Participants’ Perspectives on Healthcare Service Quality in Multispecialty Hospitals: A Qualitative Approach

Abstract

Professional services like healthcare operate with high degree of information asymmetry, where usually the seeker of service lacks knowledge and skills, and as a result, they cannot evaluate the benefits. Alternative indicators in the service delivery are sought by the seekers to bring evenness in their evaluation, which might not be reflective of providers’ perspectives of care. This study attempts to explore perspectives of both the participants in healthcare service delivery in multispecialty hospital settings. Semi-structured interviews were conducted using snowball sampling with doctors, paramedical staff and managers in multispecialty hospitals and patients and their attendants who have visited the same set of hospitals during past one year. The narratives of the respondents based on a priori interview themes were converted into textual data. Template analysis technique was used to thematically analyse and present the results. Differing accounts of two participants emerged out of the analysis and a gap between providers’ and seekers’ perspectives of each other’s expectations and perceptions of performance was observed. This study is a novel attempt to simultaneously account for both the participants’ perspectives to present a holistic picture rather than a one-sided view of healthcare service quality.

Keywords

Healthcare service quality service provider service seeker perspectives

Introduction

Service is a benefit that one person offers to another, that is essentially intangible in nature and does not result in ownership. Healthcare is a people-processing service, in which benefits are difficult to evaluate. Both provider and seeker of care might look at the benefits from the differing perspectives. For example, seeker of care might look for symptomatic relief from pain, while the providers might be looking at long-term healing as the benefit. Further, the temporal dimension of benefit might differ between seeker’s expectation and provider’s assessment. A seeker of care also compares the improvement in health with other patients who are or have been treated for similar medical conditions despite of the fact that they had differing degrees or stages of complication of disease and each individual responds differently to the same treatment.

Fochsen et al. (2006) were of view that power dominance in medical encounters is construed towards provider of care, and the provider enjoys supremacy in terms of knowledge while the patient is considered to be ignorant consumer, bound by their limited abilities and misconceptions about disease and its treatment. The egalitarian view of medical encounters, with the advent of consumerism, piggybacking on consumer satisfaction, subdued this power imbalance in the dyadic exchanges. The gradual shift of medical care from what is right to what is satisfying for the patient made the doctors more vulnerable. Courting and delighting of patients in care eventually counted on the patient’s ability to pay and at times doctor’s reimbursement linked to patient’s experiences. With increased financial pressures, resource constraints, time constraints and increasing patient expectations, medical practitioners are in a state of dilemma and tension to ensure a trade-off between quality and efficiency (Farr & Cressey, 2015).

It becomes imperative to assess healthcare service quality (HSQ) not only from the provider’s perspective but also from the seeker’s perspective. The concept of quality in terms of efficiency requires rationalism and mass production of services; contrary to this view, patient-centred care requires individualistic approach with attention to the specific needs of the patients (Farr & Cressey, 2015). This study attempts to uncover what constitutes HSQ from providers’ and seekers’ perspectives using a qualitative approach. The article reviews salient issues about HSQ. Through qualitative interviews, participants of the study narrated their lived experiences in the healthcare settings of multispecialty hospitals. The textual data collected were raked for underlying themes using thematic analysis and are presented for further deliberations in the subsequent sections.

Background

Differing Accounts of Healthcare Service Quality

Healthcare services offered are usually heterogeneous because of differing patient needs and available expertise in the field of medicine. Health care service provider is highly involved in producing service however, health care seeker has not much role to play and they usually act as reluctant co-producer of service. The tacit, intangible and relational dimension of care in terms of knowledge, staff behaviours and personal and professional values becomes an important aspect of quality being co-produced (Farr & Cressey, 2015). Nonetheless, quality of service depends upon (a) the knowledge applied rather than the knowledge possessed (Know-do gap) (Mohanan et al., 2015) and (b) the effort exerted by the practitioners during consultation (Das et al., 2012). In healthcare, the knowledge of medicine is highly skewed because of the expertise that the provider possesses (Purcărea et al., 2013), which results in information asymmetry in the dyadic exchanges (Das et al., 2008, 2012). Trusting the service provider is the only alternative left with the seeker of care. The seeker of care eventually becomes more interested in terms of interactive quality with providers (Lehtinen & Lehtinen, 1982), functional quality (Grönroos, 1984) and process quality (Parasuraman et al., 1985). On the contrary, a manager in the healthcare facility will be interested in the following: first, lesser customer complaints related to service quality (behavioural aspect) and second, compliance of the facility and procedures with legal aspects pertaining to clinical quality (administrative aspects).

Purpose of Healthcare Service Quality Evaluation

Until nineteenth century, HSQ programmes and practices were measured in terms of mortality rates and normative standards set upon time to time (Kelman, 1976). Record reviews, especially evidence from the patients’ records of practitioners and hospitals were assessed, however, at times with incomplete or erroneous information. Categorical classification of the services delivered was also done by the peers. These record reviews, measurement of end results and observational studies served administrative purposes of accreditation, licensing and evaluation of community health programmes apart from evaluation of service quality (Sheps, 1955).

Seekers’ Perspective on Healthcare Service Quality

Donabedian’s (1966) conceptualisation of the service quality consisting of structure, process and outcome took prominence in looking at healthcare from an egalitarian perspective. Healthcare seekers being in a state of physical and psychological discomfort (Berry & Bendapundi, 2007) look for immediate relief. They may not be in a state to evaluate service quality. Further, their inability to assess the technical aspects of care make them rely on functional aspects of service quality evaluation. This led functional aspects of care (Grönroos, 1984) to take centre stage in the evaluation of HSQ. The focus of improvement in service quality included customer experiences of the various touchpoints in the patient journey, which summated the overall satisfaction with care (Dagger et al., 2007). Despite the fact that healthcare services being measured in terms of outcome of care and process through which they are delivered help in understanding the perceived service quality, it seems to oversight the fact that a patient might have healthy experiences with the ‘process’ of care but as an ‘outcome’ may not get well, for example, palliative care. Eventually, Parasuraman et al. (1985, 1988, 1991) conceptualisation of service quality measured as a gap between expectations and perceptions of performance became a prominent way of customer-centric view of service quality. The proposed five dimensions, namely tangibility, reliability, responsiveness, empathy and assurance, were being researched upon in several service industries including healthcare (Altuntas et al., 2012; Bahadori et al., 2015; Ramez, 2012; Sohail, 2003; Zarei et al., 2012) for service quality evaluation.

Need for Inclusion of Providers’ Perspective in Healthcare Service Quality Evaluation

Previous work on HSQ identified that there are certain aspects which relate only to the providers of care. Professionalism/skill, including knowledge, technical expertise, amount of training and experience, (Brown & Swartz, 1989; Fowdar, 2008; Haddad et al., 1998) which is specific to the service provider impacts the quality of care delivered. Apart from this appropriateness and effectiveness of care along with benefits to patients constituted core medical services (Haywood-Farmer, 1988; Mostafa, 2005; Piligrimiene & Buciuniene, 2008), which were influenced by how the provider delivers his service. These aspects (professionalism/skills and core medical services) were ranked second and fifth important determinants in global importance ratings as HSQ indicators (Walbridge & Delene, 1993). In another study conducted by De Man et al. (2002), only responsiveness was valued similarly by the patients and the personnel (doctors, management, etc.), while exhibiting a mismatch in the perception ratings by two on the other dimensions. Being a professional service, healthcare (Haywood-Farmer, 1988) includes dyadic exchanges (Brown & Swartz, 1989); hence, perceptions of both the parties, that is, seeker and provider of care, should be taken for service quality evaluation.

Relative Importance of Service-level Attributes

Bitner et al. (1990) expanded the service marketing mix to (a) Participants: all persons, for example, customers, employees, who play a part in service delivery and thus influence the buyer’s perceptions; (b) Physical Evidence: the environment in which the service is assembled and, in which sellers and customers interact, combined with tangible commodities that facilitate performance or communication of service; and (c) Process of Service Assembly: the actual procedures, mechanisms and flow of activities through which service is delivered. The pivotal, core, and peripheral (PCP) model of service quality (Philip & Hazlett, 1997) includes service marketing mix to hierarchically categorise the HSQ evaluation which is centred around the degree of influence exerted on the satisfaction levels of the participants, namely pivotal (end product or outcome), core (people, process and organisational structure) and peripheral dimensions (incidental extras or frills around service encounters). They conceptualised single measure model of service quality for the participants of service (unlike measuring expectations and perceptions in SERVQUAL) and believed that not all dimensions of care are of a similar importance to the participants in care as like Cronin and Taylor (1992). The attributes of this model serve as a priori themes for gaining further insights from participants of care using qualitative approach to data collection and analysis.

To be more inclusive, HSQ evaluations must be done from the providers’ and seekers’ perspectives. However, they may assign different meanings to the dimensions of HSQ. This study attempts to gain insights on the deeper meaning of the dimensions of HSQ. This study also explores commonalities and salience in themes from two perspectives, that is, provider and seeker of care, using a qualitative approach.

Methods

Participants and Procedure

Face-to-face semi-structured interviews were conducted with the participants of the healthcare service delivery. Samples of this study include (a) healthcare seekers, including patients and/or their attendants who had service encounters in multispecialty hospitals and (ii) healthcare providers, including doctors, paramedical staff (because of frequent interactions with seekers of care) and managerial/administrative staff (infrequent interactions with seekers of care but more instrumental in service design).

The seekers of care were contacted during June to September 2018. The participants of the interview were both patients and/or their attendants (Chahal & Kumari, 2012; Kondasani & Panda, 2015; Pakdil & Harwood, 2005; Senić & Marincović, 2013). The participants for the interview were identified through snowball sampling. Only those participants who had experiences with a multispecialty hospital within a year were selected for the interview (Andaleeb, 2001; Fowdar, 2008; Mohamed & Azizan, 2015; Ramez, 2012). The sample comprises of 11 females and 10 males with age ranging from 25 to 62 years.

The providers of care include medical and non-medical professionals employed in multispecialty hospitals. The participants were approached through referrals during June to September 2018 and 27 participants consented to be interviewed. The respondents include 15 doctors from varied fields of medicine, 9 nursing/paramedical staff and 3 people from hospital administration. A total of 16 males and 11 females constituted the sample with age ranging from 25 to 51 years.

The interview protocol was developed, tested and revised as per the guidelines provided by Jacob and Furgerson (2012). Verbal consent was taken beforehand from the interviewees for recording the interview. The interview protocol narrowed down to four sections, namely quality in care, aspects of care, assessment of care and the gap between expectations and perceptions of care. Demographics and respective purpose of visit and role of healthcare seekers and providers were also collected before the start of interview. The open-ended questions allowed the interviewees to freely share their experiences in healthcare settings. The recordings were transcribed verbatim in form of textual data, which were subjected to thematic analysis.

Malterud et al., (2016) suggested that sampling adequacy could be established through the information power i.e. larger the information sample holds, lower is the sample size needed, and vice-versa. An information rich sample consisting of 21 seekers and 27 providers of health care generated sufficient amount of content necessary for analysis. Template analysis (TA)-based studies usually employ 20–30 samples in common (King, 2004, p. 257). Further, the study aims for ‘meaning saturation’ rather than ‘code saturation’ (Hennink et al., 2017) as the extensive literature review (Upadhyai et al., 2019) was available beforehand.

Approach to Analysis

It is assumed that there exists scope for multiple interpretations of data from differing perspectives; therefore, the epistemological position taken in this study is ‘contextual constructivism’ (Madill et al., 2000). Instead of coding reliability, reflexivity of the researcher and richness of description produced become the prime concern of interpretation (King, 2004, p. 256). Presence of a priori themes and initial engagement with the data led to the use of TA (Blair, 2015) in thematically organising and analysing the data. TA uses both deduction and induction in qualitative analysis, as a priori codes can be established in advance and later revisited and can be refined (Saunders et al., 2005, p. 505). Unlike certain other prescriptive- and protocol-based textual qualitative data analysis techniques, first TA allows flexibility to adapt to the need of a particular study and second it allows deeper insights on coding depth rather than the breadth of template, (Brooks et al., 2015). Templates are codes organised hierarchically with broader themes at the higher level and focused themes narrowing down the codes at the lower level (Slade et al., 2009).

Data Analysis and Quality Check

A theme constitutes a participant perception or experiences relevant to research question which are recurring in nature. The three attributes of PCP model (Philip & Hazlett, 1997), namely pivotal, core and peripheral attributes on how people evaluate service quality were taken as broad overarching a priori themes. Pivotal attributes are those attributes that directly affect the output of care; core attributes are made of up of people, process and organisational structure through which the consumer must interact and/or negotiate in order to achieve and receive pivotal attributes; and peripheral attributes are conceptualised as a tangible dimension of healthcare experience providing roundness to service through amenities and physical environment. Literature review done on the determinants of these dimensions was taken from the work of Upadhyai et al. (2019) as a priori themes to start with the analysis and further narrowing them down to form hierarchical coding (see Table 1). A priori themes were kept to minimum to avoid any blinkering effect. Verbatim accounts of the semi-structured interviews were transcribed into textual data. We attached codes to the textual data and organised them to create a ‘linear list’ form of template. The final template of the healthcare seeker and provider was created using the procedural steps given for TA (Brooks & King, 2014) (see Table 2).

As suggested by Nigel King (n.d.), quality check of the template was ensured by taking ‘respondent feedback’ and preparing ‘audit trails’. Audit trails were prepared while reviewing and revising the successive versions of the template in step 4 and 5. The template prepared along with a sample of scripts was given to two respondents (one each from seeker and provider of care). The aim of the study and analytic process were explained to the participants beforehand. The feedback received from the respondents was reviewed and required modification(s) which were deemed appropriate were made to the template.

Table 1.

List of a Priori Codes Identified from Literature

1. Pivotal attributes	1.7. Fair and equitable	2.3. Personnel behaviour
1.1. Clinical care	1.8. Prevention	3. Peripheral attributes
1.2. Professional knowledge, skills and competence	1.9. Promptness	3.1. Charges and quality of room and food
1.3. Diagnosis, treatment and research	1.10. Safety	3.2. Payment arrangement
1.4. Availability of medicine	2. Core attributes	3.3. Image
1.5. Availability of equipment and Instruments	2.1. Admission, stay and discharge process	3.4. Social responsibility
1.6. Need management	2.2. Medical communication	3.5. Amenities and physical infrastructure

Source: The authors.

Table 2.

Steps Involved in Template Analysis

Step 1: Become familiar with the accounts to be analysed. (Read through the full data set.)

Step 2: Carry out preliminary coding of data (use of a priori themes in identifying codes)

Step 3: Organise the emerging themes into clusters and define how they relate to each other within and between the groups (from a subset of data, hierarchical, parallel and integrative codes are identified)

Step 4: Define the initial coding template (capture good cross-section of issues and experiences covered in the data as a whole)

Step 5: Apply the initial template to further data and modify as necessary (modify and revise successive versions of template for insertion of new themes, refinement of existing themes and deletion of redundant themes)

Step 6: Finalise the template and apply the final template to the full data set (form the template as the base for interpretation of data and writing research findings)

Source: Brooks et al. (2015).

Results

The final version of the template for providers and seekers of care classifying themes and subthemes was prepared (see Tables 3 and 4). A priori themes were explored for deeper meanings resulting in two templates reflective of participants’ perspectives on HSQ. This section of the article features selective thoughts of participants on HSQ and certain themes.

Table 3.

Healthcare Providers’ Template (top and selected second-level themes)

1.	Pivotal dimensions	2.1.2.6	Patients in inpatient department (IPD) and outpatient department (OPD)
1.1.	Clinical care	2.1.2.7	Tolerance of patients
1.2.	Professional knowledge, skills, competence	2.1.2.8	Psychological problems
1.3.	Diagnosis	2.2	Process
1.4.	Treatment	2.2.1	Accreditation
1.5.	Availability of doctor	2.2.2	Admission
1.6.	Availability of medicine	2.2.3	Stay
1.7.	Availability of equipment and instruments	2.2.4	Discharge
1.8.	Need management	2.2.5	Privacy
1.9.	Promptness	2.2.6	Feedback mechanism
1.10.	Safety	2.2.7	Waiting time
1.11.	Medical communication	2.2.8	Flexible timing
1.12.	Effort	2.2.9	Coordination with other departments
2.	Core dimensions	2.2.10	Patient compliance
2.1	People	2.2.11	Availability of pharmacy
2.1.1	Personnel behaviour (of doctor and other medical and non-medical staff)	2.2.12	Availability of diagnostic facility
2.1.1.1	Communication	2.2.13	Unnecessary medication
2.1.1.2	Employee training	2.2.14	Rational investigation
2.1.1.3	Peer learning	2.2.15	Standard of prescription
2.1.1.4	Grooming of staff	2.2.16	Waste disposal
2.1.1.5	Faith in doctor	2.2.17	Crowding
2.1.1.6	Belief in doctor	2.2.18	Helpdesk
2.1.1.7	Assurance	2.2.19	Documenting the communication in file
2.1.2	Patient characteristics	3.	Peripheral dimensions
2.1.2.1	Socio-economic class	3.1	Cost of care
2.1.2.2	Rural vs. Urban	3.2	Food
2.1.2.3	First time vs. Repeat	3.3	Image (of doctor and hospital)
2.1.2.4	Perception of own illness	3.4	Amenities and physical infrastructure
2.1.2.5	Type and stage of disease

Source: The authors.

Table 4.

Healthcare Seekers’ Template (top and selected second-level themes)

1.	Pivotal dimensions	2.1.1.9	Courtesy (literature)
1.1	Professional knowledge, skills, Competence	2.1.1.10	Professional integrity of attendant
1.2	Diagnosis	2.2	Process
1.3	Treatment	2.2.1	Admission
1.4	Availability of equipment and instruments	2.2.2	Stay
1.5	Need management	2.2.3	Discharge
1.6	Promptness	2.2.4	Waiting time
1.7	Safety	2.2.5	Crowding
1.8	Medical communication	2.2.6	Availability of pharmacy
1.9	Consultation time	2.2.7	Availability of diagnostic facility
1.1	Doctor’s past experience	2.2.8	Availability of signage
2.	Core dimensions	3.	Peripheral dimensions
2.1	People	3.1	Cost of care
2.1.1	Personnel behaviour (of doctor and other medical and non-medical staff)	3.2	Food
2.1.1.1	Communication	3.3	Payment arrangement
2.1.1.2	Confidence in doctor	3.4	Image (of doctor and hospital)
2.1.1.3	Compassion	3.5	Social responsibility
2.1.1.4	Empathy	3.6	Amenities and physical infrastructure
2.1.1.5	Friendliness	3.6.1	Room
2.1.1.6	Language barrier	3.6.2	Cleanliness
2.1.1.7	Responsiveness	3.6.3	Ambience
2.1.1.8	Trust	3.7	Internal coordination

Source: The authors.

Reflections on healthcare service quality

Healthcare quality is seen from the two-pronged perspective by the providers of care. They were of the opinion that it has two components: one which is technical in nature and is highly specific to their profession and the other which is more towards the patients’ feelings of their experiences (see Table 5). Almost all clinicians assigned equal weights to both the components in HSQ evaluation. Such a bifurcation did not reflect in the verbal accounts of seekers of care, thus upholding the principle of power dominance reflecting, in component 1, by providers in healthcare (Fochsen et al., 2016). However, concerns of growing consumerism and Grönroos (1984) conceptualisation of functional quality echoed as customer-centric perspectives of HSQ as seen by the healthcare providers in component 2.

Seeker as a layman

Healthcare providers consider patients and their attendants as layman in evaluating HSQ. Their inherent inability to assess professional knowledge and the practice of medicine leaves them to trust the providers of care. This information asymmetry leads, what providers believe, us to find and look for alternate measures of service quality evaluation rather than the technical aspects. The relatively easy to assess processes and physical infrastructure aid seekers to form an attitude towards the hospital. This is reflected in the fact that despite the availability of qualified and experienced doctors at the public health facilities, these hospitals are considered inferior to private hospitals in delivering service quality.

Table 5.

Components of Healthcare Quality (providers’ perspective)

Component 1		Component 2
Medical care	vs	Hospital care
Clinical part	vs	Administrative part
Medical quality (Legal aspects)	vs	Service quality (Complaints)
Clinical Outcome (for providers)	vs	Behavioural problem (for patients)
Clinical indicators	vs	Productivity indicators
Technical aspect	vs	Behavioural aspect
Doctor’s treatment	vs	Service
Care part	vs	Service part

Source: The authors.

Illustration 1. Seeker as a Layman—Example Quotes

Patient doesn’t know technical aspect of the treatment, so patient see infrastructure, behaviour etc. (Provider)

It is very difficult to judge the quality because you do not know what has actually happened. (Seeker)

it is very difficult to tell what is the quality in the care as we do not know what is happening inside the body. (Seeker)

Once everything is done doctor would not provide medicine. We being a layman do not have idea about medical terms and medicines etc. (On role of paramedics) (Seeker)

3. Patients’ expectations

Inspite of being in the state of anxiety due to patient’s health condition, health care seekers do have several expectations from the hospital and the health care providers. Nonetheless, patient’s wellness remains the most important expectation from the care delivery process. Providers were in concurrence to the view that patients have expectations from the hospital and providers of care, however, which varies from patient to patient. The provider’s role becomes important in assessment of these expectations as their performance is judged based on these expectations. Most of the seekers and providers were of view that there exists a gap in assessing the expectations.

Illustration 2. Patients’ Expectations—Example Quotes

From doctors the expectation is very simple that there is good diagnosis and good treatment and from the staff it is expected that the time patient or their attendants are there in the hospital that time is managed properly. (Seeker)

For the first time when we visited we didn’t have any expectations. If you are already experienced or visited in the past the expectations would be different. (Seeker)

It is important to judge patient’s expectations. (Provider)

We should move according to the patients. Patient want to get care in their own way. It is important to judge patient’s expectations. (Provider)

Every patient expect that the doctor should put stethoscope and examine him. (Provider)

Doctor don’t treat disease, they treat patients. Every patient is different and with different expectations. Everyone want a different environment and treatment. Some give importance to cleanliness, some to doctor’s behaviour and some give importance to quick response from doctor. (Provider)

Sometimes patient comes with great expectations that he will get ok inspite of his problem may be irreversible. In that case he may be dissatisfied. (Provider)

If patient is not improved, he will not assess it right. (Provider)

1. Commonality in themes

There were some unequivocal views which were not only repetitive, within the healthcare seekers and providers, but were also very compelling. The excerpts from the textual data comprising of seekers’ view alongside providers’ view have been shown in Illustration 3. The prominent themes with commonalities in the dyadic nature of healthcare services are addressed in this section.

Professional knowledge, skills and competence of the doctors and nursing staff was considered to be an important determinant in assessing service quality. This quality determinant makes the healthcare services quite unique as the professional knowledge lets the provider of care at the helm of decision-making and the seeker to trust or have faith in what the service provider is doing to him. Both healthcare seekers and providers considered not only correct but also timely diagnosis and treatment for the well-being of the patient as an important indicator of service quality. Diagnosis and treatment are application of the professional knowledge, skills and competence into deliverables that the seeker of care demands.

A client may not need immediate attention and may wait for their turn to be serviced in certain professional services such as legal, consultation, software, etc. On the contrary, in healthcare, prompt response in delivery of service is a key differentiator which significantly affects the health outcomes, especially in cases such as cardiac attacks, strokes and emergency. The seeker of care at times perceives the doctor as a person who is unwilling to discuss and share information with them, primarily attributing it to power distance in the professional relationship. Doctors, however, believed that such a behaviour is nowadays not being practised and decision-making for the treatment and its medical prognosis is based on shared medical communication related to disease and its diagnosis.

Being people-processing industry, healthcare requires a great deal of emphasis on how participants in the transaction behave. Patients in healthcare service encounters are in a state of anxiety. Each patient is unique and has a lot to say and also wants to know about their medical condition. Their interactions with the staff span across the entire process of patient journey, from taking appointment to discharge and even follow-up visits. Seeker of care can not only easily but immediately evaluate personnel behaviour of providers of care in their day-to-day interactions. Providers believe that possessing interpersonal skills is nowadays an important aspect in healthcare services apart from professional knowledge. They advocate the role of training and grooming providers to build and practise these soft skills.

Uninformed wait feels longer than the informed wait. The challenge of information sharing and managing the waiting time was a common concern for both seekers and providers of care. For a seeker of care, moving around in an unknown place with anxiety is not only physically but psychologically challenging. The availability of a helpdesk will relieve some stress by getting right directions about the physical facility and the processes to save time. The demand for the healthcare services cannot be managed or, at times, cannot be predicted. The capacity constraints and the inherent nature of healthcare services do not allow it to be mass-produced. The waiting time in each step of the patient journey not only puts burden on the healthcare facility and individuals but also affects the duration of the treatment and consequently well-being.

Illustration 3. Commonality in Theme—Example Quotes
Theme	Seekers’ Perspective	Providers’ Perspective
Professional knowledge, skill, competence	The knowledge, skills and competence of the doctor is most important, there is no inhibition… first and foremost the doctor should be well versed to take care of the disease. Nursing facility must be at par.	You are dealing with the life of the patient, if you know the disease and how it presents then you will be able to describe it to the patient of family easily and give proper treatment. You can judge outcome also.
Professional knowledge, skill, competence	The most important is the doctor and second is the attendant who are there.	Even the skills of nurses and attendants also matter as the patients are misguided by them some times.
Diagnosis and treatment	In healthcare for me the most important thing is the doctor diagnose the root cause of the problem promptly. The doctor plays the most important role.	Patient can forget the bad behaviour if they get right treatment.
	See if you get properly treated that is quality, i.e., the outcome is the most important. Right diagnosis and right treatment is an important quality.	Prognosis is good if treatment is started in time
	One is diagnosing the root cause of problem and second is the line of treatment and third is what benefit it has given. If you add all these three things together, I would say it is very good quality	Patient want prompt relief from his sufferings, we also want to give prompt treatment.
	The diagnosis which came out was very well. They went into the details of everything without ignoring anything.
	Quality in healthcare should be that the person who has gone to or the patient should get the good diagnosis and in a reasonable time
Promptness	My parameter for judging the quality in healthcare would be how readily is the doctor available to the patient and in case the doctor is not there then an attendant.	Patient should be immediately shifted to triage area; priority is decided at triage area.
	We had to run and chase and find someone to please attend the patient, whereas here I had to move out of room, but a person was there	How soon we are shifting heart attack patient or stroke patient to ICU.
		We should provide immediately what is needed. We should not think if they will be able to pay or wait for money to start treatment.
Medical communication	I have seen that doctors do not completely understand the requirements of the patient. That gap is there because of doctor doing professional work, like I know what I am doing and I know what he wants. Why should I talk to him, why should I ask him?	Patient is very satisfied, if the doctor sees them, talk to them, examine them and explain them
	You must tell the truth, many a times this might happen that you (doctor) try to hide the things, or if the condition is very fatal, which is not communicated to the patients, or try to fleece the patient that should not be there. Transparency should be there.	Doctor should counsel the patient. Provide hope or clearly say no to the patient if there is such condition.
	Today’s good doctors have patience and ready to answer and discuss things	We should explain the disease, its treatment, duration of treatment and outcome, possible complications and side effects of treatment.
Personnel behaviour	He(doctor) went through the report and heard with an open mind	Gone are the days when doctor’s rude behaviour was not noticed. Now a days doctor needs to be very polite with good talking skills.
	You are going to the hospital because you have a concern and you are just looking at how your anxiety is resolved fast.	Patient will always be dissatisfied for doctor not giving much time or sister not visited. You cannot compare good quality treatment and satisfaction of patient.
	Because everything was done and we had paid every bill, so somehow there was callous approach in the next visit.	Doctor should explain the disease in the patient’s own language.
	If the doctor is friendly, a patient will be able to come out with his feelings more openly and he will be able to share his problems which will eventually help doctor to diagnose the disease.	Faith is important in doctor patient relationship
	We are not expert on how many number of medicines and test that doctor is writing… it is based upon basic trust that this doctor is going to solve my problem
Helpdesk	You have to find out the information and find out the right person first, who you can see.	There should be a person/helpdesk to guide where the patient should go.
Helpdesk	My first experience was that there was a lot of rush at the counter especially at the reception. There was lack of information of display of information to the patients when they enter hospital. The patients have to run around in the campus. They have to find out the information and the right person, whom they can see.	Sometimes patients are at wrong place; they don’t know where to go. They should be guided. They should be guided at every step. There should be a booklet to suggest to the map for each direction for the patient, where to register, where to deposit money; or a proper staff for the help of the patient should be there.
Waiting time	First of all, we were made to wait for two hours. Even if the procedure has to start late so let’s not call the patient so early. Secondly, even if you have admitted the patient, let there be some person to attend to you.	When patient enters hospital he faces queues are reception which is time loss. He again faces queues at OPD. Doctor is on round; it is not known when he will come. Doctor prescribes treatment and investigation, there is queue for lab investigation and finally the OPC closes. Patient has to come for solution the next day and then there is no OPD for the doctor. So the patient becomes frustrated. This is very common at our hospital.
Waiting time	The patient waiting area was not very well managed. There were very few chairs to sit on. The waiting area was not very big enough to accommodate so many patients and every patient was coming with 2-3 people.	Waiting time is subjective. Doctor’s criteria are different. Doctor need to prioritize. We have to team to look after if someone in the waiting area is getting sicker. If so, he/she is immediately taken to emergency or doctor.

2. Recurrent themes

There were certain views which were prominent and exclusive within the two groups of respondents, that is, seekers and providers of care. They were quite repetitive in nature and were raised many a times in the respective groups during their interviews. The next section will reproduce the findings from the providers’ perspective (Illustration 4) (patient safety, effort and patient characteristics) and seekers’ perspective (Illustration 5) (process of care, cost of care, amenities and physical infrastructure).

Patient safety: Seekers of care are unable to know, understand and evaluate the safety protocols lest something goes wrong. Most of the seekers of care indicated hygiene, medical negligence, hospital-acquired infection and hospital-induced injury as indicators of patient safety. However, apart from these indicators, hospitals ensure to follow several other protocols for patient safety. It was evident from the responses of the seekers of care that none reported about these protocols, probably because they were in a state of anxiety looking for ends rather than the means. Being highly specific and technical to the nature of job that medical professionals perform, such protocols have been reported many a times in interviews of service providers.

Effort: The consultation time and the workload of the medical practitioners emerged as a dominant theme in the providers’ interviews as compared to seekers’ interviews. Providers consistently reported in interviews that the consultation time plays a crucial role in effective delivery of care. Investing in time with patients leads to quality as well patient’s understanding of the treatment and subsequently its compliance. However, availability of time is a function of patient load upon doctors and nursing staff. Doctors usually prioritise their work, which may lead to uneven distribution of time among patients. Further, understaffing, and at times, skewed rush lead to lessor efforts in quality and more on productivity.

Patient characteristics: Doctors do not treat diseases, they treat patients. Their interactions with the seekers are two sided, where the patient characteristics are equally important to both the process and outcome of care. An urban educated patient/attendant might easily understand the medical communication as compared to the ones with rural background or with lessor education. A referral or repeat patient usually is more dependent, informed and evaluative of the HSQ. A patient who stays longer in the healthcare facility will witness higher staff behaviour and are more critical of it. Patients’ perception of own illness is also a critical indicator of their belief about how they are taken care of. Providers were of a strong view that measuring outcome of care, especially healing, as an outcome of treatment is dependent upon many factors, namely severity, staging and comorbid conditions in the disease. Thus, service quality evaluation should not solely rely on the medical practitioners but also on the patient characteristics.

Illustration 4. Recurrent Themes: Providers’ Perspective—Example Quotes
Theme	Providers’ Perspective
Patient safety	From the patients’ perspective the fundamental thing is patient safety. We have defined goals for patient safety.
Patient safety	For patient if brooming is done in OT, its clean, For doctor, it is clean only when fumigated.
Effort	In OPD many patients are in queue. We cut down the time to explain to patient and their family; the time is not enough. If you give time to the patient, they understand the treatment. If there is less communication, patient thinks that the doctor is not OK or expectations are not met.
	Patient feel satisfied, if they feel that they are examined thoroughly.
	Sometimes patient load is more, doctor might be busy he cannot give that much time that the patient expects. This may be how this gap increases.
	If rush is less, then more quality work is done.
	Workload is an issue. We are understaffed so it is a huge problem. Patient suffers a lot. There is delay at every step, because of work load and under staffing
	In Indian Scenario quality based practice is a myth. We have to wind up patients. If you see slowly patient might link that the doctor wants to see at his clinic. We have time of five hours. 11am to 1pm is the highest rush. We see 150 patients. We have two minutes only for each patient.
Patient characteristics	In metros, patient is educated, it is easier for doctor to make him understand but not in rural setup due to patient’s education level.
	Sometimes it is not possible to save the patient. So treatment and its result doesn’t always depend upon the doctors. It depends upon the severity, staging and comorbid conditions, things that we have done in past. It depends upon the patient history. So classifying service quality on outcome is not a good idea/not useful. Patient should understand his staging of disease.
	IPD patient will see the entire staff therefore, more staff behaviour is experienced by the patients.

Process of Care: Process of care has been a highly talked about theme among seekers of care. Process of care includes patients’ and their attendants’ experiences during the service encounters encompassing their journey from taking the appointment to getting discharged; especially, patients getting admitted to the hospital look for guidance and help during their stay at the hospital. The investigations should be done on time and the reports should be generated and made available in time. At the time of billing, seekers of care looked for ease and transparency in the billing process. Patient undergoes physical and psychological discomfort waiting for the care delivery process to begin. Such waiting periods are also associated with additional cost incurred by the patient to stay admitted in the hospital or arranging their stay outside the hospital.

Cost of Care: Cost of care and quality linkages brought to light some insightful findings. For a healthcare seeker, cost of care is reflective of the functional aspects of care including infrastructure, cleanliness, privacy, helpfulness, etc. Almost all believed that quality comes at a cost. While visiting a hospital, a healthcare seeker considers in advance the amount to be spent on admission and getting the procedure done. Quite a few patients mentioned that being a captive patient of the hospital, the cost of investigations and tests was high as compared to getting them done from outside. Although, some believed that cost is not an indicator of quality and everyone should get similar service quality irrespective of what they are paying, yet the link between quality and cost is deep rooted in the minds of healthcare seekers.

Amenities and Physical Infrastructure: A clear distinction was drawn between the public and private hospitals over the type of amenities provided and the state of the physical infrastructure. The general view of healthcare seekers is that private hospitals in contrast to public health facilities are expected to maintain and manage their amenities and good infrastructure. The expectations from the private healthcare facilities were ‘must-be’ rather than ‘should-be’. These must-be expectations were based on the premise that one pays more for availing the services of private healthcare as compared to the nominally charged and at times free services of public health facilities.

Illustration 5. Repetitive Themes: Seekers’ Perspective—Example Quotes
Theme	Seekers’ Perspective
Process of care	You have to find out the information and find out the right person first, who you can see.
	My first experience was that there was a lot of rush at the counter especially at the reception. There was lack of information of display of information to the patients when they enter hospital. The patients have to run around in the campus. They have to find out the information and the right person, whom they can see.
	We had to run and chase and find someone to please attend the patient whereas here I had to move out of room, but a person was always there.
	They should manage the timely flow of patient and they should inform the patient about the expected time in the various processes so that the patient is also mentally prepared.
	Staying in outstation city just waiting for the report is again a cost, so there could have been another way to it.
	I would go every 15 minutes asking the reception when would you tell us or at what time we will be relieved.
	At billing it should be told that we had asked for 10 ampules and only four have been used. Normally most of the hospital what they do is that they will ask for 10 ampules and they show that all of them have been used.
	First of all, we were made to wait for two hours. Even if the procedure has to start late so let’s not call the patient so early. Secondly, even if you have admitted the patient, let there be some person to attend to you.
	The patient waiting area was not very well managed. There were very few chairs to sit on. The waiting area was not very big enough to accommodate so many patients and every patient was coming with 2-3 people.
Cost of care	The philosophy of multispecialty private hospital is that if you can afford you should come to us, If you can’t afford it you should not come to us. In fact, it is a way of saying sorry we cannot treat you.
	The better the hospital seems to be the more expensive it would be. So quality care in not affordable as on date and comes at a very high cost.
	You pay high, you get good quality. Quality cannot be judged by cost. It depends upon the doctor what kind of knowledge and skills he is having.
	I get a CT scan done in a private lab I pay Rs. 10500/- but, in ______ and _____ I have to pay almost Rs 20000/-, so in multispecialty hospitals the charges are not rationalized… especially any pathological test and investigation the charges are not commensurate with the local market rates. Since you are admitted now you have no option of going anywhere, so you have to get all investigations done from there.
	The cost was high in terms of the test that they were conducting.
	The facilities are very costly as we have to spend huge amount to spend in …… because we are looking for a quality hospital and we are not able to get this type of quality at some other place.
	I think that financial affordability should not be taken into consideration while assessing service quality. Irrespective of what I pay I should be given the same quality as others.
	See it is a private healthcare system, so they are highly commercial. They were thoroughly professional; you get what you pay.
Amenities and physical infrastructure	Physical environment and surroundings give mental peace to the patients.
	If you go to the general ward of a government hospital you will feel that God should not make you sick or ill. But when you go this professional five-star healthcare units they are plush, you don’t feel like the same
	Waiting area has centralized AC, good facility for water, wash rooms are cleaned regularly
	The physical infrastructure is expected in a multispecialty hospital. But whenever anyone goes to a government hospital he does not expect that there would be cleanliness and physical infrastructure would be very good, but for private hospital it is expected that it should be neat and clean. We know that we had to spend money there.
	If you are ready to spend money you are expecting 5-star hotel like quality.

Discussion

Being a professional service, healthcare involves dyadic exchanges between the provider and the seeker of care. Unlike other services, healthcare seeker, in a state of anxiety, usually lacks the professional competence to assess the services. On one hand, the provider of care might assess services from their own professional perspective, while the apparent inability to assess technical aspects of care and at times long-term outcomes may lead the seeker to look for some alternate cues for service quality evaluation. This study attempts to explore these two divergent perspectives of participants in healthcare services.

The perceived inability of the healthcare seeker to understand the professional knowledge and practice of the healthcare providers results in information asymmetry in service encounters. Service providers clearly delineate healthcare services into technical and functional components. The technical aspects of care have objective measures which are usually benchmarked against the standards and protocols of care, based on regulations and available knowledge, and can often be quantitatively measured against their adherence. The functional components involve attributes which are subjective in nature and may change from individual to individual. Service receiver on the other hand compensates for their inability to assess technical aspects by forming an attitude towards the experiences with people, process and physical environment in the service delivery. This calls for a dyadic approach for HSQ evaluation rather than measuring service quality from one of the participant’s perspectives.

The commonalities in the themes were observed in both providers and seekers of care in terms of the pivotal aspect, that is, wellness. Both the participants in the service delivery process agreed upon professional knowledge, skills and competence, including correct and timely diagnosis of the disease, as the crucial aspects of care. Despite the fact that seekers were unable to assess the technical aspects of care, they considered these themes as necessary conditions in meeting their desired expectations from care. The emphasis on interpersonal aspects of medical encounters, especially verbal exchanges including the technical aspects of treatment and care and the behavioural aspects in the interactions, advocates the transition from elitist to egalitarian view of the healthcare services. Growth of consumerism has led even the healthcare providers to understand the humanness in care. The inherent anxiety of the seeker and fear of the complex service environment for the first-time visitor can be addressed by provision of helpdesk. Since, healthcare is a people-processing service, it needs time. Mass production of the service is not possible and therefore, patients need to wait for their turn at various touch points. How well the time is being managed and utilised is beneficial for both the provider in terms of overall productivity and seeker’s satisfaction in terms of quality time available.

Providers of care were deeply concerned about the safety of the patients as the life of the patient is at stake. Almost all were thoughtful of patient safety when it comes to quality in care. Patient load was of considerable importance to the providers of care. As the demand and the time for consultation and procedures for individual patient cannot be predicted, the amount of effort thus a provider applies in delivering care is not fixed. This causes unequal distribution of availability of time by for medical practitioners among the seekers of care, which has implications on the service quality and patient satisfaction. The quality of treatment and medical encounters are highly influenced by the patient’s social and physical characteristics and the precondition of the patient. Consequently, patient’s line of treatment and the outcome are not only dependent upon the provider’s knowledge and experience but also on the patient’s conditions, their adherence to treatment protocol and related things.

Supporting the view of seeker’s ignorance and the inability in HSQ evaluation, most of the respondents were concerned about the processes related to admission, stay, billing, investigation, discharge, etc. This is atypical to the healthcare services where administrative aspects of care stand almost equally important as fundamental benefit of wellness from care in service quality evaluation. The seeker compensates for information asymmetry not only through identifying easy-to-evaluate transactions, and at times even bypassing the provider’s knowledge and competence. Seekers usually have estimates of the cost of care based on their past knowledge and word-of-mouth communication. Although patient’s well-being gets priority over the cost of care in health care seeking behaviour, yet such unforeseen health care expenses are a cause of concern to all. The stark contrast in utilisation of services between almost free-of-cost public health facilities and private multispecialty was attributed not to the people component but to the mismanaged processes, poor physical infrastructure and crowding.

Limitations of the Study

This study is limited by virtue of scope, as the respondents narrated their individual experiences which might not be reflective of the broader population at large. Further, participants were chosen using non-probability sampling, which may lead to skewed samples representative of certain specific healthcare settings and environment. Utmost care has been taken in recording and coding the narratives of the respondents, analysing the textual data and presenting them in the form of templates. Researchers’ biasness and their reflections in the study cannot be ruled out.

Scope for Future Research

Incidental to the findings of this study, it was observed that there exists a gap between the seekers’ expectations from care and the providers’ assessment of seekers’ expectations. Further, what provider’s think that they have done to ensure quality is not always perceived in the same way by the seekers of care. The available research in the field of the healthcare, to the best of our knowledge, attempts to measure only the gap between seekers’ expectations and perception of service performance in the healthcare. Being a professional service, healthcare thus calls for looking deeper into the dyadic exchanges taking place between the ‘participants’ of the delivery process rather than a single ‘stakeholder’s’ perspective.

Footnotes

Declaration of Conflicting Interests

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

Funding

The authors received no financial support for the research, authorship and/or publication of this article.

References

Altuntas

Dereli

&Yilmaz

M. K.

(2012). Multi-criteria decision making methods based weighted SERVQUAL scales to measure perceived service quality in hospitals: A case study from Turkey. Total Quality Management & Business Excellence , 23(11/12), 1379–1395. http://doi.org/10.1080/14783363.2012.661136.

Andaleeb

S. S.

(2001). Service quality perceptions and patient satisfaction: A study of hospitals in a developing country. Social Science & Medicine , 52(9), 1359–1370.

Bahadori

Radabadi

Ravangard

Baldacchin

(2015). Factors affecting dental service quality. International Journal of Health Care Quality , 28(7), 678–689.

Berry

L. L.

Bendapudi

(2007). Health care: A fertile field for service research. Journal of Service Research , 10(2), 111–122.

Bitner

M. J.

Booms

B. H.

Tetreault

M. S.

(1990). The service encounter: Diagnosing favorable and unfavorable incidents. The Journal of Marketing , 54(1), 71–84.

Blair

(2015). A reflexive exploration of two qualitative data coding techniques. Journal of Methods and Measurement in the Social Sciences , 6(1), 14–29.

Brooks

King

(2014). Doing template analysis: Evaluating an end of life care service . Sage Research Methods Cases. https://dx-doi-org.web.bisu.edu.cn/10.4135/978144627305013512755.

Brooks

McCluskey

Turley

King

(2015). The utility of template analysis in qualitative psychology research. Qualitative Research in Psychology , 12(2), 202–222.

Brown

S. W.

Swartz

T. A.

(1989). A gap analysis of professional service quality. The Journal of Marketing , 53(2), 92–98.

10.

Chahal

Kumari

(2012). Consumer perceived value: The development of a multiple item scale in hospitals in the Indian context. International Journal of Pharmaceutical and Healthcare Marketing , 6(2), 167–190.

11.

Cronin

J. J.

Jr Taylor

S. A.

(1992). Measuring service quality: a reexamination and extension. The Journal of Marketing , 56(3), 55–68.

12.

Dagger

T. S.

Sweeney

J. C.

Johnson

L. W.

(2007). A hierarchical model of health service quality: Scale development and investigation of an integrated model. Journal of Service Research , 10(2), 123–142.

13.

Das

Hammer

Leonard

(2008). The quality of medical advice in low-income countries. Journal of Economic Perspectives , 22(2), 93–114.

14.

Das

Holla

Das

Mohanan

Tabak

Chan

(2012). In urban and rural India, a standardized patient study showed low levels of provider training and huge quality gaps. Health Affairs , 31(12), 2774–2784.

15.

De Man

Gemmel

Vlerick

Van Rijk

Dierckx

(2002). Patients’ and personnel’s perceptions of service quality and patient satisfaction in nuclear medicine. European Journal of Nuclear Medicine and Molecular Imaging , 29(9), 1109–1117.

16.

Donabedian

(1966). Evaluating the quality of medical care. The Milbank Memorial Fund Quarterly , 44(3), 166–206.

17.

Farr

Cressey

(2015). Understanding staff perspectives of quality in practice in healthcare. BMC Health Services Research , 15(1), 123.

18.

Fochsen

Deshpande

Thorson

(2006). Power imbalance and consumerism in the doctor-patient relationship: health care providers’ experiences of patient encounters in a rural district in India. Qualitative Health Research , 16(9), 1236–1251.

19.

Grönroos

(1984). A service quality model and its marketing implications. European Journal of Marketing , 18(4), 36–44.

20.

Haddad

Foureier

Potvin

(1998). Measuring lay people’s perceptions of the quality of primary health care services in developing countries: Validation of a 20-item scale. International Journal of Quality in Healthcare , 10(2), 93–104.

21.

Haywood-Farmer

(1988). A conceptual model of service quality. International Journal of Operations & Production Management , 8(6), 19–29.

22.

Hennink

M. M.

Kaiser

B. N.

Marconi

V. C.

(2017). Code saturation versus meaning saturation: How many interviews are enough. Qualitative Health Research , 27(4), 591–608.

23.

Jacob

S. A.

Furgerson

S. P.

(2012). Writing interview protocols and conducting interviews: Tips for students new to the field of qualitative research. The Qualitative Report , 17(42), 1–10.

24.

Kelman

H. R.

(1976). Evaluation of health care quality by consumers. International Journal of Health Services , 6(3), 431–442.

25.

King

(2004). Using templates in the thematic analysis of text. In Cassell

Symon

(Eds.), Essential guide to qualitative methods in organizational research (pp. 256–270). SAGE Publications.

26.

King

Nigel

. (n.d.). Quality and reflexivity . https://research.hud.ac.uk/research-subjects/human-health/template-analysis/technique/quality-and-reflexivity/.

27.

Kondasani

R. K. R.

Panda

R. K.

(2015). Customer perceived service quality, satisfaction and loyalty in Indian private healthcare. International Journal of Health Care Quality Assurance , 28(5), 452–467.

28.

Lehtinen

J. R.

(1982). Service quality: A study of quality dimensions . Service Management Institute.

29.

Madill

Jordan

Shirley

(2000). Objectivity and reliability in qualitative analysis: Realist, contextualist and radical constructionist epistemologies. British Journal of Psychology , 91, 1–20.

30.

Malterud

Siersma

V. D.

Guassora

A. D.

(2016). Sample size in qualitative interview studies: Guided by information power. Qualitative Health Research , 26(13), 1753–1760.

31.

Mohamed

Azizan

N. A.

(2015). Perceived service quality’s effect on patient satisfaction and behavioural compliance. International Journal of Health Care Quality Assurance , 28(3), 300–314.

32.

Mohanan

Vera-Hernández

Das

Giardili

Goldhaber-Fiebert

J. D.

Rabin

T. L.

Raj

S. S.

Schwartz

J. I.

Seth

(2015). The know-do gap in quality of health care for childhood diarrhea and pneumonia in rural India. JAMA Pediatrics , 169(4), 349–357.

33.

Mostafa

M. M.

(2005). An empirical study of patients’ expectations and satisfactions in Egyptian hospitals. International Journal of Health Care Quality Assurance , 18(6–7), 516–532. http://doi.org/10.1108/09526860510627201.

34.

Pakdil

Harwood

T. N.

(2005). Patient satisfaction in a preoperative assessment clinic: An analysis using SERVQUAL dimensions. Total Quality Management & Business Excellence , 16(1), 15–30.

35.

Parasuraman

Zeithaml

V. A.

Berry

L. L.

(1985). A conceptual model of service quality and its implications for future research. The Journal of Marketing , 49(4), 41–50.

36.

Parasuraman

Zeithaml

V. A.

Berry

L. L.

(1988). Servqual: A multiple-item scale for measuring consumer perception. Journal of Retailing , 64(1), 12.

37.

Parasuraman

Berry

L. L.

Zeithaml

V. A.

(1991). Refinement and reassessment of the SERVQUAL scale. Journal of Retailing , 67(4), 420.

38.

Philip

Hazlett

S. A.

(1997). The measurement of service quality: A new PCP attributes model. International Journal of Quality & Reliability Management , 14(3), 260–286.

39.

Piligrimiene

Buciuniene.

(2008). Different perspectives of health care quality: Is consensus possible. Engineering Economics , 1(56), 104–111.

40.

Purcărea

V. L.

Gheorghe

I. R.

Petrescu

C. M.

(2013). The assessment of perceived service quality of public health care services in Romania using the SERVQUAL scale. Procedia Economics and Finance , 6, 573–585.

41.

Ramez

W. S.

(2012). Patients’ perception of health care quality, satisfaction and behavioral intention: An empirical study in Bahrain. International Journal of Business and Social Science , 3(18), 131–141.

42.

Roshnee Ramsaran-Fowdar

(2008). The relative importance of service dimensions in a healthcare setting. International Journal of Health Care Quality Assurance , 21(1), 104–124.

43.

Saunders

Lewis

Thornhill.

(2005). Research methods for business students (5th ed.). Pearson Education.

44.

Senić

Marinković

(2013). Patient care, satisfaction and service quality in health care. International Journal of Consumer Studies , 37(3), 312–319.

45.

Sheps

M. C.

(1955). Approaches to the quality of hospital care. Public Health Reports , 70(9), 877.

46.

Slade

Haywood

King

(2009). A qualitative investigation of women’s experiences of the self and others in relation to their menstrual cycle. British Journal of Health Psychology , 14(1), 127–141.

47.

Sohail

M. S.

(2003). Service quality in hospitals: More favourable than you might think. Managing Service Quality , 13(3), 197–206. http://doi.org/10.1108/09604520310476463.

48.

Upadhyai

Jain

A. K.

Roy

Pant

(2019). A review of healthcare service quality dimensions and their measurement. Journal of Health Management , 21, 102–127.

49.

Walbridge

S. W.

Delene

L. M.

(1993). Measuring physician attitudes of service quality. Marketing Health Services , 13(1), 6.

50.

Zarei

Arab

Froushani

A. R.

Rashidian

Ghazi Tabatabaei

S. M.

(2012). Service quality of private hospitals: The Iranian Patients’ perspective. BMC Health Services Research , 12(November 2015), 31. http://doi.org/10.1186/1472-6963-12-31.