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Introducing Let's Talk Health, an initiative from Apollo Hospitals, where our endeavor is to share knowledge which you can use to keep yourself and your family fit & healthy.

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in Patient Safety

Healthcare Quality Service, Customer Satisfaction and Loyalty: A Conceptual Study on quality improvement process of Healthcare organizations.

Dr. Sandeep Chatrath Regional CEO ( AP & Telangana Region) Mr.Birupakshya Rout, Mr. D. Pavan Kumar Quality Department, Apollo Hospitals, Visakhapatnam

In India, as the healthcare sector is getting more competitive academic researchers and healthcare practitioners are increasingly interested in finding out how patients look out for the quality, before building up their satisfaction levels and generating behavioural intentions. Today, hospitals realise the importance to focus on service quality as a measure to improvise their competitive position.

Over the past two decades, patient satisfaction surveys and creating loyal customer to the health care organizations, gained increasing attention. These were also identified as essential references to information for recognizing gaps and developing an effective yet powerful action plan for quality improvement in healthcare organizations.

This article investigates in-depth number of research studies that are into critically discussing the relationship of independent and dependent influential attributes towards the overall satisfaction of the patient relating to health care quality service delivery and the impact on them on the quality improvement process of healthcare organisations.

In providing responsive, quality healthcare delivery, the importance of understanding patients’ satisfaction is accepted widely. As per Arjun Murthy (2014), consumer satisfaction is a fundamental requirement for healthcare providers, and satisfaction becomes imperative as patients and institutional health care services buyers make selective decisions.

As per many studies, in addition to positive influences on patient loyalty and retention, patient satisfaction affects the rate of patient compliance with physician advice and the healing process of patients.

Many studies have stressed the importance of patients’ views as an important tool for managing, monitoring as well as improving service quality. There are many hospitals which are shifting from the culture of the healthcare system formed by the preferences and decisions of medical professionals to one shaped by the views and needs of its users thus adopting a patient- centred attitude. As a result, number of studies investigating patient satisfaction employ a wide range of measurements depending on their patient satisfaction definition

The Servqual model is a tool used for measuring service quality and consequently the satisfaction of clients. It begins with the assumption that service quality is a function of customer’s expectation of a service and their perceptions of the service actually rendered. To ascertain satisfaction, the difference between these variables (Customer’s expectations and perceived service quality delivered) is determined.

Perceived quality of the service is turning out to be the most important competitive factor in the world of business and has the reason of naming the present business era as “Quality Era”(Peeler, 1996). Therefore, service marketing intellectuals and researchers offered a number of metaphors of this issue. For example, Berry (cited in Kandampully, 1998, p423) calls it the most powerful competition weapon and Clow(1993) calls it the organisation’s life giving blood.

Quality is a multi-dimensional phenomenon. Thus reaching service quality without differentiating the significant aspects of quality is impossible. In his lectures on service quality, Gronroos (2000) referred to three dimensions of output technical quality, service performance quality, and healthcare organization’s mental picture. International Authors Lehtinen and Lehtinen(cited in Harrison, 2000) have referred the three dimensions of service quality as physical quality, interactive quality and organisational quality.

Although these attempts had a major role in dividing service quality into process quality and output quality, they lack enough details. Based on this, Zeithaml et al.(1996) have referred to ten dimensions of service quality in their primary research. But in their further researches, a strong correlation among those dimensions was found. These dimensions were further combined and applied the fivefold dimension of Reliability, Responsiveness, Empathy, Assurances and Tangibles as a source for creating a tool for testing the service quality, SERVQUAL.In their researches, they emphasize that SERVQUAL is a lasting and reliable scale of service quality.

Customer satisfaction is a basic factor in the formation of customer’s desires for future purchases. Satisfied customers tend to talk to others about their good experiences. This is more prevalent in the Indian culture, where social life has been formed in a way that social communication with people enhances the society, is more important (Dr.Agarwal, Mumbai 2008). Satisfaction, although has been defined as the difference between expectation and performance, there are differences between quality and satisfaction. For example, as per Dr.Agarwal. (2008) satisfaction is a decision made by the customer after an experience while it cannot be said the same for quality.

International Researcher Cadotte & Turgeon (1988) have introduced a group of factors known as neutral factors. As per Liljander & Strandvik (1993) the service can be evaluated on the basis of the knowledge about the service provider, while satisfaction is an inner view, resulting from customer’s own experience from the service. Finally, several types of research have been done on the relationship between satisfaction and service quality: findings of some of these research reveal satisfaction results in service quality (Parasuraman et al., 1988). Research conducted by Sureshchandar et al. (2002) concludes that there is a two-way relation between satisfaction and service quality.

As part of relations development activities, many service organizations have developed customer loyalty programs. Customer loyalty is a complicated concept. According to Oxford Dictionary loyalty is a state of true to allegiance. But the mere repeated purchase by customers has been mixed with the above-mentioned definition of loyalty. Loyalty is defined in an extensive form as “observed behaviours” in service domain (Bloemer et al., 1999). As per international researcher, Caruana (2002) it is that behaviour which is a full expression of loyalty to the brand and not just the thoughts.

Yet, behaviour standards (such as repeatedly availing the healthcare service) have been criticized, due to necessity of a conceptual basis of a dynamic process. For example, discontinued service or service may result from different situational factors, such as non-availability or absence of a provider. According to this point of view, loyal behaviour cannot offer a comprehensive conception of fundamental causes of loyalty.

Repetition may happen due to the different restrictions from the market. Consequently, the loyalty of this type of customers mainly differs from the loyalty of those customers who sincerely support a service product, and do have a psychological bond with a service and healthcare organisation. Therefore, the loyalty of the customer was considered as an attitudinal structure. For example, this issue appears in the tendency to advise the service offered to other customers. Finally, in addition to behavioural and attitudinal approaches, another approach to the customer’s loyalty, known as the cognitive approach was introduced. Operational definition of this approach is while making decision for purchase, the first service product or service whichever comes to the mind of a person

Healthcare Quality Service, Customer Satisfaction and Loyalty - 1

From the above mentioned model, following are the main hypotheses developed:

  1. Perceived service quality is positively associated with customer satisfaction.
  2. Perceived service quality is positively associated with customer loyalty.
  3. Customer satisfaction is positively associated with customer loyalty.
  4. Customer satisfaction mediates the relationship between perceived service quality and customer loyalty.

In healthcare delivery, the understanding and measurement of service quality & satisfaction by the patient is very important as it is concept essential to the provision of better and more focused quality service for patients.

In order to achieve this, it’s important to capture information on patient needs, perceptions and expectations so as to assess their satisfaction about the services they receive. This in turn will help health professionals identify where service improvements are needed.


  1. http://journals.sagepub.com/doi/pdf/10.1177/0972063413486035
  2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2888368/
  3. Avkiran, N, K. (1994). Developing an instrument to measure customer service quality in branch banking. International Journal of Bank Marketing. 12 (6), 10-18.

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