Service quality and patient loyalty
A strong relationship between patient loyalty and service quality has been confirmed by many researchers. Evidence of a strong and direct relationship between patient loyalty and service quality has been given by (). While () stated that service quality result in patient loyalty; whereas if the level of patients also tends to be relatively high, it may also act as a vital promoter of patient loyalty. However, in today’s highly dynamic and competitive environment attaining higher levels of patient satisfaction and patient loyalty, especially in the service sector, maybe a tough task for many organization.
It was established by () that service quality dimensions (tangibility, reliability, responsiveness, assurance and empathy) have a significant and positive relationship and influence patient loyalty. So also in the same vein, according to () an insignificant relationship exist between service quality dimensions (tangibility, reliability, responsiveness, assurance and empathy) and patient loyalty.
Service quality and patient satisfaction
Service quality is unanimously recognized as an indicator of an organization’s competitiveness. Service performance is considered a strategic weapon, which leads to achieving patient satisfaction in a service industry (). In the health sector, telecommunication and banking industry, service quality is one of the most important aspects of premium patient experience. Most organizations monitor their services quality on a regular basis to ensure maximum patient satisfaction and improve patient retention and loyalty (). Patient satisfaction is attained by properly meeting their patient demands and expectations and providing services which are up to the market standards (). A positive consumption experience of patient ensure that overall their feelings for the services consumed are positive. However, patient satisfaction does not guarantee repurchase patient retention or loyalty ().
It was established by () that service quality dimensions (tangibility, reliability, responsiveness, assurance and empathy) have a significant and positive relationship and influence patient satisfaction. But according to () among the dimensions tangibility does not influence patient satisfaction, but other dimensions (reliability, responsiveness, assurance and empathy) have a positive and significant relationship with patient satisfaction. Also, () found out that tangibility and empathy are the only elements that have influence on patients satisfaction, while reliability, responsiveness and assurance do not influence patient satisfaction. Also, () found out that only reliability and responsiveness have influence on patient loyalty, tangibility, responsiveness and empathy do not influence patient loyalty. So also according to (), among the dimensions only assurance influences patient satisfaction, but other dimensions (tangibility, reliability, responsiveness and empathy) have a negative and insignificant relationship with patient satisfaction.
Patient satisfaction and patient loyalty
Patient satisfaction can lead to patient loyalty because people tend to be rational and risk adverse, so they might have a tendency to reduce risk and stay with service providers with whom they already had a good experience. There are also many types of relationship between patient satisfaction and patient loyalty suggested, such as satisfaction is the core of loyalty, satisfaction is one the necessary of components of loyalty, satisfaction and loyalty are the components of ultimate loyalty and satisfaction is the starting point of loyalty (). In addition, the relationship between patient satisfaction and patient loyalty might be nonlinear.
() () () argued that an increase in the level of patient satisfaction can increase patient loyalty toward a particular health institution that is consistent the findings of () and (). Positive patient inclination will frame trust, which can give positive judgment to the healthcare center () () (). () () found that satisfaction do not mediate patient satisfaction.
Summary of the literature review (knowledge gap)
Majority of the research studies on service quality were carried out in other countries (Singapore, Turkey, Pakistan, India, Jordan, China, Canada, etc.) context, which cannot be generalized in to the Nigerian scenario. A very few number of studies in the context of Nigeria () () () () were carried out and found that service quality analysis gives an opportunity to patients to voice their view about perceived healthcare service at different levels. It can be assumed that they have a positive effect on the quality service offered by hospitals.
2.3 Theoretical Review
Considering the work done over the last decades or so by Gronroos Service Quality Model (1984), Haywood-Farmer Service Quality Model, (1988), Cronin and Taylor Service Performance Model, (1992), Zineldin Service Quality Model, (2006) and Parasurama et al Service Quality Model, (1985) on the measurement of service quality, yet no unblemished, explicit and uniform service quality measurement model is available. Service quality is one of the most important factors in service marketing. Hence, numerous researchers had worked on service quality and recommended various models.
2.3.1 The Gronroos Service Quality Model
Gronroos (1984) acknowledged a two-dimensional service quality model; technical and functional service quality model for service quality. Conferring to him, patient gratification hinges on the gap of perceived and expected service quality. He discussed three components of service quality in his model, such as technical, functional and image. The technical aspect of the Gronroos service model refers to the routine working procedure that includes operating hours and expertise to service providers. Furthermore, it refers to the technical aspects of the equipment and the process. The functional aspect of Gronroos service model is related to the way the service is provided. Patients are directly intricate in the functional level. Hence, assessment is easy as equated to technical skills. Whereas the image aspect of the service model is related to the generosity of service providers
2.3.2 The Zineldin Service Quality Model
Zineldin (2006) recommended service quality dimensions with the help of a technical-functional service quality model and the Servqual model. He suggested five quality dimensional models for the measurement of service quality in healthcare known as the 5Q model. His proposed quality dimensions are the following;
Quality of Object: - Object quality is linked to the technical aspect of the service quality of healthcare. It is allied to the cure, for which patients go to the hospital or any healthcare centre.
Quality of Processes: - It is the functional quality showing the way the service is provided. The way patients are being treated. In short, the way the technical quality is instigated.
Quality of Infrastructure: - Infrastructure quality is the overall quality of all the important resources mandatory to perform the service. It embraces everything including technical skills, machinery, experience and the way all these activities are coped.
Quality of Interaction: - It is related to the communication process with patients; understanding a patient's problem and listening unwearyingly to the patient. It also comprises informing patients about a checkup.
Quality of Atmosphere: - It is connected to the environment where patients and doctors function. It includes the pleasant environment that the organization is providing to patient where they can share their glitches with doctors and other supporting staff members.
2.3.3 Theoretical Underpinning
The Parasuraman et al. service quality model (1985) presented the Servqual model with 5 different types of GAP between service provider and receiver. These gaps are:
Knowledge Gap
The first and obvious gap is usually between what patients want and what managers think the patient's want. Briefly, many hospitals think they know what their patients want but are in fact sometimes mistaken. For example, hospitals might mistakenly believe that patient have the same expectations and perceptions regarding hospital treatment. When a knowledge gap occurs, a variety of other mistakes tend to follow. The wrong facilities may be provided, the wrong staff may be hired and the wrong training may be undertaken. Services may be provided that patients have no use for, while the services they do desire are not offered. Closing this gap requires minutely detailed knowledge of what patients desire and then building that response into the service operating system ().
Factors Influencing the Knowledge Gap
Three main factors influence the gap. First, the firm's research orientation, which reflects its attitude toward conducting patient research, can dramatically influence the size of the gap. Information obtained from patient research defines consumer expectations. As the firm's research orientation increases and it learns more a about the needs and wants of its patients, the size of the knowledge gap should decrease. The amount of upward communication is a second factor that influences the size of the knowledge gap. Upward communication refers to the flow of information from front-line personnel to upper levels of the organization. In other words, does upper management listen to and value the feedback provided by its front line personnel? Front line personnel interact with patients on a frequent basis, so they are often more in touch with patients’ needs than top management. Consequently, as the flow of upward communication increases through the organization, the knowledge gap should become smaller. Finally the levels of management in the organization can also influence the size of the knowledge gap. As the organizational hierarchy becomes more complex and more levels of management are added, higher levels of management tend to become more distant from patients and the day-to-day activities of the organization. As a result, when the levels of management increase, the size of the knowledge gap tends to increase.
Standard Gap
Even if patients' expectations have been accurately determined, the standards gap open between management's perception of patient expectations and the actual standards set for service delivery. A simple analogy would be to consider when a patient is explaining his/her health problem and the doctor really understands the problem of the patient. Let's assume that the doctor clearly understands the patient's ailments. In this case, a knowledge gap does exist. Once the doctor understands the patient's problem, he prescribed exact specifications for a nurse and pharmacies to follow. If the doctor is unable to convert the patient's problem to a prescription, a standard gap is created (Douglas & John, 2011).
Factors Influencing the Standards Gap
In many cases, management does not believe it can or should meet the patient's requirement for service. Another factor that influences the size of the standards gap is management's commitment to the delivery of service quality. Corporate leadership may set other priorities that interfere with setting standards that lead to good service.
Delivery Gap
The delivery gap occurs between the actual performance of a service and the standard set by management. The existence of the delivery gap depends on both the willingness and the ability of employees to provide the service according to specification. If the Nurses and pharmacies do not follow the standards set by the doctor's prescription, a delivery gap is created (Douglas & John, 2011).
Factors Influencing the Delivery Gap
One factor that influences the size of the delivery gap is the employee's willingness to perform the service. Obviously, the employee's willingness to provide a service can vary greatly from employee to employee and in the same employee over time. Many employees who start off working to their full potential often become less willing to do so over time because of frustration and dissatisfaction with the organization. Furthermore, a considerable range exists between what the employee is actually capable of accomplishing and the minimum the employee must do in order to keep his/her job. Most service managers find it difficult to keep employees working at their full potential all the time.
Other employees, no matter how willing, may simply not be able to perform the service to specification. Hence, a second factor that influences the size of the delivery gap is employee job fit. Individuals may have been hired for jobs they are not qualified to handle or to which they are temperamentally unsuited or they may not have been provided with sufficient training for the roles expected of them. Generally, employees who are not capable of performing assigned roles are less willing to keep trying.
Another common factor influencing the size of the delivery gap is role conflict. Whether or not the knowledge gap has been closed, service providers may still see an inconsistency between what the service manager expects employees to provide and the service their patients actually want. Yet, another cause of the delivery gap is role ambiguity. It results when employees due to poor employee-job fit or inadequate training, do not understand the roles of their job or what their jobs are intended to accomplish. Sometimes they are even unfamiliar with the service firm and its goals. Consequently, as role ambiguity increases, the delivery gap widens. A further complication for employees is the dispersion of control, the situation in which control over the nature of the service being provided is removed from employees' hands. When employees are not allowed to make independent decisions about individual cases without first conferring with a manager, they may feel marginalized, alienated from the service firm and less committed to their job. Consequently, as the dispersion of control increases, the delivery gap becomes wider.
Finally, the delivery gap may also suffer due to inadequate support, such as not receiving personal training and/or technological and other resources necessary for employee to perform their jobs in the best possible manner. Even the best employees can be discouraged. If they are forced to work with out-of-date or faulty equipment, especially if the employees of competing firms have superior resources and are able to provide the same or superior levels of service with far less effort. Failure to properly support employees leads to a lot of wasted effort, poor employee productivity, unsatisfied patients, and an increase in the size of the delivery gap
Communication Gap
Communications gap is the difference between the service the firm promises it will deliver through its external communications and the service it actually delivers to its patients. If advertising or sales promotions promise one kind of service and the consumer receives a different kind of service, the communications gap becomes wider and wider. All Firms need to understand that all external communications are essentially promises the firm makes to its patients, thereby increasing the patients' expectations. When the communications gap is wide, the firm has broken its promises, resulting in a lack of future patient trust ().
Factors Influencing the Communications Gap
The communications gap is often influenced primarily by two factors. The first, the propensity of the firm to overpromise, occurs in highly competitive business environments, as firms try to outdo one another in the name of recruiting new patients. The second factor pertains to the flow of horizontal communication within the firm. In other words, "Does the left hand know what the right hand is doing?" All too often, communications are developed at the firm's headquarters without conferring with decentralized regional and local service operations in the field. In some instances, new service programs are announced to the public by corporate headquarters before the local service firms are aware that the new programs exist. A lack of horizontal communication places an unsuspecting service provider in an awkward position when a patient requests the service promised and the provider has no idea what the patient is talking about.
Customer Perceived Service Quality Gap
This gap takes place when patients are getting services that are not according to their expectations. This gap is reliant on the first four gaps and if these gaps are enclosed the fifth gap will automatically be obscured. According to (Mahmoud et al., 2019), service quality can be measured by quantifying the gap. They suggested the Servqual model for the service quality measurement.
A qualitative research conducted by (parasuraman 1985) administering focus group interviews and acknowledged primarily 10 service quality dimensions, which in 1988 contracted to dimensions. The dimensions identified by them are tangibles, reliability, responsiveness, assurance and empathy. The original 10 dimensions of service quality identified by them are the following:
1. Tangibles
2. Reliability
3. Responsiveness
4. Communication
5. Credibility
6. Security
7. Competence
8. Courtesy
9. Understanding/knowing the patient
10. Access
There were a 97 items scales planned for 10 different dimensions. Each statement was of two types of questions, one was expectation-related and the second one was perception-related However, (Parasuraman et al., 1988) worked again on the Servqual dimension and curtailed the 10 dimensional Servqual model to five. The first three dimensions of the traditional Servqual model remained the same. The remaining seven were dimensions amalgamated into two new dimensions of the new Servqual model. The new dimensions they proposed for the Servqual model are the following:
1. Tangibles
2. Reliability
3. Responsiveness
4. Assurance
5. Empathy
The communication, credibility, security, competence and courtesy dimensions of the traditional Servqual model were fused into assurance and the last three dimensions of the old Servqual model, understanding and access merged into empathy
Figure 2.1 (Service Quality Model)
This model represents quality of services as the difference between patients’ expectation on offered services and their perceptions regarding to service received. The evaluation of service quality is based on the assessment of service outcomes and service delivery procedures by patients. The service quality which meets their anticipation is believed as good quality of service (Parasuraman et al., 1991).
Similarly, the study of (Aboubakr & Bayoumy, 2022; Adekola, 2020; Akob et al., 2021; AlOmari, 2021; Goumairi et al., 2020; Jonathan Bermúdez-Hernández et al., 2021; Magasi et al., 2022; Sharifi et al., 2021; Sitaraman et al., 2020; Sumi & Kabir, 2021) suggested that SERVQUAL is a good scale to use and measure service quality. In this regard, service quality in primary healthcare centres at Sheka PHC is measured by this framework.
Research framework
The dependent variable of the study is patients’ loyalty: the independent variable is service quality with patient satisfaction as a mediator.
Service Quality
Figure 2.2 (Research Framework)
Source: Author
It is logical that satisfied patient will probably return for future illness and eventually become loyal. This is the formal concept and the basis for thought in marketing. In fact, this relationship between satisfaction and loyalty has been shown to be the case throughout much of the literature. Recent studies support this strong correlation between satisfaction and loyalty. Additionally, in the health service sector, it is shown that satisfaction should be treated as one of the main predictors of loyalty (Meesala & Paul, 2018).
Measurement of patient satisfaction, patient loyalty and service quality are both obtained by comparing perception to expectations. Loyalty is an attitude towards patronizing or purchasing based on prior service experience. While satisfaction compares patient perceptions to what patients would normally expect, service quality compares perception to what a patient should expect from a hospital that delivers high-quality services (Naini et al., 2022).
Tangible dimension
Because of the absence of a physical product, patient often rely on the tangible evidence that surround the service in forming evaluations. The tangibles dimension of SERVQUAL compares patient expectations to patient perceptions regarding the hospital ability to manage its tangibles, which may lead to loyalty of patient. Healthcare centre tangibles consist of a wide variety of objects, such as medical machinery and equipment, architecture, design, layout, carpeting, desk, lighting, wall colors, brochures, daily correspondence and the appearance of the personnel.
Reliability Dimension
In general, reliability dimension reflects the consistency and dependability of a hospital's performance. Does the hospital provide the same level of service time after time or does quality dramatically vary with each encounter? Does the hospital keep its promises, bill its patients accurately, keep accurate records and perform the service correctly the first time? Nothing can be more frustrating for patients than unreliable service providers. If patients are satisfied with the reliability of a particular hospital, it may lead to patient loyalty.
Responsiveness Dimension
Responsiveness reflects a service hospital commitment to provide its services in a timely manner. As such, the responsiveness dimension of SERVQUAL Concerns the willingness and/or readiness of employees to provide a service. Occasionally, patients may encounter a situation in which employees are engaged in their own conversations with one another while ignoring the needs of the patient. Obviously, this is an example of unresponsiveness. Responsiveness also reflects the preparedness of the hospital to provide the service and can lead to patient satisfaction, which in the long run may lead to patient loyalty.
Assurance Dimension
SERVQUAL's assurance dimension addresses the competence of the hospital, the courtesy it extends to its patients and the security of its operations. Competence pertains to the hospital knowledge and skill in performing its service. Does the healthcare centre possess the required skills to complete the service on a professional basis? Courtesy refers to how the hospital personnel interact with the patient and the patient's possessions. As such, courtesy reflects politeness, friendliness and consideration for the patient's property. Security is also an important component of the assurance dimension and reflects a patient's feelings that he or she is free from danger, risk and doubt. Confidentiality issues (for example, are my medical records at the hospital center kept private?) and assurance can lead to patient satisfaction and also satisfaction may lead to patient loyalty.
Empathy Dimension
Empathy is the ability to experience another's feelings as one's own. Empathetic healthcare centres have not lost touch of what it is like to be a patient of their own healthcare centres. As such, empathetic institutions understand their patients' needs and make their services accessible to their patients. In contrast, healthcare centres that do not provide their patients individualized attention when requested and offer operating hours convenient for themselves and not their patients fail to demonstrate empathetic behaviors.
The construct service quality in this research framework comprised five service quality model by (Parasuraman et al., 1991), which was tangibility, reliability, responsiveness, Assurance and empathy.
Chapter three
Research methodology
Introduction
This chapter discussed the research process used to conduct current study. It explains the research design, population of the study, sample and sampling techniques, source of data, collection and tools and data analysis techniques.
Research design
The study adopted survey method, because of its aptness for obtaining people personal and social views of facts, beliefs and attitude and determining the condition of phenomenon such as the effect of service quality on patient satisfaction and loyalty among the patient of Sheka PHC. The principal advantage of survey studies is that they provide information on large with very little effort and in a cost-effective manner. So also, the study is cross sectional, it is a study in which data gathered just once, perhaps over a period of days or weeks or months in order to answer a research question. Such studies are called one-shot or cross-sectional. The benefit associated with a cross-sectional is that it is cost-effective and has timeliness. The independent variables, tangibility, reliability, responsiveness, assurance and empathy would be used to measure service quality. The main mediating variable is patient satisfaction, which is one-dimension, while the dependent variable is patient loyalty, which is also one-dimension.
Population of the study
The population of the study consists of patients from out-patient department (OPD), The OPD unit receives an average of one hundred (200) patients during peak period (from March to October) and fifty (75) patients during off peak period (from November to February) visit daily. The time frame for data collection was two months (60 days), which make the population of the study 4500 patients. 100% of the populations are out-patients.
Sample and sampling techniques
Samples of three hundred and fifty four (354) respondents were taken from the 4500, as highlighted in the population of the study. The sample is determined using the criteria proposed by Krejcie and Morgan (1970) for sample determination. The absence of sampling frame hinders the use of the probability sampling technique, which is more reliable and acceptable for the purpose of generalization, thus influencing the use of non-probability sampling technique (convenience sampling technique).
Measurement of variables
The survey mechanism contains four (4) sections the first section is the independent variable (service quality), the second section is about the mediating variable (patient’ satisfaction), the third section is about the dependent variable (patient loyalty) and both service quality, patient satisfaction and patient loyalty were measured on five point Likert scale and the last section is about the demographic variables, which includes respondent information about gender, age, qualification and occupation.
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