This study focused on evaluating the total service quality in the healthcare firms using 5Q model based on the perspectives of employees and external customers. The objectives and hypotheses for aIDressing this aim were also set. The sample included 798 respondents out of which the employees were 399 in number while the external customers were also 399 in number. Using 5Q model, the null hypothesis was that total service quality as measured by 5Q model does not impact on the overall customer satisfaction significantly. In the results, total quality was found to influence the customer satisfaction positively and significantly (F (1, 796) = 850.55, p < .01). The dimensions of process, object, infrastructure, atmosphere and interaction were found to be vital in influencing the customer satisfaction. Moreover, the test reveals that total quality accounted for 51.7 % of overall satisfaction variation (R2= .517, ? = .719). Consequently, the results are important in aIDressing service improvements and maintaining high quality standards to enhance satisfaction level of patients and employees. Table of Contents Abstract. ii List of tables. vi List of figures. vii Chapter 1: Introduction. 8 1.1 Introduction. 8 1.2 Background. 8 1.3 Healthcare quality. 11 1.4 Internal and external customers. 13 1.5 Problem statement. 15 1.5.1 Research questions. 16 1.6 Aim.. 16 1.7 Objectives. 17 1.8 Study significance. 17 1.9 Conceptual framework. 18 1.9.1 Hypotheses. 19 1.9.1.1 Hypothesis 1. 19 1.9.1.2 Hypothesis 2. 20 1.9.1.3 Hypothesis 3. 20 1.9.1.4 Hypothesis 4. 20 1.9.1.5 Hypothesis 5. 20 1.9.1.6 Hypothesis 6. 20 1.9.1.7 Hypothesis 7. 21 1.9.1.8 Hypothesis 8. 21 1.10 Delimitations. 21 1.11 Thesis structure. 22 1.12 Summary. 23 Chapter 2: Literature review.. 24 2.1 Introduction. 24 2.2 Literature review.. 24 2.3 Role of employees in service delivery. 26 2.4 Customer satisfaction. 29 2.4.1 Satisfaction of external customers. 30 2.5 Service quality. 32 2.5.1 Internal vs. external customer perspectives on quality. 34 2.6 Measuring service quality. 35 2.7 Antecedents of quality in healthcare service. 37 2.8 5Q model 39 2.9 Patient satisfaction and service quality. 42 2.10 Summary. 42 Chapter 3: Methods. 44 3.1 Introduction. 44 3.2 Research philosophy. 44 3.3 Study design. 44 3.4 Cross-sectional study. 45 3.5 Sample. 46 3.5.1 Sampling. 46 3.6 Data collection. 47 3.6.1 Questionnaire design. 48 3.7 Data analysis. 48 3.8 Ethical considerations. 49 3.9 Pre-testing instruments. 50 3.10 Validity and reliability. 50 3.11 Summary. 51 Chapter 4: Results and Discussion. 52 4.1 Introduction. 52 4.2 Results. 52 4.3 Demographics. 52 4.4 Total quality. 60 4.4.1 Object quality. 63 4.4.2 Process quality. 64 4.4.3 Infrastructure quality. 65 4.4.4 Interaction quality. 67 4.4.5 Atmosphere quality. 68 4.5 Overall satisfaction. 70 4.6 Effect of total quality on satisfaction. 1 4.7 Discussion. 2 Chapter 5: Conclusion and Recommendations. 8 5.1 Introduction. 8 5.2 Conclusion. 8 5.3 Implications. 12 5.4 Recommendations. 12 5.5 Limitations. 13 5.6 Future studies. 14 5.7 Summary. 14 References. 16 Appendix 1. 25 Questionnaire: External customers. 25 Appendix 2. 28 Questionnaire: Employees. 28 Table 4.1 : Gender of the respondents. 52 Table 4.2 : reasons why external customers were admitted or why they visited the hospital 54 Table 4.3 : occupation of employees in the hospitals. 54 Table 4.4 : Duration that the employees have worked in the hospitals. 55 Table 4.5 : Marital status of the respondents. 56 Table 4.6 : age of respondents. 57 Table 4.7 : Number of times the external customers have visited hospital in the past 3 years. 59 Table 4.8 : Mean ratings, standard deviations and mean difference for the 5Q dimensions. 61 Table 4.9 : Independent Samples Test summary for total quality dimensions. 62 Table 4.10 : Measures of object quality. 63 Table 4.11 : measures of process. 64 Table 4.12 : measures of infrastructure. 66 Table 4.13 : measures of interaction. 68 Table 4.14 : measures of atmosphere. 69 Table 4.15 : Mean ratings, standard deviations and mean difference for the overall satisfaction. 70 Table 4.16 : Independent Samples Test for overall satisfaction. 71 Table 4.17 : measures of overall satisfaction. 1 Table 4.18: Total quality regression summary. 2 Figure 1.1: Conceptual framework. 19 Figure 2.1: Internal service process. 26 Figure 2.2: Internal service process in healthcare firms. 29 Figure 2.3: 5Q model 40 Figure 4.3 : reasons why external customers were admitted or why they visited the hospital 54 Figure 4.4 : occupation of employees in the hospitals. 55 Figure 4.5 : Duration that the employees have worked in the hospitals. 56 Figure 4.6 : Marital status of external customers. 57 Figure 4.7 : marital status of employees. 57 Figure 4.8 : Age of external customers. 58 Figure 4.9 : age of employees. 59 Figure 4.10 : Number of times the external customers have visited hospital in the past 3 years. 60 1.1 Introduction Chapter one aimed at identifying the research problem which formed the basis for the development of research questions and objectives. The study background details important information about the introduction including the major concepts in the study. In aIDition, the problem statement has been stated and the purpose of the study provided. Other sections in this chapter concerns significance of the study, delimitations, conceptual framework and a summary of the chapter. 1.2 Background In the liberalized and globalized business environment, the service sector has witnessed stiff competition in attaining profitability than ever before. Reports by Hanif et al. (2010) notes that this is mainly reflected in the survival of the organization in terms of customer retention, service acceptance, service quality and brand image development. In particular, the healthcare marketplace has increasingly become aggressive and competitive. Research argued that because of high costs involved in running firms successfully, survival in the healthcare marketplace requires the retention of current customers and attraction of new customers. The inflow of new patients and patient loyalty results mainly from achieving satisfaction of the patients with the healthcare services received. Consequently, loyalty or disloyalty stems directly from dissatisfaction or satisfaction with a healthcare firm. Besides, study by Gupta et al. (2004) indicate that dissatisfied or satisfied consumers can generate negative or positive information about the service provider which may deter or affect potential patients. Successful patient outcomes can also be influenced by patient satisfaction since patients who are satisfied are likely to conform and partake rehabilitation and treatment unlike dissatisfied patients. Consequently, it seems that the main driving force in achieving business success is the provision of high service quality. Moreover, it was indicated by Barnes et al. (2004) that in this era of high competition, improvement of quality of services and measurement of service quality are some of the significant measures towards business growth and development of efficiency. In manufacturing and service sectors, improvement of quality is a critical factor that influences customer purchase intention. It was also mentioned by Nusair et al. (2010) that a number of firms are focusing on quality issues to remain relevant in business. Healthcare firms provide services such as treatment which are vital to the well being of the public and the economy of a country since healthy workforce are more productive. Hence, the hospital and healthcare sector are concerned mainly with service provision rather than the supply of physical goods. According to Boschoff and Gray (2004), services are highly intangible and characterised by interaction between the healthcare provider and the customers unlike the case of physical goods. This implies that patients can only receive the healthcare service when they are present and involved in the service delivery process. Moreover, work of Zineldin et al. (2014) notes that successful service delivery in the healthcare firms requires the cooperation of the patient during the service encounter. This is the reason why the quality of healthcare services is considered as a vital determinant of patient satisfaction. According to Dagger et al. (2007), health systems have reported rapid changes to restructure and improve their functioning and systems in order to conform to the demographic changes, emerging diseases and changes in disease patterns coupled with high cost of medical services. As governments evaluate their systems of health to adjust them to the new customer demands, the complexities and number of problems reported increases. Wu (2011) suggested that some of the health systems have not been successful in providing the services while some are constrained by inefficient resources. Consequently, most of the issues including healthcare financing, health service quality, health governance, imbalances in healthcare staff and the impacts of healthcare reforms have affected the ability of healthcare firms to deliver services Ganguli and Roy 2010; Zineldin 2006). The important role of healthcare industry in the past decade has increased due to technical and medical progress and increasing population. Zavare et al. (2010) suggested that the increased demand in health services implicates the efficiency and quality of health services provided. The health processes today are performed by different providers who act independent with different objectives. In particular, the processes include rescue services, rehabilitation, nursing care, inpatient treatment and outpatient treatment. Consequently, Manias (2010) concluded that this situation results in a major challenge in measuring and defining what constitutes the service quality and this is made more complicated by interfering objectives like the status of health of patients. Furthermore, Lee et al. (2010) claimed that the healthcare outcomes are generally complex since they can be presented by discomfort, dissatisfaction, disability, death and disease. Different outcomes are attributed to different illnesses. Nonetheless, even when people have the same disease, they differ by general health status, age and genetic makeup thus health outcomes cannot be predictable or the same. Therefore, the blend of process, structure and outcome measures are beneficial in the overall improvement of quality. In this regards, there have been increased focus on how the structure, process and outcome of health service delivery can be improved. Although it appears that firms in other industries are more concerned about increasing their competitiveness, the hospitals in the healthcare sector have also gained increased interest in providing quality services. Hence, service quality in both healthcare and non-healthcare sectors is considered as the means of delivery services efficiently and reducing costs in the resource constrained markets. Mohammadi et al. (2010) revealed that quality concept in firms operating in the healthcare sector continues to evolve as patients; various providers, insurance groups and governments maintain high interests in improvement of quality service delivery and management. It was declared by Malewski et al. (2015) that healthcare quality is a blend of consumer, clinical and professional input, with the perspectives of users becoming more dominant. It was also suggested by Rahman et al. (2002) that quality in healthcare would become a prominent consumer issue and includes access, process, outcomes, consumer satisfaction and the appropriateness of care. Moreover, the patient outcomes in healthcare firms are regarded as important determinants of the hospital performance hence the patient outcomes are also employed in assessing the care process. 1.3 Healthcare quality A number of studies have emphasized that improving healthcare services is important despite the various challenges faced by the hospital sector. For instance, Prieto et al. (2014) explained that due to the important role of the healthcare sector, continuous improvement is essential to providing better healthcare services and high quality medical services. Schoenfelder et al. (2014) found that a number of organizations have recognized the importance of high quality medical services and have initiated efforts to promote the safety and protection of patients and quality care. The technological advancement and advent of scientific developments has also contributed to the improvement of services, however, customer dissatisfaction still occurs. In healthcare firms, the importance of quality services in customer satisfaction and gaining competitiveness was also reported by Ameryoun et al. (2013). In this regards, service quality increases customer retention and customer satisfaction and result in better financial performance of organizations. Moreover, Prasanna et al. (2009) pointed that satisfaction of patients also enhances the image of the hospital and this translates into greater market share and service use. The satisfied customers tend to exhibit positive behavioural intentions and this is important to the long term success of the healthcare provider. Evaluating the extent of satisfaction among hospital patients can be vital in facilitating the management and the provision of the hospital service as well as maintain and increase the service provision quality. AIDitionally, the indication by Scrimgeour and Barnef (2013) suggests that satisfaction of patients is a concern that is dominant and interconnected with development of strategic decision. Hence, satisfaction of patients should be incorporated in the quality assessment as well as management and design of medical systems. Service quality especially in healthcare industry can be employed as a strategic tool for differentiating the services of a firm from those of other competitors. In aIDition, Gershon et al. (2010) provided that service quality can also be used to develop a distinctive competitiveness which cannot be imitated by the competitors and a number of organizations in the service sector have also begun to understand that service quality is a major source of sustainability. According to OConnor et al. (2011) analysis of total quality provided can enable the management of firms to direct the financial resources better and improve the operations of the hospitals in the areas that are most critical in impacting the perceptions of customers about service quality. Hence, this evaluation was reported by Ladha et al. (2014) as essential in the cost conscious and competitive healthcare market today. In aIDition, Choi et al. (2005) affirmed that the hospital managers have recognized that perception of patients about service quality influences the choice of the service provider. The increased focus in patient satisfaction and service quality in recent years implies that quality improvement as a concept has gained importance in service sector. Also, Ziviani et al. (2014) stresses that one of the essential tools for improving and monitoring healthcare service quality is determination of patients views and perception. Basically, the perceptions of patients and employees about the service quality are believed to impact positively on the ability of a firm to provide quality services since it helps to highlight the areas that require improvements. Pype et al. (2014) view was that there are a number of reasons why the shift towards managing perceptions of consumers about healthcare is critical. In the first place, healthcare quality increases the intention of service reuse, compliance with treatment regimens and advice, fewer lawsuits and complaints and also better patient outcomes. In aIDition, affirmation by Humpich and Byhahn (2011) was that the methods of quality improvement require patient expectations to be met and identified in advance. Thirdly, when consumers have positive perceptions about the service quality, then the financial performance can be increased in the healthcare firms. Therefore, understanding the viewpoints of customers and service providers on what constitutes service quality are important in determining and identifying the quality and level of service required. It was also stated by Joolaee et al. (2010) that removing the difference between perception of customers and perception of service providers about quality service can lead to increased customer loyalty and customer satisfaction. However, the perception of customers and employees about quality services cannot be measured from the viewpoints of managers hence they must be involved. 1.4 Internal and external customers According to Rose and Yates (2013), there has been increased interest in understanding the perspectives of both external customer and employees about service quality in various markets. However, most of the study in the past had mainly been concerning the perception of external customers about service quality while the perspectives of employees about service quality have not received much attention. Rajani et al. (2013) opines that to meet the demands of external customers effectively and maximally as possible, focusing on customer service to external customers and the products offered is not enough. In this regards, ensuring the services and products offered to external customers are guaranteed requires the whole delivery process to be effective and in order. Interestingly, understanding of Kamimura et al. (2014) was that employees also form part of the process hence when employees are included in the entire process, the external customers will get the desired service and products that fulfil their expectations and meet their needs. It was attested by Hosseinian et al. (2011) that satisfaction of employees is correlated strongly with satisfaction of external customers. The difference between satisfaction of external customers and satisfaction of employees are related. Whereas satisfaction of external customers consists of the attitude of external customers towards the total satisfaction in the organizational service and products, Rao et al. (2006) emphasized that satisfaction of employees concerns the outcomes of the internal processes of the company. For that reason, satisfaction of employees is an accurate way of determining the processes in a firm. AIDitionally, these two kinds of satisfaction with services are linked closely together, as satisfied employees are reliable sources of high external customer service. Nathorst et al. (2001) suggested that perceptions of employees about service quality indicate the working environment of firms. Moreover, satisfied employees can leads to job satisfaction and satisfied external customers. Consequently, organizations that satisfy employees achieve high service value, resulting in increased satisfaction of external customers, leading to increased loyalty, which translates into growth and profit. 1.5 Problem statement The satisfaction of customers has been proven to be important in the survival of any business in a competitive environment. Consequently, a number of studies have recommended that service quality should be evaluated continuously by firms especially by those in the healthcare sector (Nguyen 2002; Chillingerian 2000). This is mainly because of the changing needs of patients and customers in general. A number of the studies in service industry have mainly focused on the relationship between satisfaction of external customers and service quality (Kuo-Hsien 2009; Desai 2011). However, there have been few studies which have focused on the link between the level of satisfaction of external customers and employee with service quality and the dimensions of process, object, infrastructure, atmosphere and interaction (Matsa 2011; Kang 2006). Similarly, few studies have investigated how functional and technical quality impact on the satisfaction and overall perception of quality among employees and external customers (Chu-Mei 2004; Zineldin 2005). From the studies in the background, it was clear that satisfaction and dimensions of service quality are related, however, these studies were based on the SERVQUAL model. Most studies evaluating service quality have often used SERVQUAL model and assumed that perceptions of external customers about quality dimensions are similar to those of employees (Rahman 2012; Andreassen 2000). Consequently, there have been no studies which have compared perspectives of employees about service quality to those of external customers to identify the difference and aIDress these differences. This gap in literature calls for further studies to accurately assess customer satisfaction and total quality using both employee and external customers to identify effective strategies that can prevent marginal or inefficient service provision. In this regards, this study was initiated to close this gap. In essence, a different model known as 5Q model was employed in this study to measure the total quality perception and investigates how this relates to the satisfaction in the perspectives of both employee and the external customers. The following section indicates the research questions aIDressed in this current study. 1.5.1 Research questions What is the level object quality in the healthcare firms as perceived by employees and external customers? What is the level process quality in the healthcare firms as perceived by employees and external customers? What is the level interaction quality in the healthcare firms as perceived by employees and external customers? What is the level atmosphere quality in the healthcare firms as perceived by employees and external customers? What is the level infrastructure quality in the healthcare firms as perceived by employees and external customers? What is the level of overall total service quality in the healthcare firms as perceived by employees and external customers? What is the level of employees and external customers satisfaction with in healthcare firms? How do total quality dimensions in the healthcare firms as measured by 5Q model affect the satisfaction of customers? 1.6 Aim To evaluate the total service quality in the healthcare firms using 5Q model based on the perspectives of employees and external customers 1.7 Objectives To determine the level object quality in the healthcare firms as perceived by employees and external customers To determine the level process quality in the healthcare firms as perceived by employees and external customers To determine the level interaction quality in the healthcare firms as perceived by employees and external customers To determine the level atmosphere quality in the healthcare firms as perceived by employees and external customers To determine the level infrastructure quality in the healthcare firms as perceived by employees and external customers To determine the level of overall total service quality in the healthcare firms as perceived by employees and external customers To determine the level of employees and external customers satisfaction with in healthcare firms To examine how the total quality dimensions in the healthcare firms as measured by 5Q model affect the satisfaction of customers 1.8 Study significance This study was significant because it contributes to understanding how the total quality dimensions in the healthcare firms as measured by 5Q model affect the satisfaction of both employees and external customers. In this regards, it helps to understand how relationship between healthcare providers and patients are affected and how improvements can be made to close the difference in service provision. Since competition in the healthcare industry has been increasing, maintaining high performance and achieving high quality has been difficult for the healthcare firms. Hence, the study results can be useful in making improvements on the overall total quality of healthcare firms and thus boost their performance with regards to the quality dimensions evaluated. Most importantly, the organizations will attain better satisfaction among both employees and external customers. 1.9 Conceptual framework Quality concept in organizations is a very important policy statement or business philosophy that can be translated into services and actions thereby creating a distinction between different firms. Since the dissatisfaction and satisfaction of customers is based on experience of the customers during service encounter hence satisfaction is determined by service quality. This is mainly based on the fact that service quality in organizations emanates from the service outcomes. In the hospital sector, satisfaction of patients is a major factor that fuels competition among hospitals. According to UIDin and Ashrafun (2011), the satisfaction of customers and patients is created mainly through responsiveness to the needs, and view of the patient, and continuous medical improvements as well as the improvement of patient-doctor/nurse relationships. This implies that satisfaction of patients involve different dimensions of service quality in healthcare firms. The existing literature posits that patient satisfaction is related to the service quality which can be measured using various quality dimensions. The 5Q model is specifically suitable for evaluation of the total quality provided by healthcare firms since it specifically describes all the factors related to quality of medical services or healthcare services. The conceptual framework in this study was based on the dimensions of quality in the 5Q model such as infrastructure, process, object, interaction and atmosphere. The figure 1.1 depicts the conceptual framework. Figure 1.1: Conceptual framework Source: Adopted and modified from Zineldin (2006) 1.9.1 Hypotheses 1.9.1.1 Hypothesis 1 HA: There is a difference between employees and external customers rating of object quality in the healthcare firms H0: There is no difference between employees and external customers rating of object quality in the healthcare firms 1.9.1.2 Hypothesis 2 HA: There is a difference between employees and external customers rating of process quality in the healthcare firms H0: There is no difference between employees and external customers rating of process quality in the healthcare firms 1.9.1.3 Hypothesis 3 HA: There is a difference between employees and external customers rating of infrastructure quality in the healthcare firms H0: There is no difference between employees and external customers rating of infrastructure quality in the healthcare firms 1.9.1.4 Hypothesis 4 HA: There is a difference between employees and external customers rating of interaction quality in the healthcare firms H0: There is no difference between employees and external customers rating of interaction quality in the healthcare firms 1.9.1.5 Hypothesis 5 HA: There is a difference between employees and external customers rating of atmosphere quality in the healthcare firms H0: There is no difference between employees and external customers rating of atmosphere quality in the healthcare firms 1.9.1.6 Hypothesis 6 HA: There is a difference between employees and external customers rating of the overall total quality in the healthcare firms H0: There is no difference between employees and external customers rating of the overall total quality in the healthcare firms 1.9.1.7 Hypothesis 7 HA: There is a difference between employees and external customers overall satisfaction with services provided in in the healthcare firms H0: There is no difference between employees and external customers overall satisfaction with services provided in in the healthcare firms 1.9.1.8 Hypothesis 8 HA: Total service quality as measured by 5Q model impacts on the overall customer satisfaction significantly H0: Total service quality as measured by 5Q model does not impact on the overall customer satisfaction significantly 1.10 Delimitations The study on customer satisfaction in healthcare firms is broad in nature hence this study focused on the areas that have limited information that require the gaps to be closed such as in the area of application of 5Q model within the perspectives of employees and external customers to evaluate service quality. Generally, this study evaluates how the patients (external customers) and employees in healthcare firms perceive the service quality experienced based on the dimensions of 5Q model. This study is limited only to the healthcare firms since the samples included patients and hospital staff given that they are more experienced with the kinds of services provided or received. In aIDition, since 5Q was developed specifically for healthcare firms although it can be applied to other sectors, this study found it appealing to only study the healthcare firms. In fact, the hospital administrators or management were not recruited as samples since they are not best placed to predict internal and external customer satisfaction with the services provided. In aIDition, this study focused only on the perspectives of the respondents about the consumed services from the hospitals. 1.11 Thesis structure Chapter 1 presents the background and introduction to form the basis for the problem statement and study significance. Various research questions have also been outlined in this chapter as well as research questions. External customers and employees have also been discussed in detail in relation to healthcare provision. In aIDition, the concept of quality in service provision within the hospital sector has also been detailed to provide the orientation of the study. In this regards, the concerns over service quality and relationship with total quality have been discussed and the conceptual framework provided. Chapter 2 provides further details on the 5Q model adopted by the study to evaluate the total quality provided by the healthcare firms. In aIDition, the basis for adopting this model has also been derived from the existing literature on quality measurement within firms. Furthermore, the various dimensions in 5Q model are further discussed to indicate their relevance to the healthcare sector. In this regards, the literature review also helps not only in understanding the major concepts in this study but also enable the research aim to be partly aIDressed. Chapter 3 was the methodology chapter where research design has been explained including the different related methods and approaches. In essence, the instrument considered in gathering data has been provided and explanations given on the reasons why it was deemed necessary and appropriate. Most importantly, ways in which the hypothesis was tested has been indicated and other statistical tests revealed in this chapter. It was therefore expected that the results presented in chapter 4 were accurate in attaining the desired findings since all issues concerning ethical consideration; data collection, sample, and sampling were all aIDressed. As noted, chapter 4 mainly reports results and the findings of the study while chapter 5 adequately explains these results. 1.12 Summary It can be concluded that chapter one has indicated the research purpose and identified the various questions that the subsequent chapter should aIDress. In essence, the objectives of the study were derived from the research questions in line with the problem being investigated. Hence, it is expected that the aim of the study would be effectively achieved when these research questions and objectives are aIDressed in the subsequent chapters. Thesis structure has also been outlined in detail including the chapters that will present the results. The next chapter that follows concerns literature review to discuss healthcare quality in detail and its measurement. 2.1 Introduction This chapter presents the literature review based on the study problem and the objectives hence the chapter attempts to provide insight into the concept under investigation. In essence, literature review begins with service delivery and service quality in the healthcare firms and the 5Q model illustrated including its various factors which impact on external and employee satisfaction. The chapter ends with a summary. 2.2 Literature review Hanif et al. (2010) notes that healthcare providers and firms have developed increased interest in quality and initiated various strategies to improve service quality in the recent years. This is mainly because competition has become stiff in the healthcare sector. Moreover, Uzun (2013) posited that service users have become loyal to firms and governments have minimised political interference and improved regulatory contro
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