.^32,33 Overall, literature confirms empathy’s critical importance in shaping healthcare experiences, improving patient outcomes, and enhancing service quality.²⁹ Hence this study proposed the hypotheses:

There is a positive relation between empathy and patients’ perceived service quality.

Safety and patients’ perceived service quality

A comprehensive exploration of safety dynamics within healthcare contexts, as evidenced by a plethora of scholarly investigations, underscores the multifaceted interplay between safety perceptions, service quality assessments, and patient satisfaction levels.^36,37 Safety is closely linked to the assurance dimension, emphasizing the importance of customer confidence and trust in the services provided.³⁸ Safety is a critical factor influencing perceived service quality, particularly in sectors like healthcare and aviation, where customers prioritize security and reliability.³⁹ For example, modern and well-maintained facilities can create a sense of trust and confidence in the quality of care provided.⁴⁰ Through meticulous empirical scrutiny, some previous researchers have consistently unveiled a robust association between perceived safety and the holistic evaluation of healthcare services by patients.⁴¹ Further exploration of this relationship reveals that researchers have highlighted the important role of safety climate and managerial practices as key factors that influence the connection between safety measures and healthcare performance outcomes.⁴²

Furthermore, the contemporary healthcare landscape witnesses an expansion of safety considerations to novel realms, encompassing innovative healthcare delivery modalities like online inquiry services and internet hospitals.⁴³ This nuanced understanding not only enriches the body of knowledge of safety’s influence on patient satisfaction and service quality perceptions but also underscores its profound implications for optimizing healthcare experiences, enhancing patient outcomes, and augmenting the overall quality of care delivery within healthcare ecosystems. Additionally, the extant literature underscores the imperative of a multifaceted approach towards safety enhancement strategies within healthcare domains. By synthesizing findings from diverse studies, healthcare stakeholders can glean insights into the nuanced interplay between safety perceptions, organizational practices, and patient experiences. So that, this study proposed the hypotheses:

There is a positive relation between safety and patients’ perceived service quality.

Tangibility and patients’ perceived service quality

The relationship between tangibility and patients’ perceived service quality has been extensively examined in the literature.^44,45 Tangibility, as one of the dimensions of perceived service quality, has been consistently shown to wield a significant influence on patient satisfaction and loyalty.⁴⁶ Tangibility refers to the physical aspects of a service, such as facilities, equipment, and staff appearance, which significantly influence customer perceptions of service quality.^47,48 Tangible cues, like well-maintained environments and professional presentation, are crucial in shaping customer expectations and satisfaction.⁴⁹ Organizations that invest in improving these tangible elements can enhance overall service quality and positively impact customer trust and satisfaction.⁵⁰ This dimension plays a crucial role in shaping patients’ perceptions of the quality of healthcare services, with studies indicating that patients often attribute considerable importance to tangibility when evaluating service quality.⁵¹ Furthermore, research highlights that tangibility directly influences patient satisfaction with healthcare services, serving as a significant determinant of their overall experience and perceived quality of care.⁵²

Additionally, the literature suggests that tangibility often receives the lowest satisfaction ratings among patients, indicating a potential area for improvement in healthcare services.⁵² This finding aligns with studies demonstrating that tangibility, along with other dimensions of service quality, significantly impacts patient satisfaction.⁴⁷ Notably, the physical appearance of healthcare organizations and personnel emerges as a critical factor influencing patient satisfaction, particularly concerning comfort and overall experience.⁵³ Furthermore, beyond its direct effect on satisfaction, tangibility has been identified as a driver of patient loyalty through satisfaction, emphasizing its role in fostering enduring relationships between patients and healthcare providers. Consequently, strategies aimed at improving tangibility in healthcare services, such as meticulous planning, prioritization of services, and process reviews, hold promise for enhancing patient satisfaction, loyalty, and overall healthcare quality.⁵⁴ In order that, this study proposed the hypotheses:

There is a positive relation between tangibility and patients’ perceived service quality.

Patients’ perceived service quality and patiens’ satisfaction

Patient satisfaction is a crucial element in healthcare services, reflecting patients’ perceptions and feelings about the care they receive.⁵⁵ It serves as a widely accepted metric for gauging service quality in hospitals, underscoring its importance in evaluating healthcare delivery. Notably, the quality of healthcare services provided significantly impacts patient satisfaction levels, as patients gauge their expectations against the care received.⁵⁶ Existing research consistently highlights a positive correlation between patient satisfaction and service quality, suggesting that higher levels of satisfaction correspond to more favorable evaluations of service delivery.⁵⁷ As a result, patient satisfaction is an essential measure for evaluating the quality of care provided, with its level being a key factor in this assessment. Fulfilling patient needs and expectations emerges as fundamental in defining patient satisfaction, emphasizing the importance of meeting these requirements.⁵⁸

Furthermore, patient satisfaction is influenced by a multitude of factors beyond the quality of care, including nurses’ caring behaviors, doctors’ motivation, leadership, and effective communication.⁵⁶ Effective communication between healthcare providers and patients emerges as a critical element in enhancing patient outcomes and satisfaction levels.⁵⁹ Additionally, patient satisfaction correlates with the perception of quality of life, indicating an interconnectedness between patients’ overall well-being and satisfaction.⁶⁰ Therefore, evaluating patient satisfaction becomes crucial for improving healthcare delivery, particularly within a consumer-driven culture where meeting patient expectations is paramount.⁶¹ Notably, patient satisfaction not only serves as a subjective measure but also holds tangible implications for treatment adherence and health outcomes, underscoring its significance in healthcare settings.⁶² Patient satisfaction emerges as a complex concept influenced by various factors, including service quality, communication, interpersonal skills, and patient expectations, all of which significantly shape patients’ experiences and perceptions of healthcare services, so that, this study proposed the hypotheses:

There is a positive relation between patients’ perceived service quality and patients’ satisfaction.

The moderating role of patients’ expectation between patients’ perceived service quality and patiens’ satisfaction

Patient satisfaction in healthcare is a complex concept shaped by various factors, such as the perceived quality of service and the expectations of patients.⁶³ The intricate relationship between service quality and patient satisfaction suggests that patient expectations act as a critical moderator in shaping satisfaction outcomes.⁶⁴ Patient expectations serve as a lens through which individuals evaluate the care they receive, thereby exerting a significant influence on their overall satisfaction levels.⁶⁵ The alignment between patient expectations and the actual service delivered is crucial in determining satisfaction outcomes, where a match leads to increased satisfaction, while a mismatch results in lower satisfaction levels.⁶⁶

Moreover, patient expectations play a moderating role in the relationship between perceived service quality and satisfaction, highlighting the importance of managing and meeting patient expectations to optimize satisfaction levels.⁶⁷ Recognizing and understanding the nuanced interplay between these variables is crucial for healthcare providers to tailor their services effectively and enhance overall patient satisfaction.⁶⁸ This emphasizes the significance of aligning service delivery with patient expectations to foster positive patient experiences and improve satisfaction outcomes.⁶⁹ Moreover, how patients perceive the quality of service greatly impacts their loyalty and overall satisfaction, emphasizing the crucial role of perceived quality in shaping their experiences.⁷⁰ Acknowledging the moderating influence of patient expectations is essential for healthcare organizations to cultivate patient-centered care environments and enhance the quality of care provided, so that this study proposed the hypotheses:

Patients’ expectation moderates the relationship between patients’ perceived service quality and patients’ satisfaction.

Methods

Samples and respondents

This study encompassed all hospital patients in Jakarta city, Indonesia, inviting 600 respondents to participate and ultimately securing responses from 355 individuals, yielding a questionnaire response rate of 59.2%. The selection criteria required participants to be over 17 years old, seek healthcare exclusively from hospitals, undergo both inpatient and outpatient care during hospital visits, and have visited a hospital within the past year. Through rigorous data cleaning, only respondents meeting all criteria were retained, ensuring a homogenous sample reflective of the broader population. This approach enhances the reliability and validity of the study findings, providing a comprehensive understanding of patient experiences and perceptions in Jakarta’s healthcare landscape.

The target respondents were Indonesian citizens who visited hospitals for medical treatment between April 2020 and April 2021. Data was collected from early April to mid-November 2021 via online questionnaires. Those period aligns with a significant phase of healthcare system responses during the COVID-19 pandemic, which had substantial effects on healthcare policy, service delivery, and patient outcomes. This study recorded the responses from respondents which 117 men and 238 women (Stdev: 0.47). Total 22 respondents who have age in between 17 and 19 years, 251 respondents in age of 20-29 years, 45 respondents in between 40 and 49 years, and 37 respondents in above of 50 years (Stdev: 0.72). Furthermore, there are 84 respondents who have monthly income below than IDR 5 million, 84 respondents also have in between IDR 6-10 million, 67 respondents in between IDR 11-15 million, and 50 respondents who have income more than IDR 16 million (Stdev: 1.44). From educational background, total 106 respondents educated below undergraduate degree, 201 respondents have undergraduated, and 48 holds postgraduate degree (Stdev: 0.63). There are 320 respondents from 52 private hospitals and 35 respondents from 13 public hospitals (Stdev: 0.29). So that, this study proposed theoretical framework in Figure 1.

Figure 1.

Theoretical framework.

Measurements

The measurement scales employed in this study were derived from established instruments utilized in prior research endeavors. Utilizing a 7-point Likert scale, ranging from strongly disagree (1) to strongly agree (7), the questionnaires were fashioned to gauge constructs such as empathy, safety, tangibility, patient expectations, perceived quality, and patient satisfaction. The questionnaire underwent iterative refinement through peer review sessions to optimize clarity and comprehensibility for respondents. In total, the questionnaire encompassed 8 variables, elucidated through 44 question items. Specifically, empathy, safety, tangibility, perceived quality, and patient satisfaction were assessed using a set of 25 items developed by Ampaw, Chai,⁷¹ while patient expectations were evaluated using 13 items formulated by Nguyen and Nagase.⁷²

Data analysis procedure

This study entails three sequential steps in its data analysis procedure. Initially, confirmatory factor analysis (CFA) is employed to assess the validity and reliability of the model,⁷³ focusing on four latent constructs: empathy, safety, tangibility, perceived quality, and patient satisfaction. Subsequently, structural equation modeling (SEM) is conducted to scrutinize the formulated hypotheses.⁷⁴ In the final phase, the study utilizes the SPSS PROCESS Macro to explore the moderating effect of patients’ expectations.

Results

Preliminary analysis

Table 1 shown the relationships between six variables related to patient perceptions in healthcare, including Empathy, Safety, Tangibility, Patients’ Expectations, Patients’ Perceived Quality, and Patients’ Satisfaction. Strong positive correlations are observed between Empathy and all other variables, especially with Patient Satisfaction (r = 0.81). Safety and Perceived Quality also have strong links with Empathy and Satisfaction. Tangibility shows moderate correlations with Safety and Patients’ Expectations, indicating the importance of physical factors in patient experience. The correlations are statistically significant, with a sample size of 355 and p-values less than 0.001, highlighting the robustness of the findings.

Table 1.

Discriminant and convergent validity.

Variables		1	2	3	4	5	6
1	Empathy	.71
2	Safety	.86***	.71
3	Tangibility	.74***	.86***	.73
4	Patients’ expectation	.28***	.29***	.31***	.77
5	Patients’ perceived quality	.79***	.80***	.77***	.34***	.79
6	Patients’ satisfaction	.81***	.79***	.77***	.24***	.88***	.85

N = 355, ***p < .001.

Source: Authors’ own being processed (2023).

Furthermore, according to Table 2, this study assessed the composite reliability (CR), which is considered acceptable when exceeding .60.⁷⁵ Furthermore, all variables in the study demonstrated ideal values (>.50) in terms of Average Variance Extracted (AVE), as suggested by Hair et al. (2010). Notably, the CR value surpassed that of the AVE. Additionally, Confirmatory Factor Analysis (CFA) yielded favorable results: χ2 = 182.330, df = 155, χ2/df = 1.17, p < 0.01, TLI = .99, CFI = .99, GFI = .95, AGFI = .93, RMSEA = .02. However, given the cross-sectional approach and self-reported questionnaire used in this study, the possibility of common method bias was considered. To address this concern, Harman’s single factor technique was employed, revealing that the first factor accounted for 37.77% of the variance, below the accepted threshold of 50%.⁷⁶ These findings suggest that the study mitigated the common method variance issue.

Table 2.

Reliability and factor loadings.

Items		Mean	Stdev	Loadings	CR	AVE
Empathy (E)	E1	5.87	0.93	.82	.81	.51
	E2	5.68	1.07	.73
	E3	5.80	0.98	.85
	E4	5.78	0.96	.75
Safety (S)	S1	5.71	1.16	.72	.84	.51
	S2	5.53	1.04	.78
	S3	5.87	0.93	.84
	S4	6.11	0.88	.71
	S5	5.98	0.89	.82
Tangibility (T)	T1	5.91	0.97	.76	.85	.53
	T2	5.94	0.90	.66
	T3	5.83	0.94	.85
	T4	5.94	0.88	.87
	T5	5.61	1.15	.75
Patients’s expectation (PE)	PE1	6.11	1.04	.63	.95	.60
	PE2	5.83	1.12	.73
	PE3	5.98	0.97	.84
	PE4	6.19	0.98	.86
	PE5	6.26	0.97	.81
	PE6	6.20	0.98	.84
	PE7	6.17	1.02	.84
	PE8	6.23	0.95	.85
	PE9	6.20	0.93	.73
	PE10	6.17	0.96	.85
	PE11	6.23	0.92	.81
	PE12	6.27	0.92	.81
	PE13	6.19	0.93	.65
Patients’ perceived quality (PPQ)	PPQ1	6.02	0.93	.78	.91	.63
	PPQ2	5.83	0.94	.84
	PPQ3	5.88	0.93	.85
	PPQ4	5.92	0.88	.84
	PPQ5	5.76	1.11	.82
	PPQ6	5.96	0.90	.85
Patients’ satisfaction (PS)	PS1	6.01	0.92	.86	.93	.72
	PS2	5.76	0.96	.85
	PS3	5.78	0.93	.91
	PS4	5.91	0.92	.89
	PS5	5.94	0.91	.90

Source: Authors’ own being processed (2023).

Hypotheses testing

This study used structural equation modelling (SEM) to examine the direct relationship between corporate ethical value and organizatioan commitment. Moreover, this study also investigates the indirect relationship between corporate ethical value and organizatioan commitment, whether this relationship is able to improve trust in manager. This model showed a good fit: χ² = 60.578, df = 47, χ²/df = 1.28, p < 0.01, TLI = .99, CFI = .99, GFI = .97, AGFI = .95, RMSEA = .03. This study shown that Empathy is positively and significantly correlated with Patients’ Perceived Quality (γ = .48, p < .001) proving that Hypotheses 1 (H1) is accepted. Conversely, opposed with expectation, Safety negative not significantly correlated with Patients’ Perceived Quality (γ = −.07, p = .77), so that Hypotheses 2 (H2) is rejected. Then, this study revealed that Tangibility is positively and not significant correlated with Patients’ Perceived Quality (γ = .61, p = .005), so that Hypotheses 3 (H3) is rejected. Last but not least, this study also found that Patients’ Perceived Quality positive significantly correlated with Patients’ Satisfaction (γ = 1.02, p < .001), so that Hypotheses 4 (H4) is accepted.

In addition to the causal relationships, this study also identified significant interplay relationships among the endogenous variables. Specifically, according Table 3, safety and tangibility (γ = .42, p < .001), safety and empathy (γ = .43, p < .001), and also tangibility and empathy (γ = .35, p < .001) demonstrated significant associations, highlighting the interconnected nature of these variables (Table 4).

Table 3.

Exogenous variables interplay relationships.

	Path		B	SE	p
Safety	<-->	Tangibility	.47	.05	***
Safety	<-->	Empathy	.42	.05	***
Empathy	<-->	Tangibility	.34	.04	***

***p < .001.

Sources: Authors’ own being processed (2024).

Table 4.

Hypotheses test results.

	Path		B	SE	p	Results
Empathy	-->	Patients’ perceived quality	.48	3.37	***	Accepted
Safety	-->	Patients’ perceived quality	−.07	−.29	.771	Rejected
Tangibility	-->	Patients’ perceived quality	.61	2.82	.005	Rejected
Patients’ perceived quality	-->	Patients’ satisfaction	1,03	16.12	***	Accepted

***p < .001.

Sources: Authors’ own being processed (2024).

Patients’ expectation as moderator

According to Table 5, the moderation effect of patients’ expectation was observed. Table 5 also shows that every 1 unit increase in patients’ perceived quality, there will be .11 unit increasing of patients’ satisfaction. Those statements confirms that Hypotheses 5 (H5) is accepted. Furthermore, patients’ expectation significantly moderates the association between patients’ perceived quality and satisfaction for low and high levels, and its not significant in the moderate level. This finding partly supports Hypotheses 5 (H5) which shows a significant moderation effect of patient’s expectation (B = .10, t = 2.95, p = .00). The results show that patients with low expectations can experience increased satisfaction when the perceived quality is initially high. Conversely, those with high expectations require a correspondingly high level of perceived quality to achieve the same satisfaction. Low expectations mean that even modest perceived quality can exceed what is anticipated, thus enhancing satisfaction.⁷⁷ In contrast, high expectations necessitate high perceived quality to meet or surpass these expectations, thereby resulting in greater satisfaction.⁷⁸

Table 5.

Moderation role of patients’ expectation.

	B	SE	t	p
Constant	5.09	1.28	3.96	.0001
Patients’ perceived quality	.11	.22	.46	.6402
Patients’ expectation	−.59	.20	−2.90	.0039*
Patients’ perceived quality * patients’ expectation	.10	.03	2.95	.0033***
R² = .78
F = 187.61

Source: authors’ own being processed (2023).

Theoretical contribution

This study investigated, first, the relationship between empathy, safety, tangibility on patients’ perceived quality. Secondly, the relationship between patients’ perceived quality and patients’ satisfaction. Thirdly, measuring the role of moderator of patients’ expectation between patients’ perceived quality and patients’ satisfaction. According to structural equation modelling results, empathy is positively related with patients’ perceived quality. Empathy stands as a cornerstone in healthcare settings, significantly intertwined with patients’ perceived quality of care. Studies by Kirby et al. (2021) underscore the robust correlation between empathy and patient satisfaction, emphasizing its pivotal role in shaping patients’ perceptions of care quality. These findings are particularly relevant amid the burgeoning hospital sector, where the emphasis on patient-centered care continues to escalate.

As healthcare institutions strive to meet the evolving needs and expectations of patients, cultivating empathetic interactions between healthcare providers and patients emerges as a critical strategy. In this rapidly evolving landscape, characterized by advancements in medical technology, shifts in healthcare delivery models, and increasing patient empowerment, the importance of empathetic care becomes even more pronounced. Goodarzi, Azma³³ further corroborate this notion, demonstrating that patient satisfaction is intricately linked to provider empathy. Those alignment between empathetic care and patient satisfaction is reinforced by elucidating the profound impact of empathy on fostering trust, facilitating meaningful interactions, and fortifying the doctor-patient relationship⁷⁹. In essence, as the hospital sector grows and adapts to the increasing demand for quality healthcare, fostering a culture of empathy becomes a key factor in improving patients’ perceived quality of care and overall satisfaction in healthcare settings.

In the context of the growing hospital sector, the negative correlation between safety and patients’ perceived quality might be due to various factors. For instance, despite advancements in medical technology and healthcare practices, safety concerns such as medical errors, hospital-acquired infections, or inadequate patient safety protocols can still persist in some healthcare settings.⁸⁰ These safety issues can undermine patients’ confidence in the quality of care provided by hospitals, thereby influencing their perception of the overall quality of service.

Additionally, in a rapidly expanding hospital sector where there may be increased pressure to accommodate more patients and streamline processes, safety protocols might inadvertently be compromised, leading to adverse outcomes that impact patients’ perceived quality.⁸¹ Thus, addressing safety concerns and implementing robust safety measures are crucial for maintaining and improving patients’ perceived quality in the evolving hospital sector landscape.

Tangibility is a crucial aspect of the SERVQUAL model, but its impact on perceived service quality may be overshadowed by other dimensions, such as reliability, responsiveness, assurance, and empathy, especially if these dimensions are more salient in the research context. Kumar, Tat Kee⁸² highlighted how different SERVQUAL dimensions can have varying effects on overall service quality. If these dimensions are exceptionally strong, they might diminish the influence of tangibility.

The relationship between patients’ perceived quality and their satisfaction is a pivotal aspect of healthcare service delivery, with numerous studies providing robust evidence of a positive correlation. Singh and Dixit⁸³ have consistently demonstrated this association, highlighting that higher perceived service quality leads to increased patient satisfaction. Moreover, Abidova, da Silva⁸⁴ has underscored the significant impact of service quality on patient satisfaction within hospital settings. Additionally, Leonnard⁸⁵ have delved into specific dimensions of service quality such as tangibility, empathy, and responsiveness, revealing their crucial role in shaping patient satisfaction levels. As the hospital sector continues to expand and evolve, the importance of delivering high-quality care to enhance patient satisfaction becomes increasingly evident. In an environment marked by heightened competition and evolving patient expectations, healthcare providers must prioritize perceived quality to ensure optimal patient experiences and maintain a competitive edge in the sector.

In the context of patient satisfaction in healthcare, the interaction between patients’ expectations and perceived quality plays a crucial role. Initially, patients with lower expectations may find themselves pleasantly surprised by the quality of care they receive, leading to an initial boost in satisfaction. This phenomenon occurs when the actual quality of care exceeds the relatively modest expectations set by the patient.⁸⁶ Conversely, patients entering healthcare encounters with high expectations may experience initial disappointment if the delivered care falls short of these elevated standards. However, as patients with high expectations gradually receive care that aligns with or even surpasses their initial anticipations, their satisfaction levels tend to correspondingly rise. This pattern underscores the dynamic nature of patient satisfaction, wherein the interplay between perceived quality and expectation fulfillment significantly influences the overall satisfaction experience. Therefore, healthcare providers must not only strive to deliver high-quality care but also effectively manage patient expectations to ensure optimal satisfaction outcomes. By comprehending and addressing the intricate interplay between expectations and perceived quality, healthcare organizations can better tailor their services to meet patient needs and enhance overall satisfaction in the long term.

Through this study, the lack of significant correlation between safety and patients’ perceived quality (PPQ) suggests that safety concerns may not be the primary factor influencing perceptions of care quality. Public hospitals face challenges like resource constraints and high patient volumes,⁸⁷ which can overshadow safety improvements and impact perceived quality.⁸⁸ Private hospitals, despite having better resources, also encounter safety issues⁸⁹ that may not directly influence PPQ but highlight the importance of other factors like service quality and empathy. This indicates that in both types of hospitals, factors beyond safety are crucial in shaping patient perceptions. Addressing these broader factors may be essential for enhancing overall patient satisfaction and care quality.

Practical contribution

The findings of this study offer several practical implications for healthcare providers and organizations. Firstly, the positive relationship between empathy and patients’ perceived quality underscores the importance of fostering empathetic interactions between healthcare providers and patients. As the hospital sector continues to evolve, nurturing a culture of empathy becomes crucial for enhancing patients’ perceived quality of care and overall satisfaction. Healthcare institutions should prioritize training and development programs aimed at enhancing providers’ empathetic skills to meet the evolving needs and expectations of patients effectively. Secondly, the significance of tangibility in shaping patients’ perceived quality suggests that tangible elements potentially play a positive and significant role in patient satisfaction. As patient expectations continue to rise, healthcare organizations should recognize the potential impact of these tangible aspects in enhancing the perceived quality of care. Thirdly, the dynamic interaction between patients’ expectations and perceived quality underscores the need for effective expectation management strategies. Healthcare providers should strive to align patient expectations with the actual quality of care delivered to ensure optimal satisfaction outcomes. By comprehending and addressing the intricate interplay between expectations and perceived quality, healthcare organizations can better tailor their services to meet patient needs and enhance overall satisfaction in the long term. Overall, these practical implications emphasize the importance of patient-centered care, quality improvement initiatives, and effective communication strategies in enhancing patient experiences and satisfaction within healthcare settings.

Limitations and future research

The limitations of the study include the sample size of 355 respondents, which may not fully represent all hospital patients in Jakarta, Indonesia. The selection criteria, such as the requirement for participants to seek healthcare exclusively from hospitals and have visited a hospital within the past year, could introduce selection bias and exclude certain segments of the population. Additionally, the uneven distribution of respondents across demographic categories, including gender, age, income levels, and educational backgrounds, may skew the findings and limit their generalizability. The variability within the sample, as indicated by the standard deviations provided for demographic variables, poses challenges in interpreting the significance of this variability. Furthermore, while the study offers insights into patient experiences and perceptions in Jakarta’s healthcare landscape, its findings may not be applicable to other regions or healthcare settings due to potential cultural, structural, and socioeconomic differences.

In addition to the issue of sample distribution, this study also faces challenges with its results that require further refinement. According to the WHO,⁹⁰ safety is one of the most critical components of services provided in health facilities. However, this study found that safety has an insignificant negative relationship with PPQ, a result that ideally should be positive. One possible explanation is that patients in countries with developing health sectors may place greater emphasis on empathy, although this does not diminish the importance of safety. This interpretation is supported by findings from Ampaw, Chai,⁷¹ which showed that safety did not have a significantly positive relationship with PPQ in countries with developing health sectors. Consequently, future research should re-evaluate the reliability of the measurement tools used in this study by incorporating samples from countries with developed health sectors.

Furthermore, some issue for future research could be to delve deeper into understanding the dynamics of patient expectations and their impact on satisfaction levels across different levels of perceived quality in healthcare settings. Specifically, researchers could explore how healthcare providers can effectively manage and align patient expectations to optimize satisfaction outcomes, particularly in light of the observed interaction between patients’ expectations and perceived quality. This research could involve longitudinal studies or experimental designs to track changes in patient satisfaction over time in response to interventions aimed at modifying patient expectations. Additionally, investigating the role of communication strategies, such as education and transparency, in shaping patient expectations and ultimately influencing satisfaction levels could provide valuable insights for healthcare practitioners. Understanding how patients’ expectations evolve and influence their perceptions of care quality and satisfaction can inform the development of tailored interventions and strategies to enhance patient experiences and improve overall healthcare service delivery.

Supplemental Material

Supplemental Material - Understanding hospital quality: Empirical insights from patients’ perspectives in the growing hospital sector

Supplemental Material for Understanding hospital quality: Empirical insights from patients’ perspectives in the growing hospital sector by Aulia Vidya Almadana, Suharnomo Suharnomo and Mirwan Surya Perdhana in Health Services Management Research.

Footnotes

ORCID iD

Aulia Vidya Almadana

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: this work was supported by the PMDSU-UNDIP; 14-07/UN7.P4.3/PP/2020 under Institute for Research.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Supplemental Material

Supplemental material for this article is available online.

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