Satisfaction with the quality of health care services at Hue university hospital

Hue University Journal of Science ISSN 1859-1388 Vol. 113, No. 14, 2015, pp. 33-40 *Corresponding: minhnhathoa@yahoo.com Submitted: October 27, 2015; Revised: January 06, 2016; Accepted: February 25, 2016. SATISFACTION WITH THE QUALITY OF HEALTH CARE SERVICES AT HUE UNIVERSITY HOSPITAL Nguyen Thi Minh Hoa* College of Economics, Hue University Abstract: This study focuses on examining the patient's satisfaction with the quality of health care services at Hue University Hospital. Data were collected from 200 patients. The scale of measuring the quality of health care services was developed based on the SERVQUAL scale. Reliability and validity of the scale were evaluated by Cronbach’s Alpha and Exploratory Factor Analysis (EFA). Results from multi linear regression show that there are six components contributing to the patients’ satisfaction, as follows: Assurance (0.403), Tangible (0.208), Price (0.184), Image (0.170), Trust (0.160) and Reliability (0.100). Keywords: service quality, health care, satisfaction, SERVQUAL, hospital 1 Introduction Vietnam has gained remarkable achievements in economic development since the introduction of economic reforms. Following this economic development, the annual income per capita has been increasing. People with growing incomes are increasingly paying attention to health care. A majority of patients who have a high demand for health services begin to choose private health services providing better quality. Many patients are willing to go abroad for examination and treatment. Also, foreign hospitals’ promotion is attracting more patients in the country. This has posed great challenges for public hospitals in the country. Hue University Hospital (HUH) is one of the largest public hospitals in Hue City that are equipped with modern medical machines and applied with advanced technologies in health care and surgery. However, in order to attract patients to come and go back to the hospital for examination and treatment, attention must be paid not only to equipments and facilities but also the quality of health care services. How is the patient's satisfaction with the health care ser- vice quality evaluated at HUH? This paper focuses on evaluating the patient's perception on the quality of health care services at HUH and their effects on the satisfaction of the patients. 2 Method 2.1 Service quality and the research model Service quality is a measure of how well the service level that is delivered matches customer expectations. Parasuraman et al. (1988) defined service quality as the difference between cus- tomer's expectation and perception. SERVQUAL is one of famous service quality scales having much acceptance by researchers in studying service quality of many different types of services. According to Parasuraman et al. (1988) the items in SERVQUAL are grouped into five distinct Nguyen Thi Minh Hoa Vol. 113, No.14, 2015 34 dimensions including reliability (ability to perform the promised service dependably and accu- rately), responsiveness (willingness to help customers and provide prompt service), assurance (knowledge and courtesy of employees and their ability), empathy (caring, individualized at- tention the firm provides for its customers) and tangibility (physical facilities, equipment, and appearance of personnel). SERVQUAL has been applied to many different types of services and is considered to be highly reliable. Considering health care service organization, a number of studies applied SERVQUAL to measure service quality. For example, Youssef et al. (1996) assessed service qual- ity in the National Health Service of United Kingdom Hospital. Lim and Tang (2000) evaluated patients’ expectations and satisfactions in hospitals in Singapore. Anderson (1995) also meas- ured the quality of service provided by the clinic at the University of Houston Health Center. SERVQUAL is also applied in this study. However, HUH is a typical public hospital in Hue City. Its functions are not only examination, treatment but also education, training and conduct- ing scientific researches. SERVQUAL scale was first adjusted to fit with the environment of HUH. The second adjustment of the scale was made after discussing with the staff from Market- ing Department of HUH and 10 patients. Discussion results show that items of “responsive- ness” can be subsumed into “empathy” and "price" and should be added into the scale because the price highly affects the patient’s satisfaction. After adjusting and adding new observation variables, the service quality scale of HUH includes 26 observation variables measuring its five components: reliability (6), assurance (4), empathy (6), tangible (6) and price(4). Studies of Youssef et al. (1996), Lim and Tang (2000) and Anderson (1995) showed that factors of the service quality scale are highly related to patients’ satisfaction. According to Zeithaml and Bitner (2003), customers’ satisfaction is measured by the level of their overall sat- isfaction with the service. The scale of patients’ satisfaction in this study includes 5 variables to assess the degree of patients’ satisfaction with medical services, attitude of staff, qualifications of doctors, hospital charges and medical equipments of the hospital. The relation between ser- vice quality factors and patients’ satisfaction in HUH is shown in the following proposed re- search model. Factors of the model are defined as follows: ─ Reliability: expressed through the professional qualifications of doctors, test results, image diagnosis, and the hospital’s appropriate treatment. ─ Assurance: expressed through communication standards of the hospital’s medical staff, the sensible medical examination, treatment time. ─ Empathy: expressing the concern, caring and sharing to the patients. ─ Tangibility: expressed through medical equipments and applied technologies, staff’s uniforms. ─ Price: expressing the suitable cost of the medical examination, treatment. Jos.hueuni.edu.vn Vol. 113, No.14,2015 35 Source: survey in 2015 Fig. 1. Proposed Research Model The hypotheses to be tested in this study are as follows: ─ H1: assurance has a positive impact on patients’ satisfaction. ─ H2: the price (the suitable cost of medical examination and treatment) has a positive impact on patients’ satisfaction. ─ H3: reliability has a positive impact on patients’ satisfaction. ─ H4: the level of tangible equipments and facilities have a positive impact on patients’ satisfaction. ─ H5: empathy has a positive impact on patients’ satisfaction. 2.2 Data collection and analysis The main respondents of this study are the patients who have been examined at HUH, aged 18 years old and over, and qualified to answer the questionnaire. The survey was conducted in January 2015 at all faculties providing medical services at HUH. There were 200 patients ran- domly selected from the list of patients provided by the Marketing Department. Data were pro- cessed by SPSS 19.0. Reliability and validity of the scale were evaluated by Cronbach’s Alpha and Exploratory Factor Analysis (EFA). Variables that did not meet reliability, validity and con- vergence were eliminated to restructure the scale and readjust the research model and hypothe- ses. In addition, the study used the multi linear regression model to test the research hypotheses and determine the importance of components. 3 Results of the Study 3.1 Demographic Profile of the Sample Table 1 shows that the percentages of female and male patients are 58.5% and 41.5%, respective- ly. The distribution of patients’ age was reasonable:, the group from 31 to 45 years old is the highest (63.5 %), followed by the group of 18 – 30 (15.5%) and over 45 years old (21%). The sur- vey results discovered that the majority of the patients using health care services is public offi- cials (59.5%), 25.5% of the patients are other workers and 15% for licensed business. Regarding Nguyen Thi Minh Hoa Vol. 113, No.14, 2015 36 to income levels, the largest group consists of people with a monthly income between 3 and 5 million VND (63.5%), then the next groups with 5 million VND (24%) and less than 3 million VND (12.5%). This result seems to be reasonable with the economic conditions and the average income per capita in Thua Thien Hue province. Table 1. Demographic Profile of the Sample Profile variables Frequency (n) Percentage (%) Gender Female 117 58.5 Male 83 41.5 Age 18 - 30 31 15.5 31 - 45 127 63.5 46 or older 42 21 Job characteristics Public officials 119 59.5 Licensed business 30 15 Other workers 51 25.5 Income levels Less than 3 million VND 25 12.5 Between 3 and 5 million VND 127 63.5 Over 5 million VND 48 24 Source: survey in 2015 3.2 Patients’ satisfaction A five-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree) was used. The Cronbach’s Alpha values of reliability, assurance, empathy, tangible, price and satisfaction are 0.705, 0.712, 0.739, 0.734, 0.791 and 0.81, respectively. According to Churchill (1979), a Cronbach’s Alpha score larger than 0.7 is generally acceptable as sufficiently accurate for a con- struct. Therefore, the scale is considered to be satisfactory. In order to conduct the EFA of health care service quality at HUH, the entire study sample has to be tested for their fitness. Eight items (the hospital staff is not harassed), do not ask the patients for bribes; examination & treatment areas are clean, airy, well-equipped; the doctors work conscientiously, medical ser- vices (examination, diagnostic imaging, ultrasound scan) should be performed during the day; no appointments for the following day; the medical records are stored carefully; the hospital has an exemption policy for poor patients; the staff is attentive and polite; and medical workers who are always welcoming were eliminated step by step because the loading factors of these items are less than 0.5. Kaiser- Meyer – Olkin (KMO) value is 0.742 (> 0.7) and the Bartlett's Test Jos.hueuni.edu.vn Vol. 113, No.14,2015 37 of Sphericity is significant at 0.000 (< 0.05). These results indicate that the study sample is ade- quate to be used in factor analysis. There are 6 factors extracted with Cumulative Variance ex- plaining 69.767% (> 50%) of the sample total variance, which proves the suitability of factor formation. Table 2. Loading Factors of Health Care Service Quality Construct Items Component 1 2 3 4 5 6 Medical costs and the quality of services provided are suitable (A1) 0.743 Doctors always help and encourage patients (A2) 0.741 Records, medical procedures are simple, fast (A3) 0.737 Waiting time for examination, diagnostic tests, and procedures of obtaining results are reasonable (A4) 0.642 Medical fees in private clinics are higher than those at the hospital (P1) 0.824 Willing to pay higher costs to get better services (P2) 0.819 Medical fees at the hospital are reasonable (P3) 0.770 Doctors’ prescriptions are very reasonable (R1) 0.793 Test results, diagnostic imaging performed by the hospital are cor- rect (R2) 0.655 The hospital’s treatment is relatively good (R3) 0.633 The architecture of the hospital gives the patients impression (T1) 0.815 Uniforms of the hospital employees are easily identified (T2) 0.639 Medical equipments at the hospital are modern (T3) 0.565 The guidelines set is prominently observed (T4) 0.557 Medical waiting rooms are clean and comfortable (I1) 0.876 Guidance and counseling staff answers clearly (procedures, medical procedures, queries) (I2) 0.624 Doctors have professional ethics (Tr1) 0.754 Trust in doctors’ professional qualifications (Tr2) 0.670 Source: survey in 2015 The final EFA of health care service quality presented in Table 2 shows that the scale of health care service quality at HUH is restructured into 6 components. Component 1 includes items A1, A2, A3 and A4. These variables are related to the assurance issues for the patients when they go to the hospital for health check-ups. Therefore, this factor is named as "Assur- ance". Component 2 includes three items P1, P2 and P3. These variables are relevant to price, thus it is named as "Price". Three items of component 3 are R1, R2 and R3. These variables are related to the confidence of customers to HUH. It is named as "Reliability". T1, T2, T3 and T4 are four items of component 4. These variables are related to medical equipment, facilities, and staff Nguyen Thi Minh Hoa Vol. 113, No.14, 2015 38 uniforms. It is called "Tangibles". I1 and I2 are related to a picture that HUH is developing. Therefore, it can be called "Image". Tr1 and Tr2 cover patients’ trust in the hospital’s doctors, thus it is named as "Trust". As mentioned above, The Cronbach’s Alpha value of patients’ satisfaction is 0.81. KMO is 0.763, the Barlett's test is significant at 0.000 and Cumulative Variance explains 59.488% of the sample total variance, which also proves the suitability of the factor formation. In order to study the impacts of health care service quality on patients’ satisfaction, the following multi-linear regression model is used. Y = β0 + β1F1 + β2F2+ β3F3 + β4F4 + β5F5 +β6F6 in which, Y is the patient's satisfaction with the quality of health care services at HUH; F1, F2, F3, F4, F5 and F6 are Assurance, Price, Reliability, Tangibles, Image and Trust, respectively. Based on this regression, H5 needs to be adjusted and H6 will be added for testing. H5: good image has a positive impact on patients’ satisfaction H6: trust has a positive impact on patients’ satisfaction Table 3 shows that R2 is 0.744 and adjusted R2 is 0.736. It means that 73.6% of the patient's satisfaction variation is generally explained by 6 observed variables. In addition, F is significant at 0.000; it means that with the statistical confidence level of 95%, the hypothesis H0 (H0: β2 = β3 =β4 = β5 = β6 = 0) is rejected. Table 3. Suitability of the Regression Model Model Summary Model R R Square Adjusted R Square Std. Error of the Estimate Durbin-Watson 1 0.863a 0.744 0.736 0.51372095 1.891 Source: survey in 2015 Table 4. Regression Coefficients Model Unstandardized Coefficients Standardized Coefficients T Sig. 95% Confidence Interval for B Collinearity Statistics B Std. Error Beta Lower Bound Upper Bound Tolerance VIF Constant 0.470 0.158 2.967 0.003 0.158 0.783 F1 0.324 0.036 0.403 8.997 0.000 0.253 0.395 0.695 1.438 F2 0.122 0.029 0.184 4.199 0.000 0.064 0.179 0.723 1.383 F3 0.082 0.037 0.100 2.216 0.028 0.009 0.155 0.685 1.460 F4 0.159 0.035 0.208 4.551 0.000 0.090 0.228 0.666 1.501 F5 0.115 0.029 0.170 3.997 0.000 0.058 0.171 0.769 1.300 F6 0.130 0.035 0.162 3.721 0.000 0.061 0.198 0.735 1.361 Source: survey in 2015 Jos.hueuni.edu.vn Vol. 113, No.14,2015 39 Regression results are presented in Table 4. There are six components/factors that affect the patient's satisfaction with the quality of health care services at HUH. Six components of health care service quality are positively related to the patient's satisfaction. It means that six components play an important role in contributing to the patient's satisfaction, as follows: Assurance (0.403), Tangible (0.208), Price (0.184), Image (0.170), Trust (0.160) and Reliability (0.100). Therefore, it is necessary to pay attention to the improvement of Assurance, Tangible, Price, Image, Trust and Reliability to increase the patient's satisfaction. In fact, there are many factors forming the impact of health care service quality on the patient's satisfaction, but com- munication by doctors and other medical staffs, time for examining, testing, receiving results are the most important. Patients come to the hospital to get an insight understanding of their health situation; they expect not only specialist qualifications from doctors but also good com- munication and polite attitude by other medical staffs at all time (from ordering, consulting, testing, etc.). In order to increase the patient's satisfaction, HUH needs to improve the quality of health care services in general and pay much attention to the development of human resources, improvement of staff performance and capacity to serve patients in particular. Table 4 also shows that the regression model has no multicollinarity because the Variance Inflation Factor (VIF) of all independent variables are less than 10 and the tolerance of variables is larger than 0.1. In addition, Durbin – Watson statistical index is 1.891 (< 2); it means that there is no autocorrelation of errors occuring (Hoàng Trọng & Chu Nguyễn Mộng Ngọc, 2008). Therefore, the regression model and all hypotheses (H1, H2, H3, H4, H5 and H6) are accepted. It means that components of health care service quality at HUH have positive impact on the patient's satisfaction. 4 Concluding remarks From on the data collected from 200 patients, the results of the study on the patient's satisfac- tion with the quality of health care services at HUH are as follows: ─ The majority of the patients using health care services are females older than 30 years of age. These patients are working in public organizations with a monthly income of 3 to 5 million VND. ─ There are six components (Assurance, Price, Reliability, Tangibles, Image and Trust) that constructed the scale of health care service quality in HUH. ─ These six components play an important role in contributing to the patient's satisfaction, as follows: Assurance (0.403), Tangible (0.208), Price (0.184), Image (0.170), Trust (0.160) and Reliability (0.100). In order to increase the patient's satisfaction, it is necessary to pay attention to the improvement of Assurance, Tangible, Price, Image, Trust and Reliability, especially HUH needs to pay much attention to the development of human resources, improvement of staff performance and capacity to serve patients. Nguyen Thi Minh Hoa Vol. 113, No.14, 2015 40 Reference 1. Anderson, E. (1995) “Measuring service quality in a university health clinic”, International Journal of Health Care Quality Assurance, vol. 8(2), p. 32-37. 2. Churchill Jr, G. A. (1979),"A paradigm for Developing Better Measures of Marketing Constructs", Jour- nal of Marketing Research, Vol. 19, February, pp. 64-73. 3. Youssef F. N., Nel D., and Novaird T. (1996) “Health care quality in NHS hospitals”, International Jour- nal of Health Care Quality Assurance Vol. 9, No. 1, pp. 15-29. 4. Hoàng Trọng và Chu Nguyễn Mộng Ngọc (2008), Phân tích dữ liệu nghiên cứu với SPSS, Nhà Xuất bản Thống kê, Hà Nội. 5. Lim P. C. and Tang N. K. H. (2000), “A study of patients’ expectations and satisfaction in Singapore hospitals”, International Journal of Health Care Quality Assurance, Vol. 13, No. 7, pp. 290-299. 6. Parasuraman A., Zeithaml V. A. and Berry L. L. (1988), “Servqual: A multiple-item scale for measuring consumer perception of service quality”, Journal of Retailing, 64, 12-40. 7. Shelton, Partrick J. (2000), Measuring and Improving Patient Satisfaction, Copyright 2000 by Aspen Pub- lisherm Inc., pp 16 – 24. 8. Zeithaml, V. and Bitner, M. (2003) Service Marketing: Integrating Customer Focus across the Firm, McGrawHill, New York.