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Procedia - Social and Behavioral Sciences 235 (2016) 557 – 565

12th International Strategic Management Conference, ISMC 2016, 28-30 October 2016, Antalya,
Turkey

Service quality assessment in health care sector: the case of Durres

public hospital
Rezarta Kalajaa , Redi Myshketab , Francesco Scalerac,
a,b
University of Durres “Aleksander Moisiu”, Durres 2000, Albania
c
University of Bari “Aldo Moro”, Bari 70120, Italy

Abstract

The aim of this paper is to assess the quality of services in the public regional hospital of Durres, as one of the most important in
Albania, considering that the quality is a key parameter in performance evaluation. Patients are the main actors in appraising and
assessing the quality, therefore this study is based on a questionnaire completed by 200 hospitalized patients between July and
September, 2015. The survey is based on "SERVQUAL” model using five dimensions of service quality such as: empathy,
tangibility, responsiveness, assurance and reliability all essential in measuring the perceptions and expectations of patients in each
of them.
Data elaboration and processing identify main factors affecting the overall patients’ preferences where the findings in particular
demonstrate positive results towards quality services without significant differences between expectations and actual perceptions of
patients. In this context conclusion and results found should be taken in considerations as very important aspects for hospital
managers and also policy makers when dealing with decisions affecting service quality assessment.

©©2016
2016TheThe Authors.
Authors. Published
Published by Elsevier
by Elsevier Ltd.is an open access article under the CC BY-NC-ND license
Ltd. This
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
Peer-review under responsibility of the organizing committee committee
Peer-review under responsibility of the organizing of ISMC 2016. of ISMC 2016.

Keywords: service quality, health care, SERVQUAL

1. Introduction

The importance of measurement, evaluation and monitoring of service quality in the health sector, it is now an
unquestionable fact. Modern medicine has gradually understood and recognized patient's importance and their
perception on health care (Asadi-Lari, Tamburini and Gray, 2004) by conducting necessary researches to understand
the importance of joint relations between patients, satisfaction and quality of life. Health care is a growing sector
which has received a lot of attention from researchers and doctors worldwide and that requires a lot of consideration

Corresponding author. Tel. + 39 3357817952
Email address: roby_sca@virgilio.it

1877-0428 © 2016 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
Peer-review under responsibility of the organizing committee of ISMC 2016.
doi:10.1016/j.sbspro.2016.11.082
558 Rezarta Kalaja et al. / Procedia - Social and Behavioral Sciences 235 (2016) 557 – 565

even in Albania, due to the deficiencies that the sector have and challenges to overcome as a result of competition
between public and private sectors. Durres’ hospital is one of the largest regional hospitals in Albania; with a capacity
of 340 beds and the surgery service has the status of a university clinic. All costs of this hospital are carried out by the
institute of health care insurance, while resource allocation is managed by the hospital itself, representing this way a
lot of defiance’s for its managers. As Peprah and Atarah (2014) has argued for limited healthcare resources to be
allocated and managed effectively, it is essential for healthcare providers to access and identify patients’ priorities
among various service quality dimensions to improve these dimensions for patient satisfaction. That is why this article
will use SERVQUAL model as a tool used for measuring service quality and consequently the satisfaction of patients
in Durres hospital. All starts with the assumption that service quality is a function of customer’s expectation of a
service and their perceptions of the service already rendered. The difference between these variables determines the
satisfaction. (Zeithaml, Berry and Parasuraman, 1990).
This way the purpose of this paper is to assess the quality of service in Durres Regional Hospital, by determining the
key factors impacting the services to give appropriate recommendations for managers and directors of this hospital in
order to attract more investors, clients. In addition the identification of the main factors will support the right
references for the public sector in general to increase quality of service and of medical staff in order to compete with
private hospitals.

2. Literature Review

Early research on leader behavior conducted by psychologist in 1950s-60s, much of the studies on leadership
behaviour has been affected by two pioneering school: The Ohio State Leadership Studies and The Michigan
Leadership Studies. Researchers at Ohio State University surveyed leaders have identified two major behaviors, called
consideration and initiating structure. Consideration falls in to category of people-oriented behavior and is the extent
to which leader is mindful of subordinates, respects their ideas and feelings, and establishes mutual trust.

Considerate leaders are friendly, provide open communication, develop teamwork, and are oriented toward their
subordinates. On the other hand initiating structure is the degree of task behavior that is the extent to which the leader
is task oriented and directs subordinate work activities toward goal attainment. Leaders with this style typically give
instructions, spend time planning, emphasize deadlines, and provide explicit schedules of work activities (Daft, 2008).

Customers are the key evaluator that plays a significant role in measuring the quality of service or product. In health
care sectors, customers are the patients and their perceptions are considered to be the main indicator while assessing
the service quality (Cronin and Taylor, 1994). According to the definition of Zeithaml et al. (1990) service quality is
customer’s perceptions and it is judged by them in person not by organizations. Moreover, service quality can be
defined as well as “conformance to customer specification”.

According to Gronroos (1984), service quality is measured as technical and functional quality, where technical
quality in the health care sector is defined primary on the basis of the technical accuracy of the medical diagnoses and
procedures, or the conformance to professional specifications, while functional quality refers to the manner in which
the health care service is delivered to patients (Lam, 1997). Even though, claimed that technical qualities are not a
truly useful measure for describing how patients evaluate the quality of a medical service encounter, Ware and Snyder
(1975) stated that technical quality has high priority but most patients do not have the knowledge to evaluate
effectively the quality of the diagnostic and therapeutic intervention process or do not have necessary information for
such evaluation cause it is not shared with patients.

Thus patients base their evaluations of quality on interpersonal and environmental factors, which medical
professionals have always regarded as less important (Yeşilada et al., 2010). In their studies Parasuraman, Zeithaml
and Berry (1985, 1994) found a positive and significant relationship between individual’s perception of service quality
and their willingness to recommend the company. They conclude that service quality is the difference between
customer expectation and perception as it is being received by the customer, because consumer’s perception is the
main indicator of quality in health care service. Service quality have a significant effect on patient satisfaction, and
satisfaction in turn has a positive relationship to purchase intentions and customer loyalty (Cronin and Taylor, 1992,
O’Connor 1994).
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Garvin (1988) determined quality along 8 dimensions – performance, features, reliability, conformability,
durability, serviceability, aesthetics and perceived quality. Finally, Parasuraman, Zeithaml and Berry (1985) describes
service quality using a disconfirmation model that compared customer expectations and perception, from which they
developed the “gap model’.

This model has been used in a wide variety of studies to assess both the customer’s service expectations and
perceptions of the provider’s performance (Ladhari 2009; Zarei, Arab et al., 2012). The SERVQUAL instrument was
designed to measure service quality using both the gap concept and service quality dimensions. The original
SERVQUAL contains 22 pairs of the statements using a seven - point Likert scale, on five service quality dimensions
which are:

1. Tangibles: - The appearance of physical facilities, equipment, appearance of personnel and communication
material.
2. Reliability: - The ability to perform the promised service dependably and accurately.
3. Responsiveness: - The willingness to help customers and provide prompt service.
4. Assurance: - The knowledge and courtesy of employees and their ability to inspire trust and confidence.
5. Empathy: - The caring, individualized attention the hospital provides to its patients.

According to this scale, quality defines a gap between perceived expectation and performance and if the
performance exceeds expectations the customer will attain more satisfaction (Kopalle and Lehmann, 2001). The
questionnaire has two sets of similar statements where the first is a customer expectations measure, and the second is a
measure of customer perceptions to the actual service delivered. It has widely applied by different researchers in a
diversity of service settings, including hospitals (Andaleeb, 2000).

Although there is a dose of criticism on the validity and reliability of SERVQUAL instrument, different researchers
argued that it remains a useful tool for measuring service quality and it is reliable and valid in the hospital
environment (Buttle 1996, Babakus and Mangold, 1992).

3. Methodology

The study is carried during the period from July to September in the regional hospital of Durres and has been
interviewed 200 patients. This hospital is one of the biggest regional hospitals in Albania, and one of the most
financed from the state budget, and surgery service has the status of a university clinic. It has a staff of 125 doctors
and 236 nurses with a capacity of 340 beds, and by the end of 2014 there were 15,782 hospitalized patients and 75,306
outpatient visits.

The research was based on a questionnaire of “SERVQUAL” type, consisted of three parts. The first part comprises
demographic characteristics of the hospital patients such as gender, age, education and their level of incomes. The
second part was used to assess the patients’ expectation and perception of service quality. This included 31 items on 5
dimensions: tangibles (8 items), reliability (5 items), responsiveness (4 items), assurance (9 items) and empathy (5
items). A 5 point Likert-type scale was used to evaluate the level of expectation and perceptions.

Many studies outlines the advantages of SERVQUAL as following:

x It is accepted as a standard for accessing different dimension of service quality;

x It has been shown to be valid for a number of service situations;
x It has been known to be reliable;
x It can be used in a variety of ways, to compare performance in different parts of the service or in different
customer groups;
x Iti s able to alert management to consider the perception of both management and customers.

The internal consistency of the SERVQUAL scale was validated by calculating the Cronbach’alpha values for
overall scale, for perceptions and expectations scale, for every dimension included. Second Nunnally (1978) the value
560 Rezarta Kalaja et al. / Procedia - Social and Behavioral Sciences 235 (2016) 557 – 565

0,7 was accepted as limit. However, the critical value of Cronbach’alpha should not be lower than 0,5. The reliability
of the scale was tested using Cronbach’s alpha and the ɑ values were 0.94 for expectations and 0,95 for perceptions
scores. On the third part there is three items on loyalty which are overall satisfaction, willingness to recommend to
other people and disposition to return back at the same hospital. The difference between the perceptions of actual
experience and expectations has been used to evaluate the service quality. Positive difference means that their actual
experience was better than their expectations. Negative difference means that the performance failed to reach the
expectations.

4. Survey’s Findings

4.1 Respondent’s Demographic characteristics

The respondents of this study were 200 patients, of whom 42% were male and 58% were female (Table 1). The
major part of these patients 34.67% were more than 60 years old as this age has greater need for health care, followed
by the group aging between 45-60 years old by 32%, while 18.67% were 30-45 years old and 14.76% were between
18-30 years old. Regarding the level of education, 43.33% had only primary education; 35.33% had secondary
education; 17.33% had bachelor degree and only 4% had postgraduate degree.

Meanwhile with reference to the level of monthly incomes, as one of the main factors that affect the decision of
picking out the hospital people will receive health services, the sample has the following distribution. 70% of patients
have low incomes less than 30.000 ALL, 16% of them has incomes at the interval between 30.001-50.000 ALL,
followed by the group of 50.001-70.000 ALL in 8% of cases, and only 6% of the patients get more than 70.000 ALL
per month.

Table 1. Overall Information

Age Gender Education Monthly Incomes
Age In % Sex In % Level In % In Albanian Lek In %
18 - 30 14.67 Primary education 43.33 < 30.000 70.00
Male 42.00
30 – 45 18.67 High School 35.33 30.001 – 50.000 16.00
45 – 60 32.00 University Degree 17.33 50.001 – 70.000 8.00
Female 58.00
> 60 34.67 Post Graduate 4.00 > 70.000 6.00
Source: Authors [2015]

4.2 Gap and hypotheses analyses

Service quality is calculated as the difference between the perception and the expectations for each dimension,
known as the “gap” (Parasuraman et al., 1988). Tables 2-6, indicate the gaps assessed for each of the dimension. In
general, expectations of patients tended to average or slightly above it. What is worth underlining is that despite
average expectations, patients have rated positively almost all dimensions of quality of service which is reflected in
positive values of the gap in almost all dimensions. While regarding to responsiveness of patients' expectations were a
little higher than average and their real perceptions on quality of service were evaluated 4.28 slightly above that good,
with a gap value of 0.51 indicating that patients were relatively satisfied with this dimension.

Table 2. Average Responsiveness SERVQUAL Score

Factors under Responsiveness Gap Score (Expectation -
Expectation (Average) Patient's Perception (Average)
Dimension Perception)
RES1 3,79 4,31 0,52
RES2 3,75 4,36 0,61
RES3 3,76 4,21 0,45
RES4 3,75 4,22 0,47
Average Responsiveness Gap Score 0,51
Source: Authors [2015]
 Rezarta Kalaja et al. / Procedia - Social and Behavioral Sciences 235 (2016) 557 – 565 561

Reliability is the dimension where patient’s satisfaction is higher comparing with other dimensions.

This happened because expectations were not at the maximum but also because the service assessment averaged
4.49 so was assessed and tended to very well.

Table 3. Average Reliability SERVQUAL Score

Gap Score (Expectation -
Factors under Reliability Dimension Expectation (Average) Patient's Perception (Average)
Perception)

REL1 3,92 4,57 0,65

REL2 4,09 4,61 0,51
REL3 3,93 4,47 0,54
REL4 3,83 4,24 0,41

REL5 4,01 4,58 0,57

Average Reliability Gap Score 0,54

Source: Authors [2015]

Assurance is another dimension where patients result satisfied but with a gap lower than two other dimensions, as
the expectations of the patients for this dimension were higher.

This is normal and expected given that this dimension deals with the ability and capacity of doctors to diagnose. It is
also important to highlight that even the estimations on realistic perceptions are high with an average of 4.38 resulting
in a positive gap that indicate satisfied patients.

Table 4. Average Assurance SERVQUAL Score

Gap Score (Expectation -
Factors under Assurance Dimension Expectation (Average) Patient's Perception (Average)
Perception)

ASS1 4,12 4,68 0,56

ASS2 4,02 4,71 0,69
ASS3 4,13 4,61 0,48
ASS4 4,19 4,51 0,32
ASS5 4,00 4,25 0,25
ASS6 4,25 4,60 0,35
ASS7 3,49 3,57 0,08
ASS8 3,76 4,09 0,33

ASS9 4,00 4,37 0,37

Average Assurance Gap Score 0,38

Source: Authors [2015]

Tangibles are the dimension with the lowest scores in terms of service quality, although expectations for this
variable again were lower compared to the others.

Estimations with a negative gap in this dimension are associated with the modernization of equipment’s and
technology used, which leave much to be desired, and food.

Slightly higher ratings are evidenced for cleanliness of the hospital and of the cleaning staff. However, the average
gap is still positive indicating that the patients are at least not dissatisfied for this dimension.
562 Rezarta Kalaja et al. / Procedia - Social and Behavioral Sciences 235 (2016) 557 – 565

Table 5. Average Tangibles SERVQUAL Score

Gap Score (Expectation -
Factors under Tangibles Dimension Expectation (Average) Patient's Perception (Average)
Perception)
TAN1 3,13 3,11 -0,02
TAN2 3,82 4,56 0,74

TAN3 3,64 4,06 0,42

TAN4 3,41 3,52 0,11

TAN5 3,41 3,47 0,06

TAN6 3,11 2,97 -0,14

TAN7 3,06 3,03 -0,03

TAN8 3,30 3,29 -0,01

Average Tangibles Gap Score 0,14
Source: Authors [2015]

Empathy is another dimension of a positive gap indicator for patient satisfaction, cause the staff is relatively
sensitive, polite which can sincerely worried for their patients.

Table 6. Average Empathy SERVQUAL Score

Gap Score (Expectation -
Factors under Empathy Dimension Expectation (Average) Patient's Perception (Average)
Perception)
EMP1 3,81 4,15 0,34
EMP2 3,93 4,43 0,5
EMP3 3,89 4,44 0,55
EMP4 3,91 4,41 0,5

EMP5 3,73 4,23 0,5

Average Empathy Gap Score 0,48

Source: Authors [2015]

In order to achieve the purpose of this study were formulated the following hypotheses:
H1: there is no significant relationship between responsiveness as service quality dimension and overall patient
satisfaction on Durrës hospital.

To analyze the hypotheses, we conduct Chi Square test of independence, where Value Sig. (2-sided), in the
independence test between the dimensions of responsiveness and service quality satisfaction is 0.000, less than 0.05
(5%), which means that we reject. H0 the two variables depends by each-other and the coefficient of correlation rxy =
0.718 (of strengthens between them), shows a relatively strong relation, in positive values, which means that a grow in
responsiveness dimension occurs a lift up in the patient’s level of satisfaction, according to the quality of public
hospital services.

H2: there is no significant relationship between reliability as service quality dimension and overall patient
satisfaction on Durrës hospital.

We followed the same procedure for the dimension of reliability and his relation with the patient’s satisfaction. The
value of Sig. (2 sided) in Pearson Chi Square Coefficient is 0.000<0.05, which shows that the statement of their
independency in Ho, doesn’t stands and these variables depends on each-other. The rxy = 0.663, a strong and positive
relation.
 Rezarta Kalaja et al. / Procedia - Social and Behavioral Sciences 235 (2016) 557 – 565 563

H3: there is no significant relationship between assurance as service quality dimension and overall patient
satisfaction on Durrës hospital.

The value of Sig. = 0.000 < 0.05, confirms the interdependency of these two variables. We reject the Ho, because
there is a relatively strong and positive relation, according to the value of rxy = 0.611

H4: there is no significant relationship between tangible as service quality dimension and overall patient satisfaction
on Durrës hospital.

These two variables depend on each-other. Sig. (2-sided) = 0.000 < 0.05, falls Ho and rxy = 0.502 shows a positive
correlation and relatively strong

H5: there is no significant relationship between empathy as service quality dimension and overall patient satisfaction
on Durrës hospital.

In these case too, we reject Ho, because the value of Sig. (2-sided) = 0.000 < 0.05, shows a interdependency
relation. The value of the coefficient rxy = 0.787 is relatively strong and positive. However to further analyse which of
the dimensions of quality impact more the patient overall satisfaction, we performed multiple regression analysis.
Before continuing with the regression analysis, the reliability of the measurement scale was checked. All Cronbach’s
Alpha values were greater than 0.70 which shows us good reliability.

The dependent variable was patient’s satisfaction on hospital services, and the independent variables were five
dimensions of service quality (overall patient satisfaction) = 0.746 + 0.143 (responsiveness) + 0.153 (reliability) +
0.209 (assurance) + 0.258 (tangibles) + 0.393 (empathy).
All five dimensions of service quality were significant in explaining patient satisfaction. The equation explains
71.1% of the satisfaction variances’ values. We may easily notice, in the equation, that all the public hospital service
quality dimensions affect the overall patient satisfaction .Here, the highest impact has the empathy dimension,
because, compared, β = 0.393 is bigger than the other coefficients.

4.4 Overall patient satisfaction

In general, when patients were questioned on pleasure on the overall hospital services, about 75% were satisfied or
very satisfied which is reflected (i) in their willingness to come back when needed to this hospital because round 95%
of them had answered “Yes” and (ii) in the disposition of recommending this institution to others in 80% of cases
(Table 7).
Table 7. Overall satisfaction of patients

1. Are you satisfied with hospital service quality?

From 1 to 5 1 2 3 4 5
% 0,67 4,67 25,33 23,33 46,00

2. Would you recommend this hospital to others?

Yes/No Yes No
% 80 20

3. Would you come back to this hospital?

Yes/No Yes No
% 94,67 5,33
Source: Authors [2015]

5. Conclusion

Data analysis for Durres hospital indicates improvements done in this institution in recent years to increase service
quality. This fact is evidenced from the comparison between low patients’ expectations followed by relatively higher
564 Rezarta Kalaja et al. / Procedia - Social and Behavioral Sciences 235 (2016) 557 – 565

ratings, but also from the statements of the patients noticed during the interviews where especially patients who have
been hospitalized for the first time has claimed that that the situation has improved. However, the path to achieve high
results in quality service is long and troublesome.

Despite the analysis reveals that patients resulted satisfied in all service dimension (positive gap), average values of
the gaps are relatively low. One explanation for this result is low expectations of patients due to the service they had
encountered when hospitalized in previous years. Even though dimensions analyzed have been scored relatively high,
if all of them would be ranked in the first place is reliability followed by assurance, empathy, responsiveness and
tangibles.

This finding is not in full compliance with the gap values where the ranking list would be: reliability,
responsiveness, empathy, assurance and tangibles. The latter dimension is weighted as one of the lowest by the
patients, because the efforts made to improve the conditions, equipment’s, facilities and cleanliness are still too far to
consider the hospital as being a modern one.

Also important to highlight is that patients have estimated with high scores staff skills in defining accurate
diagnosis, staff readiness to respond in time in a kind and polite way. This is an important message for hospital
managers which should direct all their efforts to improve equipment’s and other contents conditions to make the
hospital more attractive that would enhance quality services and patients satisfactions in the future.

Furthermore occasional estimation on quality service in different ways to assess the situation through patients’ eyes
is highly recommended to develop and improve Durres hospital competitiveness in health sector. However, analysis
results demonstrate that despite the assessments carried out patients of this hospital are faithful, and they would return
back to this hospital. This happens mainly for the improvement made in the services offered but also because a high
percentage of the patients asked have limited financial resources to run in private health institutions.

To conclude, with the aim of offering high quality medical services and gaining customer preferences, hospital
managers should be alert to these requirements by listening to their patients and involving in further improvement
projects.

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