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Distinguishing service quality from patient satisfaction in developing health care marketing strategies Steven A. Taylor

Hospital & Health Services Administration. 39.2 (Summer 1994): p221+.

Copyright: COPYRIGHT 1994 Lippincott Williams & Wilkins, WK Health http://www.lww.com

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Abstract:

Health care quality is distinct from consumer satisfaction, but health service organizations need to be able to incorporate patient satisfaction into their quality standards. This is important as more health organizations engage in strategic marketing. Data from the health services literature on patient satisfaction and health care quality was analyzed. Four models of perceived service quality were tested. Health care marketers are urged to include their own research data before making decisions based on any model. Ultimately, a new multidimensional scale of service quality may be needed.

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Summary

The marketing function in health care is increasingly becoming strategic in nature. The quality of care provided and the level of patient satisfaction are emerging as the core of many marketing strategies in health services as a means to achieve a distinctive competency in ever-more competitive markets. Therefore, it is not surprising that few issues have generated more discussion in both practitioner and research circles. Nonetheless, according to the health services literature, service quality and patient satisfaction have confounded many, the outcome of which may be an inability of health care managers to effectively derive, implement, and control marketing strategies. This article identifies emerging literature that assists in overcoming these limitations.

Strategic marketing is playing an increasingly important role in the effective management of health service organizations. Zallocco and Joseph (1991) suggest four reasons for the recent rise of strategic marketing in the health care industry: (1) a maturing in the area of traditional hospital planning, from an emphasis on physical plant and facilities to planning as a means to compete in dynamic competitive markets; (2) a greater understanding by hospitals industry itself with consequent saturation, overcapacity, and intense competition; and (4)

a growth in hospital marketers' knowledge of the practical implementation of strategic planning processes. San Augustine, Long, and Pantzallis (1992) further suggest that health care organizations will increasingly rely on positioning as a key marketing strategy in order to gain a sustainable competitive advantage.

The literature suggests that a primary positioning strategy used to attain a sustainable competitive advantage for service organizations, such as those in the health care industry, is through the provision of best-in-the-world service quality and customer satisfaction in the minds of consumers (cf., Cronin and Taylor 1992, 1994; Quinn 1992). Thus, the provision of service quality and satisfaction appear as critical objectives in the strategic planning processes of health care organizations (cf., Gilbert, Lumpkin, and Dant 1992; Lytle and Mokva 1992). Consequently, it is not surprising that the recent health services literature is replete with discussions on the importance of service quality and customer satisfaction in the delivery of health care.

The relationship of service quality to patient satisfaction in the consumption of health services appears fairly well understood. Specifically, consumer satisfaction is believed to mediate the relationship between service quality evaluations and the ultimate behavioral intentions of customers toward service providers (cf., John 1991; Woodside, Frey, and Daly 1989). However, in spite of the attention patient satisfaction and service quality have received in the health services literature, this article suggests that confusion remains in terms of distinguishing service quality from customer satisfaction. Indeed, Kleinsorge and Koenig (1991) refer to "quality" and "customer satisfaction" as synonymous terms. I take an alternative position by suggesting that the ability for health care practitioners and researchers to conceptually and empirically distinguish service quality from satisfaction is important because health care marketers need to know whether marketing strategies (i.e., positioning) should be largely derived, implemented, and controlled based on providing service quality or satisfying patients. More specifically, since service quality perceptions are considered long- term consumer attitudes and patient satisfaction refers to short-term, service encounter-specific consumer judgments (cf., Cronin and Taylor 1992, 1994; Oliver 1993; Patterson and Johnson 1993), clear conceptual distinctions between service quality and satisfaction appear necessary as differential bases of marketing strategies.

This article first reviews how service quality and patient satisfaction are currently related, conceptualized, and measured in health care settings. The conclusion of this review is that service quality and patient satisfaction appear poorly distinguished in many health care applications. Second, a discussion presented that may assist in overcoming this apparent confusion. Finally, the conclusion of this discussion identifies managerial and research implications for health care

marketers that should assist in better measurement and use of patient satisfaction and service quality information.

Satisfaction versus Service Quality in the Health Services Literature

Woodside, Frey, and Daly (1989) empirically support the casual ordering of the relevant constructs in the selection of health services providers as service quality [right arrow] patient satisfaction [right arrow] purchase decision. Specifically, patients' service quality perceptions are believed to positively influence patient satisfaction, which in turn positively influences the patient's decision to choose a specific health care provider (e.g., physician, hospital, ancillary service). Based on this model of consumer behavior in health services, marketing professionals have developed, implemented, and controlled marketing strategies within their own competitive environments. However, a review of the literature suggests that the efficacy of such strategies in the practice of health care marketing may be attenuated by the confounding of service quality and patient satisfaction in terms of both conceptualization and measurement. That is, the confounding of short- term consumer satisfaction judgments with long-term consumer service quality attitudes makes it difficult for health care marketers to sort out the long-term versus short-term impacts of alternative marketings strategies.

Conceptualizing and Measuring Patient Satisfaction

Patient satisfaction has been conceptualized and measured by a number of alternative means in the existing health services literature. Ware, Davies-Avery, and Stewart (1978) provide an early comprehensive investigation of the measurement and meaning of the patient satisfaction construct. These authors suggest that three reasons are apparent for measuring patient satisfaction with health services: (1) satisfaction is the ultimate outcome of the delivery of health care; (2) satisfaction ratings provide useful information about the structure, process, and outcomes of care; and (3) satisfied and dissatisfied patients behave differently. They further argue that previous studies have failed to adequately consider the validity and reliability of patient satisfaction data.

Ware and Hays (1988) present an empirical investigation of patient satisfaction that assesses six-point response scales anchored by "very satisfied" to "very dissatisfied" poles against five-point response scales anchored by "poor" to "excellent" poles. Based on a number of multi-item scales of patient satisfaction in use at that time, Ware and Hays (1988) conclude that anchoring operationalizations of the patient satisfaction construct with "excellent to poor" proves a more reliable and valid measure of patient satisfaction. However, a review of their discussion fails to identify a clear conceptual definition of the patient satisfaction construct underlying their analyses.

Woodside, Frey, and Daly (1989) present a seminal study that defines patient satisfaction as a special form of consumer attitude--that is, as a postexperience phenomenon reflecting how much a patient likes or dislikes the service. Woodside, Frey, and Daly (1989) measure patient satisfaction using a series of questionnaire items that range from "very dissatisfied" (0) to "very satisfied" (10).

Fisk et al. (1990) report a five-year study of patient satisfaction in relation to consumer loyalty. They support the position that patient satisfaction and loyalty are basic to the ultimate satisfaction of the other constituencies of health services organizations (e.g., doctors, third party payers, families). Fisk et al. (1990) propose a model of patient-satisfaction management based on the premises that (1) satisfaction is a second-order construct comprised of the levels of satisfaction with the individual components of a service, and (2) the individual service features vary in importance. These authors use 40 to 90 questions to operationalize the satisfaction construct; however, they fail to report the items or a specific conceptual definition of the patient satisfaction construct. However, Fisk et al. (1990) note that "the classic model of satisfaction is that it results when service experience meets consumer expectations." Thus, they appear to suggest that patient satisfaction is classically defined in health services by the disconfirmation of expectations paradigm (Oliver 1980), or by achieving a level of perceived service performance that exceeds customer expectations (see equation 1).

Singh (1990) presents an analysis of the patient satisfaction construct that is an excellent attempt to specifically address the questions of conceptualizing and measuring patient satisfaction. Based on an extensive literature review, Singh (1990) suggests that early conceptualizations of patient satisfaction viewed the construct as an attitude that could be operationalized by an index of service quality evaluations. Singh (1990) further suggests that subsequent research has led to the belief that the domain of patient satisfaction is broader and that patient satisfaction might best be treated through a taxonomy. Singh (1990) specifically states that "it also suggests growing consensus for the notion that patient satisfaction is a multidimensional (probably tripartite) evaluation of various aspects (quality and non-quality) of health care received in a specific episode." Ultimately, Singh (1990) argues that patients can be categorized as either "satisfied" or "dissatisfied" based on three facets--the physician, the hospital, and the insurance provider. Singh (1990) operationalizes the measures of the three identified facets through six-point Likert-type scales that are anchored by poles ranging from "very dissatisfied" (1) to "very satisfied" (6).

Reidenbach and Sandifer-Smallwood (1990) investigate three models of the relations implicit between patient satisfaction, service quality, and the willingness to recommend the service facility to others. These authors find that a dimension

they term "patient confidence" has a significant and generalizable impact on their measures of patient satisfaction.

Reidenbach and Sandifer-Smallwood (1990) operationalize patient satisfaction by three Likert-scale items: (1) how the patient rates the overall service received in the hospital (1 = very good to 5 = very bad); (2) how satisfied the patient is with the treatment received (1 = very satisfied to 5 = very dissatisfied); and (3) willingness to recommend this hospital (1 = very willing to 5 = very unwilling).

Kleinsorge and Koenig (1991) consider patient satisfaction relative to nursing homes, conceptually defining patient satisfaction as service quality. Specifically, Kleinsorge and Koenig (1991) state, "Hereafter, we use 'quality' and 'customer satisfaction' synonymously. We do so in part because customer satisfaction is a function of the perceived quality of any product or service (Woodside, Frey, and Daly 1989)." Based on this premise, Kleinsorge and Koenig (1991) operationalize patient satisfaction based on measures developed from the SERVQUAL scale, a multidimensional scale of perceived service quality (Parasuraman, Zeithaml, and Berry 1988).

The SERVQUAL scale is a 44-item multidimensional scale of perceived service quality that purports to be reliable and valid when generalized across service settings, such as health care. The scale employs paired expectations/perceptions items to capture disconfirmation (see equation 1). Readers interested in discussions concerning the specific development of the SERVQUAL scale are referred to the following studies: Babakus and Mangold (1992); Babakus and Boller (1992); Brown, Churchill, and Peter (1993); Carman (1990); Cronin and Taylor (1992, 1994); Oliver (1993); Parasuraman, Zeithaml, and Berry (1988, 1994).

Gilbert, Lumpkin, and Dant (1992) address the conceptualization and operationalization of patient satisfaction in their investigation of adaptation and customer expectations. They support the traditional argument that Oliver's (1980) disconfirmation of expectations paradigm applies to the measurement of patient satisfaction in health care service encounters. Specifically, Gilbert, Lumpkin, and Dant (1992) define disconfirmation of expectations as follows:

Dis/confirmation = [sigma] ([e.sub.i] - [p.sub.i]) (1)

where [e.sub.i] = expectation of performance; [p.sub.i] = evaluation of performance; and i = salient attribute evaluated

Referring to equation 1, when (e [less than or equal to] p), confirmation occurs with satisfaction being the outcome, and when (e [greater than] p),

disconfirmation occurs leading to dissatisfaction. Expectations ([e.sub.i]) and perceptions of service-firm performance ([p.sub.i]) are operationalized in their study by three-point Likert scales anchored by 1 (very likely) to 3 (very unlikely) that are related to seven attributes (i).

John (1992) furthers the discussion of the role of patient satisfaction in the development of patients' purchase intentions. John (1992) suggests that prior satisfaction with the health care system in general and the specific health care provider appears to have a significant effect on patient evaluations of their current hospital experience. Similar to Gilbert, Lumpkin, and Dant (1992) and Fisk et al. (1990), John (1992) first defines patient satisfaction as an attitude determined by the (dis)confirmation of patient expectations. Thus,

Patient Satisfaction = f({dis}confirmation of expectations) (2)

Contrary to the position advanced by Kleinsorge and Koenig (1991), John (1992) next conceptually distinguishes patient satisfaction from service quality by defining perceived quality as "the evaluation of a hospital experience as determined by perceptions of the hospital performance." John (1992) further argues that perceptions of hospital performance, when mediated by patient expectations coming into the service encounter, result in perceived quality. Thus, the patient's perceived quality of his or her current hospital experience can be modelled as follows:

Perceived Quality = f(expectations, perceptions of current firm performance) (3)

John (1992) also operationally distinguishes patient satisfaction from service quality. First, John (1992) appears to operationalize patient satisfaction by a single-item five-point Likert-type response scale. Service quality is operationalized by John (1992) using a modified version of the SERVQUAL scale. John (1992) ultimately concludes that patient satisfaction and service quality evaluations with the current episode of care are a function of the level of satisfaction a consumer carries into the service encounter (e.g., the previous level of patient satisfaction).

In summary, the conceptualization of patient satisfaction appears traditionally viewed in the literature as an attitude (e.g., an emotional response) that derives as a function of the disconfirmation of expectations (see equation 2). While patient satisfaction can be viewed as a multidimensional construct (Singh 1990), the majority of studies appear to treat patient satisfaction as a second-order global measure that can be operationalized by either single-item measures of disconfirmation of expectations or the SERVQUAL scale.

Conceptualizing and Measuring Service Quality

As stated previously, the conceptualization and measurement of service quality has also enjoyed a great deal of attention in the recent health services literature. An appropriate place to begin this discussion may be Woodside, Frey, and Daly's (1989) seminal framework of the relationships between service quality, patient satisfaction, and purchase intentions. They define service quality as "the consumer's comparison between service expectations and service performance." They measure the service quality construct based on a modified version of the SERVQUAL scale and ultimately argue that service quality is related to consumer purchase intentions through the moderating influences of patient satisfaction.

Bopp (1990) investigates the formation of consumers' perceptions of service quality specific to ambulatory medical-service encounters. Based on an extensive literature review, Bopp (1990) contends that the traditional conceptual definition of the service quality construct is "conformance to professional specifications." Bopp proposes that quality, from the health professional's perspective, is technical in nature and is operationalized in terms of three constructs--structure, process, and outcome. However, Bopp (1990) also convincingly argues that consumers define service quality in terms of functional quality (e.g., expressive- interpersonal and environmental factors) rather than technical quality and that technical quality perceptions depend on functional quality perceptions.

Regarding this functional (or expressive) type of quality, Bopp (1990) states, "A medical encounter achieves quality in perception when it meets or exceeds the patient's expectations." Bopp (1990) operationalizes this conceptual definition by capturing 72 paired expectation/performance items. Thus, Bopp (1990) conceptualizes and operationalizes service quality by the same type of expectancy disconfirmation measures as employed by the SERVQUAL scale (see equation 1). Bopp's (1990) analyses ultimately identify three factors in the domain of service quality--expressive caring, expressive professionalism, and expressive competence.

John (1991) presents a study that suggests that service quality perceptions in hospitals can be improved through improving communication between patients and providers. John (1991) conceptually defines service quality in health care environments based on Brook and Williams' (1975) definition:

Quality of Health Care = (Technical care) + (Art of care) + (Technical care x Art of care) + [epsilon] (4)

where: Technical care refers to the adequacy of diagnostic and therapeutic processes; art of care refers to the milieu, manner, and behavior of the provider in delivering the care, and in communicating to the patient; the interaction term emphasizes that the two terms are not additive; the error term [epsilon] represents random error.

The independent variables used by John (1991) to operationalize this definition are based on the SERVQUAL scale and designed to measure disconfirmation. The scale items employ five-point Likert-type responses anchored by "strongly agree" (5) and "strongly disagree" (1).

Woodside (1991) attempts to address the question of whether quality even matters in health care environments. Woodside (1991) states that four issues concerning the quality of health services are relevant to marketers: (1) What is quality? (2) Does quality really matter? (3) How should we measure quality? and (4) How do we accurately measure the impact of marketing actions based on service-quality issues?

Concerning the first question, Woodside (1991) suggests that no single definition of service quality fits all circumstances or situations and reaches this conclusion based on both micro and macro definitions of quality. Woodside (1991) appears to define micro quality in terms of actual service firm performance from a short- term perspective, while macro quality appears to be defined more in terms of a long-term attitude. Based on these definitions, Woodside (1991) proposes three major components of quality in health care: "(1) Conformance quality--doing things right in the first place, meeting the requirements stated in the specifications, zero defects. (2) Design quality--simplicity of style, assembly, and operation. (3) Fitness-of-use quality--the product-service matching or surpassing the expectations and benefits sought by the customer (cf., Day 1990)."

Woodside (1991) ultimately suggests that service quality is important to health services organizations and that health care marketers should engage in more measurement of service quality. Woodside (1991) also appears to call for multidimensional operationalizations of the service quality construct.

Lytle and Mokva (1992) investigate how outcomes moderate service quality evaluations relative to a large fertility center. They suggest that patient perceptions of health care quality are formed by a process involving three evaluations--service outcome, service process, and physical environments. Health care quality, in their view, is conformance to patient requirements. Lytle and Mokva (1992) subsequently present a conceptual model of health care quality that views the service quality construct as comprised of measures of three dimensions--physician interactions, staff interactions, and the physical

environment. They also operationalize their model using five-point Likert-type measures based on the SERVQUAL scale.

Boscarino (1992) provides a large recent study of the service quality perceptions of hospital patients across 40 U.S. market areas. While he does not appear to provide a specific conceptual definition of the service quality construct, a definition is apparent in his operationalization. Boscarino (1992) uses five-point Likert-type questions that are anchored by poles consisting of "overall, this hospital is better than other hospitals" to "overall, this hospital is much worse than other hospitals." These types of questions are generally believed to capture disconfirmation perceptions in consumers (cf., Westbrook and Oliver 1991).

Babakus and Mangold (1992) provide the final study of service quality considered in the current discussion, suggesting that two forms of quality are relevant to health service organizations--technical quality and functional quality. According to Babakus and Mangold (1992), technical quality in a health care setting is "defined primarily on the basis of the technical accuracy of the diagnosis and procedures." They say functional quality "refers to the manner in which the health service is delivered to the patient" (Babakus and Mangold 1992).

Like Bopp (1990), Babakus and Mangold (1992) persuasively argue that technical quality is a function of functional quality, and therefore, hospital marketers should ultimately concentrate on assessing patients' perceptions of functional quality. Babakus and Mangold (1992) suggest that the SERVQUAL scale, while widely applied to health service settings as a measure of functional quality, has not been empirically validated specific to health services applications. Thus, they undertake an empirical assessment of the efficacy of the SERVQUAL scale relative to health services. The conclusion of their assessment is that the disconfirmation format that underlies the SERVQUAL scale may be an inappropriate operationalization of functional quality in health care. Rather, Babakus and Mangold (1992) found that (1) expectations may not be significantly related to the strength of the relationship between service quality and third variables (i.e., return intentions) and (2) the perceptions-of-performance subscale of the SERVQUAL scale may be best described as unidimensional rather than multidimensional.

The preceding review of the health service literature related to the service quality construct identifies a number of commonalities. First, some consensus is apparent concerning the argument that patient perceptions of service quality should be based on functional quality as opposed to technical quality. In this view, technical quality is related to functional quality. Strategically, this supports

the paramount importance for health service organizations to first appropriately measure patients' perceptions of service quality.

Second, the service quality construct is widely believed to be multidimensional in nature, although the number of dimensions appear to vary from study to study. Further, there is little evidenceapparent in the literature to suggest that the number of dimensions implicit in functional quality perceptions is related to the number of dimensions implicit in technical quality perceptions. However, it does appear clear that most of the studies reviewed conceptualize service quality as a function of disconfirmation (see equation 1). Finally, the vast majority of studies investigated operationalize the service quality construct using measures based on the SERVQUAL scale.

In summary, the weight of the evidence in the literature supports the position that the disconfirmation of expectations paradigm is currently being used in the health services literature as the predominant conceptual underpinning of both the patient satisfaction and service quality constructs. Further, the SERVQUAL scale appears to be a dominant operationalization of the disconfirmation of expectations paradigm to measure both patient satisfaction and perceptions of functional service quality in health care settings. Fortunately, recent evidence emerging in the general services literature concerning disconfirmation and the SERVQUAL scale provides health care marketing practitioners and researchers the ability to uniquely conceptualize and operationalize service quality from patient satisfaction.

Distinguishing Service Quality from Patient Satisfaction

The confusion between consumer satisfaction and service quality in health care strategic marketing practices is not unique; service industries in general appear to similarly exhibit this phenomenon. Studies that specifically attempt to overcome this dilemma are discussed below.

Cronin and Taylor (1992) provide a four-industry study of service quality measurement that tests a number of competing service quality operationalizations identified in the literature. The four models of service quality tested were SERVQUAL, importance-weighted SERVQUAL, SERVPERF, and importance-weighted SERVPERF. Cronin and Taylor (1992) have coined the term SERVPERF to denote the service-firm performance subscale of the full SERVQUAL survey instrument. In other words, they call the 22 perceptions-of- performance items of the 44 (total) paired expectations/perceptions items SERVPERF.

The results of their LISREL VII-based empirical analyses first demonstrate that performance-based measures of service quality (e.g., SERVPERF) appear to be a more appropriate operationalization of service quality than do disconfirmation- based operationalizations (e.g., SERVQUAL). The addition of importance weights appears to add little to either model. Second, the SERVQUAL operationalization does not exhibit a consistent factor structure across service settings. This finding casts suspicion on the efficacy of the SERVQUAL scale as a reliable and generalizable multidimensional operationalization. Third, an investigation of their causal path model demonstrates that satisfaction consistently appears more closely related to purchase intentions than does service quality. This finding supports the traditional causal ordering of the relevant constructs previously identified in the literature (e.g., service quality [right arrow] satisfaction [right arrow] purchase intentions).

Cronin and Taylor (1992) conclude that much of the confusion apparent in the literature appears traceable to Parasuraman, Zeithaml, and Berry's (1985, 1988) conceptualization and operationalization of the service quality construct. Parasuraman, Zeithaml, and Berry (1985, 1988) first conceptually define service quality as similar to an attitude and then operationalize the service quality construct by measures of disconfirmation. However, a review of the satisfaction literature demonstrates that the disconfirmation format has historically been used specifically as an operationalization of consumer satisfaction (cf., Cronin and Taylor 1992, 1994; Oliver 1993; Westbrook and Oliver 1991).

Cronin and Taylor (1992, 1994) suggest that a solution to the problem begins with conceptually distinguishing service quality from consumer satisfaction. Based on their empirical results and a review of the satisfaction and attitude literatures, they first propose that service quality should be viewed as an attitude. Cronin and Taylor (1992, 1994) then suggest that the service quality attitude should be operationalized by measures of service-firm performance (e.g., SERVPERF). Conversely, satisfaction is conceptually defined by them by its traditional definition (e.g., disconfirmation). The distinction is that service quality is proposed by Cronin and Taylor (1994) to be a long-term attitude, while satisfaction is proposed to be a transitory, service encounter-specific perception. Thus, at best, they imply that the SERVQUAL scale is probably a better operationalization of consumer satisfaction than of service quality.

Support for the findings of Cronin and Taylor (1992) is apparent in a number of more recent studies. Babakus and Boller (1992) undertake a recent empirical assessment of the SERVQUAL scale and report that the scale appears to suffer from a number of methodological shortcomings. First, Babakus and Boller (1992) conclude that the dimensionality of the SERVQUAL scale may depend on the service industry under investigation. They further support the call of Cronin and

Taylor (1992) to thus treat the SERVQUAL scale as a unidimensional measure rather than a multidimensional scale. Second, Babakus and Boller (1992) conclude that expectations appear to add little to the explanatory power of the disconfirmation process relative to service quality evaluations. These findings support Cronin and Taylor's (1992) position that the disconfirmation format appears suspect as an operationalization of service quality and that performance-based measures may be more appropriate.

Brown, Churchill, and Peter (1993) also assess the psychometric properties of the SERVQUAL scale and report similarly disappointing results. Like Cronin and Taylor (1992) and Babakus and Boller (1992), they find that (1) the dimensionality of the SERVQUAL scale is probably best described as unidimensional rather than multidimensional, (2) the use of difference scores (e.g., disconfirmation) to operationalize service quality is a suspect practice, and (3) service quality is probably best measured by service-firm performance.

Perhaps the most telling evidence derives from Babakus and Mangold (1992), who specifically assess the SERVQUAL scale in the health services industry. Their results suggest that (1) service quality might best be captured by measures of service-firm performance, (2) the disconfirmation format is suspect as an operationalization of the service quality construct, and (3) the expectations and performance subscales implicit in the SERVQUAL scale might best be treated as unidimensional rather than multidimensional.

In summary, the weight of the recent evidence suggests that service quality and patient satisfaction can (and should) be uniquely conceptualized and operationalized in the practice of health care. Specifically, service quality appears best conceptualized as a long-term attitude that can be operationalized by measures of service-firm performance. The perceptions portion of the SERVQUAL scale appears a valid place to begin the development of such a survey; however, health care marketers should be cognizant of the fact that this subscale is probably best described as unidimensional rather than multidimensional. In short, the best that the literature appears to be able to offer health care marketers at this time is the SERVPERF scale as an index of service quality. Cronin and Taylor (1992, 1994) and Taylor and Cronin (1994) argue that the SERVPERF scale should be considered an index of service quality rather than a scale. The difference is that an index is an exact linear combination of observed items--that is, a general service quality score can be derived based on the SERVPERF scale items when summed and averaged; however, attempting to seek out additional information from the data appears a suspect practice.

Patient satisfaction, as a shorter-term judgment of a service encounter than service quality, appears best conceptualized at this time as very closely related

to disconfirmation judgments (see equation 1) and operationalized by measures that capture the gap between patients' perceptions of performance relative to their expectations. Interestingly, the SERVQUAL scale is even suspect as an operationalization of disconfirmation, the construct for which it was originally designed to measure. Westbrook and Oliver (1991) recently demonstrate that single items designed to capture the disconfirmation process (e.g., worse than/better than scales) appear more appropriate than paired expectations/perceptions items. These findings cast suspicion on the efficacy of the SERVQUAL scale as an operationalization of either service quality or patient satisfaction. Thus, the evidence to date suggests that marketers should reconsider the use of the SERVQUAL scale in health services settings.

Managerial Implications and Recommendations

A number of managerial and research implications are implicit based on the preceding discussion. The first managerial implication is that effective strategic management of health services organizations can benefit from the ability to uniquely conceptualize and measure service quality from patient satisfaction. The reason is that health services practitioners require the ability to design, implement, and control effective positioning strategies that are largely based on providing the highest possible level of service quality and/or the greatest level of patient satisfaction. Confounding these constructs may preclude the ability to effectively measure and control the adequacy of performance of marketing positioning strategies because health care marketers will be unable to ascertain the long- versus short-term effects of their marketing strategies.

Second, managers should refrain from using the SERVQUAL scale as a basis for surveys designed to measure service qualtiy perceptions. Evidence that calls into question both the appropriateness of measuring service quality by measures of disconfirmation and the efficacy of the SERVQUAL scale to capture disconfirmation perceptions is growing. Specifically, the use of the expectations portion of the SERVQUAL scale appears to offer little in the way of psychometric efficacy and may actually impede the collection of data because 22 additional questions must be answered to capture the expectations portion of the SERVQUAL scale.

Rather, health care practitioners are encouraged to begin with the SERVPERF scale (see Cronin and Taylor 1992) as a basis for developing measures of service quality. However, health care marketing practitioners are also cautioned to empirically validate their scales specific to their own research data prior to managerial decision-making. Clearly, the practice of assuming that the SERVQUAL scale will exhibit the five-factor structure purported by its developers in every health setting is not warranted. Rather, it appears more probable that the

data collected by the SERVPERF scale will prove unidimensional. Similarly, health services practitioners are additionally cautioned not to sum and average scores derived from the SERVQUAL scale into overall factor scores (e.g., Tangibles, Reliability, Responsiveness, Assurance, and Empathy), contrary to the recommendations of Zeithaml, Parasuraman, and Berry (1990).

From a research perspective, it appears that the search begins anew for a multidimensional scale of service quality for the health care industry and for service industries in general. However, such a survey instrument may be overly ambitious, particularly for health services. Given that functional and technical quality perceptions appear implicit in patients' perceptions of overall service quality, and given that technical quality is related to functional quality, finding a series of scale items that uniquely distinguish the potential multitude of dimensions of overall service quality perceptions may prove unattainable. Nonetheless, marketing researchers are encouraged to continue attempts to develop such an instrument.

Continued efforts toward the development of multidimensional operationalizations of patient satisfaction also appear appropriate. Singh (1990) has laid the foundation for such advances in our understanding of the multitude of influences inherent in the development of patient satisfaction. The finding of Westbrook and Oliver (1991) and Oliver (1993) concerning the role of emotion in satisfaction judgments may also assist in these endeavors. Health services practitioners and researchers are also encouraged to further investigate the temporal nature of patient satisfaction in relation to service quality. The literature supporting the position that service quality is a long-term attitude while satisfaction is a short-term consumer judgment has yet to be validated specific to health services settings.

Perhaps the final research consideration might concern the increasing role that total quality management (TQM) appears to be playing in health services industries. Operationally distinguishing providers' perceptions of service quality and satisfaction from patients' perceptions of service quality and satisfaction will undoubtedly prove important if TQM strategies are to be successfully employed in health service organizations (cf., Brown and Swartz 1989; Counte et al. 1992). In other words, efforts to manage the provision of quality should benefit from clear and concise conceptual and operational definitions of service quality and patient satisfaction. Brown and Swartz (1989) provide an initial step in this direction by suggesting that the number of gaps implicit in measuring the differences between the providers versus the receivers of health care may not be the same as other service industries. Certainly, a great deal of research is warranted relative to these important issues.

References

Babakus, E., and G. W. Boller. "An Empirical Assessment of the SERVQUAL Scale." Journal of Business Research 24 (May 1992): 253-68.

Babakus, E., and W. G. Mangold. "Adapting the SERVQUAL Scale to Hospital Services: An Empirical Investigation." Health Services Research 26, no. 6 (1992): 676-86.

Bopp, K. D. "How Patients Evaluate the Quality of Ambulatory Medical Encounters: A Marketing Perspective." Journal of Health Care Marketing 10, no. 1 (1990): 6-16.

Boscarino, J. A. "The Public's Perception of Quality Hospitals II: Implications for Patient Surveys." Hospital & Health Services Administration 37, no. 1 (1992): 13- 36.

Brook, R. H., and K. N. Williams. "Quality of Health Care for the Disadvantaged." Journal of Community Health 1 (1975): 32-156.

Brown, S. W., and T. A. Swartz. "A Gap Analysis of Professional Service Quality." Journal of Marketing 63 (1989): 92-98.

Brown, T. J., G. A. Churchill, Jr., and J. P. Peter. "Research Note: Improving the Measurement of Service Quality." Journal of Retailing 69, no. 1 (1993): 127-39.

Carman, J. H. "Consumer Perceptions of Service Quality: An Assessment of the SERVQUAL Dimensions." Journal of Retailing 66, no. 1 (1990): 33-66.

Counte, M. A., G. L. Glandon, D. M. Oleske, and J. P. Hill. "Total Quality Management in a Health Care Organization: How Are Employees Affected?" Hospital & Health Services Administration 37, no. 4 (1992): 603-18.

Cronin, J. J., Jr., and S. A. Taylor. "Measuring Service Quality: A Reexamination and Extension." Journal of Marketing 56 (July 1992): 55-68.

-----. "SERVPERF versus SERVQUAL: Reconciling Performance-Based and Perceptions-Minus-Expectations Measurement of Service Quality." Journal of Marketing 58 (January 1994): 125-31.

Day, G. S. Market Driven Strategy. New York: The Free Press, 1990.

Fisk, T. A., C. J. Brown, K. Cannizzaro, and B. Naftal. "Creating Patient Satisfaction and Loyalty." Journal of Health Care Marketing 10, no. 2 (1990): 5- 15.

Gilbert, F. W., J. R. Lumpkin, and R. P. Dant. "Adaptation and Customer Expectations of Health Care Options," Journal of Health Care Marketing 12, no. 3 (1992): 46-55.

John, J. "Improving Quality Through Patient-Provider Communication." Journal of Health Care Marketing 11, no. 4 (1991): 51-60.

-----. "Research in Brief: Patient Satisfaction: The Impact of Past Experience." Journal of Health Care Marketing 12, no. 3 (1992): 56-64.

Kleinsorge, I. K., and H. F. Koenig. "The Silent Customers: Measuring Customer Satisfaction in Nursing Homes." Journal of Health Care Marketing 11, no. 4 (1991): 2-13.

Lytle, R. S., and M. P. Mokva. "Evaluating Health Care Quality: The Moderating Role of Outcomes." Journal of Health Care Marketing 12, no. 1 (1992): 4-14.

Oliver, R. "A Cognitive Model of the Antecedents and Consequences of Satisfaction Decisions." Journal of Marketing Research 17 (November 1980): 460-69.

-----. "A Conceptual Model of Service Quality and Service Satisfaction: Compatible Goals, Different Concepts." In Advances in Service Marketing and Management: Research and Practice, Vol. 2, edited by T. A. Swartz, D. E. Bowen, and S. W. Brown. Greenwich, CT: JAI Press, 1993.

Parasuraman, A., V. A. Zeithaml, and L. L. Berry. "A Conceptual Model of Service Quality and Its Implications for Future Research." Journal of Marketing 49 (Fall 1985): 41-50.

-----. "Reassessment of Expectations as a Comparison Standard in Measuring Service Quality: Implications for Future Research." Journal of Marketing 58 (January 1994): 111-24.

-----. "SERVQUAL: A Multi-Item Scale for Measuring Consumer Perceptions of Service Quality." Journal of Retailing 64 no. 1 (1988): 12-37.

Patterson, P. G., and L. W. Johnson. "Disconfirmation of Expectations and the Gap Model of Service Quality: An Integrated Paradigm." Working Paper No. 93- 01, The University of Sydney Graduate School of Management, Australia, 1993.

Quinn, J. B. Intelligent Enterprise. New York. The Free Press, 1992.

Reidenbach, R. E., and B. Sandifer-Smallwood. "Exploring Perceptions of Hospital Operations by a Modified SERVQUAL Approach." Journal of Health Care Marketing 10, no. 4 (1990): 47-66.

San Augustine, A., W. J. Long, and J. Pantzallis. "Hospital Positioning: A Strategic Tool for the 1990s," Journal of Health Care Marketing 12, no. 1 (1992): 16-23.

Singh, J. "A Multifacet Typology of Patient Satisfaction with a Hospital." Journal of Health Care Marketing 10, no. 4 (1990): 8-21.

Taylor, S. A., and J. J. Cronin, Jr. "Modeling Patient Satisfaction versus Service Quality in Health Care Settings." Journal of Health Care Marketing (1994).

Ware, J. E., A. Davies-Avery, and A. L. Stewart. "The Measurement and Meaning of Patient Satisfaction." Health & Medical Care Services Review 1, no. 1 (1978): 1-15.

Ware, J. E., and R. D. Hays. "Methods for Measuring Patient Satisfaction with Specific Medical Encounters." Medical Care 26, no. 4 (1988): 393-402.

Westbrook, R. A., and R. L. Oliver. "The Dimensionality of Consumption Emotion Patterns and Consumer Satisfaction." Journal of Consumer Research 18, no. 1 (1991): 84-91.

Woodside, A. G. "Commentary: What Is Quality and How Much Does It Really Matter?" Journal of Health Care Marketing 11, no. 4 (1991): 61-67.

Woodside, A. G., L. L. Frey, and R. T. Daly. "Linking Service Quality, Customer Satisfaction, and Behavioral Intention." Journal of Health Care Marketing 9, no. 4 (1989): 5-17.

Zallocco, R. L., and W. B. Joseph. "Strategic Market Planning in Hospitals: Is It Done? Does It Work?" Journal of Health Care Marketing 11, no. 1 (1991): 6-11.

Zeithaml, V., A. Parasuraman, and L. L. Berry. Delivering Service Quality: Balancing Customer Perceptions and Expectations. New York: The Free Press, 1990.