Zarei et al.

BMC Health Services Research 2012, 12:31

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RESEARCH ARTICLE Open Access

Service quality of private hospitals: The Iranian

Patients’ perspective
Asghar Zarei1, Mohammad Arab1*, Abbas Rahimi Froushani2, Arash Rashidian1 and S Mahmoud Ghazi Tabatabaei3

Abstract
Background: Highly competitive market in the private hospital industry has caused increasing pressure on them to
provide services with higher quality. The aim of this study was to determine the different dimensions of the service
quality in the private hospitals of Iran and evaluating the service quality from the patients’ perspective.
Methods: A cross-sectional study was conducted between October and November 2010 in Tehran, Iran. The study
sample was composed of 983 patients randomly selected from 8 private general hospitals. The study questionnaire
was the SERVQUAL questionnaire, consisting of 21 items in service quality dimensions.
Results: The result of factor analysis revealed 3 factors, explaining 69% of the total variance. The total mean score
of patients’ expectation and perception was 4.91(SD = 0.2) and 4.02(SD = 0.6), respectively. The highest expectation
and perception related to the tangibles dimension and the lowest expectation and perception related to the
empathy dimension. The differences between perception and expectation were significant (p < 0.001). There was a
significant difference between the expectations scores based on gender, education level, and previous
hospitalization in that same hospital. Also, there was a significant difference between the perception scores based
on insurance coverage, average length of stay, and patients’ health conditions on discharge.
Conclusion: The results showed that SERVQUAL is a valid, reliable, and flexible instrument to monitor and measure
the quality of the services in private hospitals of Iran. Our findings clarified the importance of creating a strong
relationship between patients and the hospital practitioners/personnel and the need for hospital staff to be
responsive, credible, and empathetic when dealing with patients.

Background pressure on them to provide services with higher

Service sector is the rapidly growing area of the world quality.
economy and the health services organizations play an Quality is considered a key factor in differentiation and
important role in such growth [1,2]. During the recent excellence of services and is a potential source of sustain-
decade, the number of private centers providing health able competitive advantage so that its understanding, mea-
care services in Iran has been ever increasingly growing, surement, and improvement are important challenges for
and the private health care services market has turned all health services organizations [4,5]. Hospitals provide
out to be a competitive environment. Based on the sta- similar services with different quality. The quality can be
tistics issued by the Ministry of Health of Iran (2009), used as a strategic differentiation for establishing a distinc-
54 (40%) of 134 private hospitals active in the health tive advantage, those difficult for rivals to follow or copy
sector of Iran and possessing 48% of the hospital beds [6]. Many of researchers have emphasized on the impor-
of this sector have been operating in Tehran, the capital tance of determining role of quality in hospital choice by
of Islamic Republic of Iran [3]. Highly competitive mar- the patients, as well as satisfying and retaining customers
ket in the private hospital industry has caused increasing and have claimed that the improvement of the quality of
hospital services will increase the number of satisfied
patients and thereby customer loyalty [5,7].
* Correspondence: [email protected] Quality in health services entails two dimensions:
1
Department of Health Management and Economics, School of Public technical quality (outcome quality) and functional qual-
Health, Tehran University of Medical Sciences, Tehran, Iran
Full list of author information is available at the end of the article
ity (process quality). Technical quality focuses on the

© 2012 Zraei et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
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accuracy of medical diagnoses and procedures whereas Sampling

functional quality refers to the way in which health care The study sample was selected from among all patients
services are delivered to patients [8]. Because most of who were hospitalized in private hospitals of Tehran.
patients lack the required knowledge for evaluating the Eight general hospitals were considered for investigation
technical quality of the services, their evaluation of qual- and the samples were divided among the 8 hospitals based
ity is based on the medical care process [9]. on proportionality to the size. The inclusion criteria com-
Providing patients with the services according to their prised adult patients aged 15 years and older who were
needs and expectations is crucial for survival and suc- stayed at least 24 hours in the hospital and willing to parti-
cess of the organization in the competitive environment cipate in the study. The samples were selected randomly
of the health care market [10]. Accurate recognition of in each hospital, and the questionnaires were given to
the customers’ needs and expectations is the most them on the day of discharge. The aim of the study was
important step in defining and delivering high-quality explained to patients, and they were assured of the privacy
services [11]. The patients’ expectations are derived of their information. The illiterate patients were inter-
from their perception of the ideal care standards or viewed by a trained interviewer. Finally, 983 of the 1100
their previous experiences in the use of services [12]. questionnaires distributed between the patients (response
Different study results show that meeting the patients’ rate = 89%) were filled out and gathered for analysis.
expectations is related to his/her high satisfaction from
the related services, in the same way as unmet expecta- Survey instrument
tions relate to dissatisfaction [13]. After delivering the The study questionnaire was composed of 2 parts: the
services, service providers also must monitor how well first part includes 8 questions relating to the socio-
the customers’ expectations have been met. demographic data of the patient. In the second part, the
Different methods exist for determining the patients’ SERVQUAL questionnaire [18], with some modifications
expectations and the way they are met. However, the that are suitable for hospital environment, was used for
SERVQUAL model, developed by Parasuraman et al assessing the patients’ expectations and perceptions of
[14], is one of the best and most used models for evalu- service quality. The questionnaire included 21 items in
ating customer expectations and their perceptions of the 5 service quality dimensions: tangibles (4 items), reliabil-
quality of the services. In this model, the quality is equal ity (4 items), responsiveness (4 items), assurance (4
to performance minus expectations. SERVQUAL is items), and empathy (5 items). The SERVQUAL ques-
based on the idea that the quality is a subjective evalua- tionnaire has been translated to an Iranian language,
tion of the customer, as the service is not a physical and the Farsi version was available.
item but an experience. Hence, customer perception is
better compared with other measures of performance Analysis
[15]. SERVQUAL is useful in showing the difference SERVQUAL has been tested in health care environ-
between the patients’ preferences and his/her actual ments and has produced various results (from 1 to 9
experience and specifies the areas that need improve- dimensions), and there is no consensus on the number
ment. The analysis of service quality enables hospital of quality dimensions [19]. Hence, because this was the
management to allocating the financial resources for first study across the private hospitals of Iran, it was
improving performance in the areas that have more necessary to use factor analysis for determining the
influential on the customers’ perception of service qual- quality dimensions from the patients’ perspective. A
ity [6]. five-point Likert scale was used, ranging from strongly
Studies carried out in Iran on the quality of the health disagree (1) to strongly agree (5) to assess the level of
services have been basically focused on the primary patients’ expectation and perception of service quality.
health care [16,17]. To the best of our knowledge, the Data analysis was done using SPSS 17.0 software.
present study is the first one to investigate the service Exploratory factor analysis (EFA) was used for determin-
quality of private hospitals in Iran. This study follows ing the dimensions of service quality. Also, the Wil-
the aim of determining the different dimensions of the coxon test was used in comparing the patients’
quality of the services being provided in private hospi- “perception” and “expectations” scores and in analyzing
tals of Iran and evaluating service quality from the such mean score in the different groups; the t-test and
patients’ perspective. Kruskal-Wallis tests were used.

Methods Ethics
A cross-sectional study was conducted between October This study was approved by the ethics committee of the
and November 2010 in Tehran, the capital of Islamic Deputy of Research, Tehran University of Medical
Republic of Iran. Sciences (code: 130/1293).
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Results Table 2. The EFA results specified three dimensions of

Patients’ characteristics the service quality as follows:
Table 1 shows the demographic findings of the patients.
The patients’ average age was 47.9 years (SD = 16.9). • Factor 1 included 10 items relating to the reliabil-
About 898 patients (91%) had insurance coverage. The ity, responsiveness, and assurance, which explained
average length of stay of the patients was 4.6 days (SD = 27.8% of the total variance and was labeled as “relia-
4.4). A total of 320 patients (33%) had been previously bility/responsiveness.”
admitted in the current hospital, and 266 patients (27%) • Factor 2 includes 5 empathy items and 2 assurance
had used outpatient services of the current hospital items, which explained 22.1% of the total variance
(imaging, laboratory, clinics, and emergency services). and was named “empathy.”
• Factor 3 includes 4 tangible items, which explained
Construct validity and reliability 19.1% of total variance and was named “tangibles.”
The first aim of the study was to determine the service
quality dimensions of private hospitals in Iran from the To evaluate the reliability of the three service quality
patients’ perspective. The construct validity was deter- dimensions, the internal consistency analysis was per-
mined using EFA (principal components analysis with formed. The Cronbach alpha coefficient ranged from
Varimax rotation method). The sample adequacy for 0.85 to 0.95 for perception dimensions and 0.96 for
extraction of the factors was confirmed through Kaiser- overall perception, as well as 0.80 to 0.90 for expectation
Meyer-Olkin (KMO) test and Bartlett’s test of sphericity. dimensions and 0.93 for overall expectation, showing
The Bartlett’s test result was significant (p < 0.001), and that the instrument is sufficiently reliable.
the KMO value (0.975) showed that using exploratory
EFA was suitable. Descriptive statistics
In this analysis, the factors with eigenvalues equal or Based on our findings, the mean scores of expectations
higher than 1 were considered significant and chosen were high and ranged from 4.78 for (item 16: Having
for interpretation. By EFA, 3 factors were extracted, patients’ best interest at heart) to 4.97 for (item 19:
explaining 69% of the total variance. All factor loadings Clean and comfortable environment of the hospital).
were higher than 0.4, indicating that they were statisti- The total means score of patients’ expectation was
cally significant and higher than the recommended level 4.91. Among the three dimensions, the highest expec-
[20]. The factor loading of each item has been listed in tation related to the tangibles dimension (dimension’s
mean score = 4.95) and the lowest expectation related
to the empathy dimension (dimension’s mean score =
Table 1 Socio-demographic data of the sample (N = 983) 4.87). Among the four items with highest expectation
Variables N % score, three items related to the tangibles and one
Gender Male 450 45.8 item related to the empathy dimension. Of the four
Female 533 54.2 items with lowest expectation score, all 4 items related
Age ≤ 30 178 18.1 to empathy.
31-40 169 17.2 The mean score of the perceptions ranged from 3.34
41-50 228 23.2 for (item 13: Individual attention to patients) to 4.39 for
51-60 145 14.8 (item 11: Polite and friendly dealing of personnel with
≥ 61 263 26.8 patients). The total means score of patients’ perceptions
Education level Illiterate 64 6.5 was 4.02. Among the three dimensions of quality, the
Primary and secondary school 441 44.9 highest perception related to the tangibles dimension
Academic Degree 478 48.6 (dimension’s mean score = 4.18) and the lowest percep-
Residence Urban 949 96.5
tion related to the empathy dimension (dimension’s
Rural 34 3.5
mean score = 3.89). Among the four items with highest
perception score, 3 items related to the tangibles and
Hospital ward Internal 249 25.3
one item related to the empathy dimension. From the
Surgery 320 32.6
items with lowest perception score, all 4 items related to
Obstetrics and Gynecology 168 17.1
empathy. These items had the lowest expectation scores,
Other 246 25.0
as well.
Health condition Excellent 74 7.5
The gap score for each item and dimension was com-
Good 538 54.7
puted by subtracting the expectation score from the per-
Average 331 33.7
ception score. The Wilcoxon test results show that the
Bad 40 4.1
differences between perception and expectation for all
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Table 2 Dimensions of hospital service quality, mean scores for patients’ expectations, perceptions, and quality gaps
and Wilcoxon test results
Dimensions and items Factor Mean perception Mean expectation Mean quality gap
loading score score scores
Reliability/Responsiveness 4.05 4.93 -0.88
1. Sincere interest of personnel in solving patients’ 0.59 4.04 4.94 -0.89
problems
2. Carrying out of the services right at the first time 0.56 4.08 4.92 -0.84
3. Providing services at appointed time 0.62 4.11 4.92 -0.81
4. Error-free and fast retrieval of documents 0.58 3.97 4.93 -0.96
5. Telling when services will be performed 0.71 4.02 4.90 -0.88
6. Prompt performance of medical and non-medical 0.74 4.03 4.91 -0.87
services
7. Willingness of personnel to help patients 0.80 4.08 4.93 -0.84
8. Aattending of personnel whenever called 0.80 4.09 4.94 -0.84
9. Instilling confidence in patients 0.76 4.04 4.95 -0.91
10. Feeling safety and security in interaction with 0.74 4.04 4.95 -0.91
personnel
Empathy 3.89 4.87 -0.98
11. Polite and friendly dealing of personnel with 0.47 4.39 4.96 -0.57
patients
12. Knowledgeable personnel to answer patients’ 0.59 3.95 4.90 -0.94
questions
13. Individual attention to patients 0.64 3.34 4.87 -1.52
14. Availability of 24-hour services 0.67 3.97 4.94 -0.96
15. Attention to the patient’s beliefs and emotions 0.84 3.90 4.86 -0.96
16. Having patients’ best interest at heart 0.85 3.83 4.78 -0.94
17. Understanding specific needs of patients 0.82 3.86 4.82 -0.96
Tangibles 4.18 4.95 -0.76
18. Neat and well-dressed personnel 0.75 4.36 4.96 -0.59
19. Clean and comfortable environment of the hospital 0.81 4.29 4.97 -0.67
20. Modern and up-to-date equipment 0.69 3.96 4.95 -0.99
21. Visually appeal of physical facilities 0.70 4.12 4.94 -0.81
Overall Quality 4.02 4.91 -0.89

the 21 items and 3 dimensions are statically significant Investigating the difference between the patients’
(p < 0.001). Also, the difference between the total mean expectations scores based on the socio-demographic
score of perceptions and expectations is statistically sig- variables showed that there is a relatively significant dif-
nificant, and hence, there is a gap between the patients’ ference between the expectations mean scores based on
perception and their expectation of the service quality of gender)t(848) = 2.78, p = 0.05 (and the women’s expec-
Tehran private hospitals (see Table 2). tations were more than the men’s regarding service
Our findings show that the highest gap of the quality quality. There was a statistically significant difference
relates to the empathy dimension (gap mean score = between the patients’ expectation scores based on the
-0.98), and there is a considerable gap between the education level (H (2) = 16.64, p = 0.001), and the illit-
patients’ expectations and perceptions. The lowest gap erate patients had higher expectations than the educated
of the quality relates to the tangibles dimension (gap ones. Also patients with previous hospitalization in that
mean score = -0.76). An overview of 21-items gap scores same hospital had less expectations than the others
shows that from those five items with highest gap, four regarding service quality (t (539) = 2.32, p = 0.02).
items relate to the empathy dimension (items 13, 14, 15, Investigating the difference between the patients’ per-
and 17), and one item relates to the tangibles dimension ception scores based on the socio-demographic variables
(item 20), confirming the above-mentioned results (see regarding quality of the services showed that there is a
Table 2). statistically significant difference between the patients’
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perception scores among those with and without insur- medical aspects, considerably satisfying the patients’
ance coverage)t(981) = 2.59, p = 0.01), and patients expectations.
without insurance coverage had lower quality percep- Low perception and expectation score and high gap
tion. The difference between the perception scores score of empathy dimension is indicative of a weak rela-
based on the average length of stay (LOS) was statisti- tionship between the physician, nurses, and the person-
cally significant (H (4) = 17.88, p = 0.001), and the per- nel with patients and need to improve behavior and
ceptions score is decreased by the increase in the LOS. communication between personnel and patients. This is
The difference between the perceptions’ scores based on similar to the results gained from the study by Huang et
the patients’ health conditions on discharge was statisti- al [26], but contrary to the results of Jabnoun and Cha-
cally significant (H (3) = 18.55, p = 0.001), and patients ker study [27]. The human elements have higher impor-
who had described their health conditions as “excellent” tance relative to nonhuman elements in the patients’
and “good” had higher perception score than others. perception of the quality of the private health care ser-
vices [28], and the interpersonal relationships are one of
Discussion the most important factors in the perception of service
The main objective of this study was to provide a con- quality [29,30]. Results from several studies have shown
ceptual and operational framework to the policy makers the importance of the interpersonal relationship compo-
and decision makers about the patients’ expectations nent of service quality regarding satisfaction
and perceptions of service quality in private hospitals. [28,29,31,32] and patient loyalty [2]. The practitioners/
SERVQUAL questionnaire was used in this study, but personnel must make the patients aware of their disease
results from the factor analysis did not confirm the conditions, answer their questions, recognize and pay
structure suggested by the Parasuraman et al.[14,18] and attention to their emotional and social needs and be
three dimensions of reliability, responsiveness, and available when needed.
assurance were converted into a single dimension. In Professional, timely, and proper services are what the
Yasilda and Direjtor study, these three dimensions were patients expect from the hospitals. The quality of ser-
converted into one dimension named reliability/confi- vices provided by the hospitals is determined mainly by
dence [21] and in Dengjuin et al. study; the three the process-related factors like scheduling, delivery of
dimensions were converted into one dimension named care in the fastest time, and correctness [31]. Previous
responsiveness [22]. Therefore, the patients in private study results show that process of care delivery is a
hospitals of Iran define the quality of services in three determining factor in the patients’ perception of the
dimensions: tangibles, reliability/responsiveness, and quality of the services, and they are more sensitive to
empathy. the process of care delivered by the nurses and person-
Generally, the patients have high expectations in pri- nel [4,31,33]. Accordingly, the reliability/responsiveness
vate hospitals (4.91 of 5 [≈98%]), which is not unusual dimension, focusing on the process of care, still requires
and similar to the results of previous studies accom- more attention to meet the patients’ expectations
plished in Cyprus [7], Turkey [4] and Taiwan [22,23]. regarding this aspect of quality. Hospitals must design a
The service quality of private hospitals have been satis- scheduling system of service provision and be bound to
factory from the patients’ perspective (4.02 of 5 [≈80%]), it.
although there is much work to do for improvement in Based on our study results, women’s expectation score
all areas of service quality. Similar results have been was higher than that of the men. The women’s higher
reported for the quality score in other parts of the expectations compared with the men had been reported
world [4,7,22,24]. in the previous studies [22,23]. Unlike the results of two
The highest expectation and perception and lowest studies in Turkey [34] and Taiwan [22] in our study,
gap of quality is related to the tangibles dimension, patients with higher education level had lower expecta-
showing that the private hospitals have paid attention to tions than the others. It seems that with higher educa-
the physical aspects and infrastructures of care delivery. tion levels, the individuals’ expectations become more
Our findings confirm two previously carried out study reasonable. The patients with previous admission in the
results in Singapore and Malaysia [6,25]. The tangibles current hospital had lower expectations than the other
dimension entails considerable importance for customer patients. It seems that their previous experience and
evaluation of service quality [14], so that attractive recognition has caused them to adjust their expectations
environment and suitable hotel services are compelling in accordance with that specific hospital’s facilities and
reasons for them to choose a specific private hospital. In conditions. The patients without insurance coverage had
recent years, the new private hospitals in Tehran have lower perception of quality. Because these patients pay
invested more in physical and environmental besides the their costs through out of pocket, they expect that the
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private hospitals meet their expectations. The patients Competing interests

The authors declare that they have no competing interests.
with longer average LOS in the hospital had lower per-
ception of the quality of the services. The relationship Received: 25 July 2011 Accepted: 2 February 2012
between longer average length of stay and lower satis- Published: 2 February 2012
faction level has been reported in previous studies as
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Pre-publication history
The pre-publication history for this paper can be accessed here:
http://www.biomedcentral.com/1472-6963/12/31/prepub

doi:10.1186/1472-6963-12-31
Cite this article as: Zarei et al.: Service quality of private hospitals: The
Iranian Patients’ perspective. BMC Health Services Research 2012 12:31.

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