Public health service quality at Thai Nguyen National Hospital (Chất lượng dịch vụ y tế công tại Bệnh viên Đa Khoa Trung Ưng Thái Nguyên)

Những đóng góp mới về mặt lý luận (1) Luận án đã chỉ ra được các yếu tố đo lường chất lượng dịch vụ y tế tại bệnh viện công, tập trung vào chất lượng chức năng liên quan đến cách thức cung ứng dịch vụ y tế của bệnh viện. Mô hình nghiên cứu được xây dựng trên cơ sở tổng hợp nhiều nghiên cứu trước đây về chất lượng dịch vụ, trong đó có dịch vụ y tế. Tác giả đã áp dụng mô hình đo lường chất lượng dịch vụ của Parasuraman để đo lường chất lượng dịch vụ y tế tại bệnh viện Đa Khoa Trung Ương Thái Nguyên (nay là bệnh viện Trung Ương Thái Nguyên), xây dựng thang đo chất lượng dịch vụ dựa vào thang đo SERQUAL để tiến hành thu thập số liệu sơ cấp về mong đợi và cảm nhận cũng như sự hài lòng của người bệnh trong quá trình sử dụng dịch vụ y tế tại bệnh viện. Các yếu tố đưa ra trong khung phân tích của luận án là sự kết hợp hợp lý của các yếu tố ảnh hưởng đến chất lượng dịch vụ y tế tại bệnh viện. Những điểm mới về kết quả nghiên cứu (2) Kết quả nghiên cứu của luận án cho thấy rằng chất lượng dịch vụ y tế tại bệnh viện công như bệnh viện Trung Ương Thái Nguyên được đánh giá thông qua 5 yếu tố bao gồm Sự tin cậy, Sự phản hồi, Sự cảm thông, Tính hữu hình và Sự đảm bảo. Năm nhân tố trên đã được xắp xếp theo mức độ quan trọng dựa vào kết quả phân tích của mô hình hồi quy tuyến tính trên cơ sở phân tích số liệu sơ cấp được điều tra tại bệnh viện. Các nhân tố trên đều có tác động cùng chiều đến chất lượng dịch vụ y tế công tại bệnh viện thông qua sự thay đổi tích cực đến nhận thức về chất lượng dịch vụ và sự hài lòng của người bệnh. Sự hài lòng của người bệnh cũng có tác động tích cực đến lòng trung thành và đến lượt mình, sự trung thành của người bệnh là cơ sở cho việc nâng cao chất lượng và sự phát triển bền vững của bệnh viện. (3) Nghiên cứu gợi ý rằng, để nâng cao chất lượng dịch vụ y tế, bệnh viện cần có những thay đổi tích cực nhằm thay đổi nhận thức về sự cảm nhận chất lượng dịch vụ của người bệnh, qua đó làm họ hài lòng hơn, thỏa mãn hơn và sẽ tiếp tục sử dụng dịch vụ của bệnh viện trong tương lai. Bên cạnh đó, cần xây dựng bộ tiêu chí đánh giá chất lượng phù hợp, tập trung và đặc biệt ưu tiên việc cải tiến hệ thống quản lý chất lượng bệnh viện, một yếu tố quan trọng đối với các bệnh viện trong giai đoạn hiện nay, khi mà sự mong đợi của người bệnh ngày càng cao. Bệnh viện cũng cần chú ý đến việc đầu tư cải tiến chất lượng dịch vụ thông qua các nhân tố trong mô hình đánh giá chất lượng dịch vụ (SERVQUAL) từ việc thay đổi nhận thức và thái độ phục vụ của nhân viên y tế, đầu tư thêm trang thiết bị hiện đại, nâng cao tinh thần trách nhiệm, sự cảm thông đối với bệnh nhân đến sự đảm bảo dịch vụ về tính chính xác và hiệu quả. KHẢ NĂNG ỨNG DỤNG TRONG THỰC TIỄN VÀ NHỮNG VẤN ĐỀ BỎ NGỎ CẦN TIẾP TỤC NGHIÊN CỨU * Khả năng ứng dụng trong thực tiễn Kết quả nghiên cứu giúp bệnh viện xác định được những điểm mạnh, điểm yếu và sự hài lòng của người bệnh. Phân tích từ mô hình đánh giá chất lượng dịch vụ (SERVQUAL) chỉ ra rằng các yếu tố đưa ra trong mô hình nghiên cứu có tác động tích cực và cùng chiều đến nhận thức về chất lượng dịch vụ y tế của người bệnh thông qua sự hài lòng của họ. Bệnh nhân càng hài lòng thì chất lượng dịch vụ càng được đánh giá cao. Ban giám đốc bệnh viện có thể thấy được những điểm mạnh, điểm yếu trong việc cung ứng dịch vụ y tế để có các biện pháp cải tiến chất lượng dịch vụ, nâng cao năng lực cạnh tranh của bệnh viện để tận dụng một cách tối ưu các nguồn lực nhằm đáp ứng tốt hơn nữa nhu cầu của người bệnh. Bệnh nhân có cơ hội để bày tỏ quan điểm và ý kiến của mình trong việc đánh giá chất lượng dịch vụ, góp phần cải tiến hơn nữa chất lượng dịch vụ y tế công tại bệnh viện. Nghiên cứu có những đóng góp về mặt lý luận và học thuật cho công chúng về chất lượng dịch vụ nói chung và chất lượng dịch vụ y tế nói riêng, giúp họ nâng cao nhận thức về chất lượng dịch vụ y tế, nhìn nhận đúng hơn về quyền và nghĩa vụ của mình khi tham gia dịch vụ y tế. Trong thực tế, các nhà cung cấp dịch vụ y tế cần đo lường chất lượng dịch vụ y tế và sự hài lòng của người bệnh bời vì điều này có mối quan hệ chặt chẽ với các vấn đề nhạy cảm của bệnh viện và uy tín của bệnh viện trên thị trường. Bằng cách phát hiện được những mảng thiếu sót qua mô hình đo lường chất lượng dịch vụ, các bệnh viện sẽ sử dụng tối ưu hơn các nguồn lực hiện có và làm hài lòng người bệnh với các dịch vụ mà mình cung ứng. Sự hài lòng của người bệnh về chất lượng dịch vụ sẽ là điều kiện cơ bản để họ tái sử dụng dịch vụ và giới thiệu cho người khác cùng sử dụng dịch vụ của bệnh viện. * Những vấn đề bỏ ngỏ cần tiếp tục nghiên cứu Các nghiên cứu trong tương lai có thể làm với phạm vi rộng hơn và có sự so sánh với các bệnh viện công ở các quốc gia khác có điều kiện tương tự Việt Nam. Các tác giả cũng có thể tập trung vào việc xây dựng thêm các thang đo mới để đo lường chất lượng dịch vụ y tế hoặc thêm một số khía cạnh khác phản ánh kết quả trong quá trình thực hiện dịch vụ y tế. Các tác giả cũng có thể tập trung nghiên cứu chất lượng dịch vụ y tế trên quan điểm của người cung ứng dịch vụ. Để có được những hiểu biết sâu sắc hơn, tác giả có thể nghiên cứu thêm về vấn đề chất lượng dịch vụ y tế trong khu vực tư nhân và tiến hành so sánh giữa chất lượng dịch vụ y tế công. Việc hỏi bệnh nhân về mong đợi và cảm nhận của họ về chất lượng dịch vụ cùng một lúc có thể gây nhầm lẫn, các nghiên cứu sau có thể hỏi người bệnh về mong đợi tại thời điểm bệnh nhân nhập viện, sau đó hỏi lại họ về mức độ cảm nhận khi họ sắp ra viện. Điều này sẽ tránh được sự nhầm lẫn giữa mong đợi và cảm nhận của bệnh nhân, tuy nhiên sẽ đòi hỏi nhiều thời gian và công sức hơn. THE NEW SCIENTIFIC FINDINGS New academic and theoretical contribution of the dissertation as follow: (1) The dissertation points out the factors measuring public health service quality in hospital with focusing on functional quality which relates to the manner of delivery of health-care services. The research model is derived from the combination of previous research models, especially applying model of measuring service quality of Parasuraman. The author use SERVQUAL to measure health service quality at health care sector in Thainguyen National Hospital through the patients’ satisfaction. The factors in the conceptual framework are reasonably selected to measure service quality public health services of hospital. Findings and new recommendations from the research results (2) The research results of the dissertation have shown the health service quality are evaluated by five main factors according to their level of importance: Reliability, Responsiveness, Empathy, Tangibility, and Assurrance . The five factors mentioned-above have a direct impact in the same way on patient satisfaction and indirect impact in the same direction on patient loyalty in public health service of Thainguyen National Hospital. Satisfaction has a big impact on patient loyalty, and in turn patient loyalty serves as a basis for a sustainable development of health service of hospital. (3) In order to get better quality of health service, the hospital need to satisfy patient demand through changing their perceived of service quality, thus getting their loyalty. Besides the development of instructor quality, the hospital needs to pay more attention and take priorities in improving the quality management system, one of the indispensable activities and becoming increasingly more important in health facilities in the current period, when the patient''s expectations are higher and higher. The hospital also needs to put their attention in investing in and improving the quality according to the application of five factors in SERQUAL model including: Responsiveness - Empathy - Reliability - Tangibles - Assurance. PRACTICAL APPLICABILITY AND RECOMMENDATIONS FOR FURTHER STUDIES * Practical applicability The study findings help to identify and highlight the weaknesses in health care service of hospital and how is patients ‘satisfaction. The analysis of SERVQUAL model indicates that all patient satisfaction dimensions positively and significantly contributes to patient satisfaction and which also act as an important mediating factor between the satisfaction dimensions and service quality. Hospital’s board of manager can find their strengths and weakness in delivering health services, improving their services quality and enhancing competition capacity of hospital to utilize resources and meet the need of patients. The patients would have chance to express their opinion to contribute to the continuously improvement of health care services in public hospital. The study is also expected to add knowledge about health care services to the public. This will help the public recognize and appreciate health care services. On a practical note, healthcare providers need to measure health service quality and patients ‘satisfaction due to its high correlation with issues essential to the hospital bottom-line and the reputation of the hospital in the market. By identifying defective areas through implementation of the scale and the model, the service provider could address each need and reallocate resources accordingly thus aiming to improve patients’ perceptions and eventually satisfaction with the services provided by the hospital. And since patient‘s satisfaction has been strongly linked to future purchase and recommendation behavior in the current research, this stresses the importance of measuring patient satisfaction in hospitals in accordance with the hospital quality. * Recommendations for future studies Future research may cover wider range with the comparisons of different hospitals or in different countries. The researcher could also add more dimensions to measuring the outcome of healthcare services or develop a new scale for evaluating the quality of services in health care sector. The researcher also focuses on the providers’ point of view in assessing quality of health care services. For the further understanding of health care services, researcher may study quality of these services in the private sector and make the comparison between them. Asking patients about expectations and perceptions at the same time can cause confusion. Future research should ask the patient about the expected moment of admission, and then asked about the perception of the patient after they have experienced the service. This requires more time and effort, but can get better results. There should be regular evaluation, continuously conducting to improve the quality of hospital services, better meet the needs of the patient.

PUBLIC HEALTH SERVICE QUALITY

AT THAI NGUYEN NATIONAL GENERAL HOSPITAL

A Dissertation Proposal

Presented to the Faculty of the Graduate Program

of the College of Arts and Sciences Central Philippine University, Philippines

In Collaboration with Thai Nguyen University, Vietnam

TABLE OF CONTENTS

ACKNOWLEDGEMENTS i

TABLE OF CONTENTS ii

LIST OF TABLES iv

LIST OF FIGURES v

LIST OF ABRIVIATIONS vi

ABSTRACT vii

CHAPTER I THE PROBLEM AND ITS SETTING 1

1.1 Background and Rationale of the Study 1

1.2 Objectives of the Study 4

1.2.1 General objective 4

1.2.2 Specific objectives 4

1.3 Hypothesis of the study 5

1.4 Theoretical Framework 6

1.4.1 Donabedian‘s Model (1988) 6

1.4.2 Measuring service quality: SERVQUAL model 8

1.5 Conceptual Framework 11

1.6 The Operational Definition of Variables and other Terms 13

1.7 Significance of the study 15

1.8 Scope and Delimitation 16

1.8.1 Scope of the study 16

1.8.2 Delimitation 16

CHAPTER II REVIEW OF RELATED LITERATURE AND STUDIES 17

2.1 Review of related literature 17

2.1.1 The concept of public health service 17

2.1.2 Quality of public health services 19

2.1.3 Factors affecting health service quality 25

2.1.4 Measuring the quality of healthcare service 27

2.1.5 Patients‘ satisfaction 30

2.1.6 Service quality and Relationship with Customer Satisfaction 31

2.2 Review of Related Studies 33

CHAPTER III METHODOLOGY 42

3.1 Research Design 42

3.2 Population, Sample Size and Sampling Technique 44

3.3 Research Instrument 46

3.3.1 Delphi study 46

3.3.2 Cronbach's Alpha 46

3.3.3 Likert Scale 47

3.3.4 Exploratory Factor Analysis (EFA) 48

3.3.5 Analysis of variance (ANOVA) 52

3.4 Ethical Considerations 52

3.5 Data Gathering Procedure 53

3.6 Data Processing and Data Analysis 54

CHAPTER IV DATA PRESENTATION, ANALYSIS AND INTERPRETATION 57

4.1 Some health care indicators in Thainguyen province 57

4.2 General information of Thai Nguyen National Hospital 59

4.3 Current status of public health services at Thai Nguyen National Hospital 67

4.4 Survey results about health services at Thainguyen National Hospital 71

4.4.1 General information of surveyed department 71

4.4.2 General information of respondents 74

4.4.3 Analysis of service quality through SERVQUAL model 77

4.4.4 Exploratory Factor Analysis (EFA) according to the patient‘s perception 88

4.4.5 Regression analysis 97

4.4.6 Analyzing the difference in accordance with personal characteristics 100

CHAPTER V CONCLUSION AND POLICY RECOMMENDATION 104

5.1 Summary of findings 104

5.2 Conclusions 109

5.3 Policy recommendations 111

REFERENCES 117

APPENDIX 121

LIST OF TABLES

Table 2.1 Summary of service quality (SQ) definition 24

Table 2.2 Types of quality measures 28

Table 2.3 Summary of related studies according to methods and factors in measuring health service quality 39

Table 3.1 Research scheduling and respondent‘s distribution 45

Table 3.2 Scale of Cronbach's Alpha 47

Table 3.3 Likert scale 47

Table 3.4 The process variables measured by Likert scale 48

Table 3.5.Coding factors and items for EFA analysis 51

Table 4.1 Labor structure of TN hospital 63

Table 4.2.Quality score in 5 level of measurement 70

Table 4.3.General Information of departments 72

Table 4.4 Residential of respondents 75

Table 4.5 Classification of respondents according to reasons of choosing hospital 75

Table 4.6 Demographic characteristics of respondents 76

Table 4.7 Expectation and perception of Tangibility dimension 77

Table 4.8 Expectation and perception of Reliability dimension 79

Table 4.9 Expectation and perception of Responsiveness dimension 80

Table 4.10 Expectation and perception of Assurance dimension 82

Table 4.11 Expectation and perception of Empathy dimension 83

Table 4.12 Expectation and perception of overall 5 dimensions 87

Table 4.13 Test of reliability by Cronbach‘s alpha coefficient 88

Table 4.14 Rotated Component Matrix (a) – first rotated time 90

Table 4.15 Rotated Component Matrix – second rotated time 91

Table 4.16 The structure of the scale after the 2nd factor analysis 92

Table 4.17 Results of Cronbach's alpha coefficient after extracting factors 94

Table 4.18 Component Score Coefficient Matrix 95

Table 4.19 Model Summary 97

Table 4.20 Coefficients (a) 98

Table 4.21 ANOVA (b) 98

Table 4.22 Summary of Residuals Statistics (a) 99

Table 5.1 Comparing Dimensions of service quality of the study with theories 107

LIST OF FIGURES

Figure 1.1 Donabedian‘s model in assessing quality of health services 7

Figure 1.2 Model of service quality by PZB 10

Figure 1.3 Modified SERVQUAL model in health care sector 12

Figure 1.4 The conceptual Framework 12

Figure 2.1 Health care environment – setting system regulation 21

Figure 2.2 Factors affecting services quality of Parasuraman 26

Figure 3.1 Research process 44

Figure 3.2 Model of 5 factor affecting service quality at TNH 49

Figure 4.1 Averge Yearly per capita GDP of Thainguyen and Vietnam 57

Figure 4.2 Health personnel density and Hospital bed density of Thainguyen 58

Figure 4.3 Image of Thai Nguyen National Hospital 59

Figure 4.4.Organizational structure of Thai Nguyen National Hospital 62

Figure 4.5 Number of patient from 2013 to 2015 68

Figure 4.6 Total quality score of hospital according to 83 criteria 69

Figure 4.7 Radar chart of quality score in 5 aspects of hospital quality 70

Figure 4.8 Figure of quality improvement in 2014 and 2015 via radar chart 71

Figure 4.9 Examination process maps 73

Figure 4.10 Electronic Table Name 73

Figure 4.11 Electronic transport system for patients 74

Figure 4.12 Survey result of using Health Insurance Card (HIC) 74

Figure 4.13 Expectation and perception of Tangibility dimension 78

Figure 4.14 Expectation and perception of Reliability dimension 79

Figure 4.15 Expectation and perception of Responsiveness dimension 81

Figure 4.16 Expectation and perception of Assurance dimension 83

Figure 4.17 Expectation and perception of Empathy dimension 84

Figure 4.18 Expectation and perception of 5 dimensions 85

Figure 4.19 Satisfaction level of 5 dimensions 101

EHR Electronic Health Record

IMS Indicator Measurement System

PZB Parasuraman, Zeithaml and Berry

QIP Quality Indicator Project

TNH ThaiNguyen National Hospital

JCI Joint Commission International

EFA Exploratory Factor Analysis

USD United States Dollar

SPSS Statistical Package for the Social Sciences

GSO General Statistics Office

WHO World Health Organization

NHS National Health Service

KMO Kaiser-Meyer-Olkin-Kriterium

VIF Variance Inflation Factor

ANOVA Analysis of Variance

SERVQUAL Service Quality

SERVPERF Service performance

ABSTRACT

While quality in tangible goods has been thoroughly described and measured by marketers, quality of services has yet a lot to be done Accurate measurement of service quality as perceived by patients has yet to reach a consensus for healthcare organizations Quality has not happen by chance; it needs to be systematically developed with objective planning, staff involvement and considering patient need

Today for the health service market in Vietnam and the all over the world, there is a need for a health service quality model that takes into consideration a complete coverage of the dimensions that consumers use in evaluating healthcare service quality The research to

be conducted focuses on service quality, patient satisfaction and intentions to return, and the consumer role in the health care service encounter

The main objective of this research was to formulate and empirically investigate a fully tested and applicable healthcare service quality model that encompasses the criteria patient use in evaluating health services in Thainguyen province for public sector hospitals Also, research aims to provide a valid and reliable scale with which healthcare providers can use for measurement of the service quality in their organizations

The research was composed of two phases The first phase aimed to assess health service quality through SERVQUAL model using questionnaire and through a secondary data gathering process, qualitative interviews with experts and Thainguyen patients The second phase was a full-fledged quantitative survey to test and verify the quality of health service through EFA model and the scale developed for the health care market at Thai Nguyen National Hospital

The first phase has enabled the researcher to achieve several goals The in-depth interviews with patients enabled gathering their insight on what are the factors that patients expected and perceived in their recent hospital experience and the secondary data gathering process identified the dimensions uncovered by previous researchers for healthcare service quality A tentative questionnaire was constructed based on this and was further refined through the pilot study and the in-depth interviews with healthcare experts This further developed the previous preliminary questionnaire and model constructs and final modification were done on the questionnaire format preparing it for the next phase of quantitative data collection

The second phase enabled the researcher to establish a healthcare service quality model for public hospital as Thainguyen National Hospital in the field functional quality aspect The researcher was able to determine the underlying constructs and sub-constructs

of healthcare service quality as well as determining which of the sub-constructs have greater impact on the patients ‗overall perception of service quality in the hospital Several relationships were also uncovered between the variables of the patients‘ satisfaction, intention to return and recommend value for money Finally, the role of demographics as a discriminating variable was also established to test whether existed the differences in satisfaction between vary age, income and education groups

Marketers can use the model and the scale to evaluate patient perceptions from their health service providers and thus be used as a valuable tool to identify and elevate the level

of services in areas that need to be addressed This will ensure a higher level of patient satisfaction and thus ensuring loyalty, repeat patronage and positive recommendation behavior, which is the ultimate goal of health service providers Thus the current research could prove invaluable for improving the level of services in areas defected by the consumers of the service

The research findings will help to identify and highlight the weaknesses in health service of hospital and how services quality in the hospital was The analysis of the models indicates that all patient satisfaction dimensions positively and significantly contributes to service quality and which also act as an important mediating factor between the satisfaction dimensions and patient loyalty Hospital‘s board of manager will find their strengths and weakness in delivering health services, improving their services quality and enhancing competition capacity of hospital to utilize resources and meet the need of patients Patients will have chance to express their opinion to contribute to the continuously improvement of public health care services

CHAPTER I THE PROBLEM AND ITS SETTING 1.1 Background and Rationale of the Study

Health quality can be defined as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (Institute of Medicine, 2001)

Major health care quality concerns (such as patient safety and effectiveness of care) are basically the same across different types of countries In a low – income country like Vietnam, quality related problems are much more prevalent Major factors that cause health care quality problems in Vietnam are: Lack of sufficient management (clinical and administrative); Inadequate medical staffs and training; Weak performance monitoring systems; Non-empowered patients and families Once we can assess the relative appropriateness and effectiveness of health services, we can provide optimal care to patients and maximize our use of scarce resources

Because of increasing competition, service providers and more demanding patients, service quality has become a watchword for healthcare service providers but as yet has proven difficult to measure Service quality has been directly linked to repeat sales, positive word-of-mouth and recommendation Consumer satisfaction is directly linked to service quality thus perceived quality, patient satisfaction and behavioural intentions are concepts of foremost importance to healthcare marketers (Ross et al., 1987; John Joby, 1992; Paul, 2003)

There exists number of shortcomings in medical policies and medical services mechanisms in Vietnam Large investment resources but effective use of resources to supply medical services doesn‘t meet practical requirements posed Currently, people assess the quality of health services are implemented only sensible levels, mainly through external audio visual facilities and the behaviour, reception and care of medical staffs As for the quality of technical, medical science, in fact, underestimate people The provision of health services is now revealing many negative issues such as drug abuse, chemical, laboratory to the attitude, spirit of service, ethics It was real severe economic and popular in many establishments providing health services, both public and private sector (Tran Tuan - Director

of the Centre for Research and Training Community Development, Vietnam Union of Science and Technology Associations)

Vietnam‘s health sector hasn‘t met the criteria of both quantity and quality of health services for the people The accessibility of people to health services is very difficult, especially for the poor, near poor and remote populations Inequality in the supply and

beneficiaries of health services tends to increase Mechanisms and policies in managing operating health sector are inadequate Management information system for health care is not comprehensive and overlaps Quality management system of health services as well as quality inspection of health services in both the public sector and private sector remains weak The management of drug prices in hospitals is inadequate push higher drug costs put pressure on hospital charges for patients (Truong Bao Thanh, 2013)

Vietnamese health sector is facing with an imbalance in the demand for health care among central hospitals and local people in the provinces and cities nationwide Demand for health care is increasing, whereas, only a few hospitals in the big city have capabilities to deal with Especially over the last 10 years, the phenomenon of hospital overcrowding has worsened and appeared at all levels The situation of combining 2-3 patients a bed; 1 clinic doctor must examine 60-100 patients per day is common in Central National, provincial hospitals and becomes a priority health issue, an urgent concern of the health sector as well as the entire society needs to be addressed The utilization rate of over 100 % regular beds and ranged from

120 % to 150 %, even up to 200% in some large hospitals (Le Quang Cuong et al., 2011)

According to Vietnam health statistics, there are about 40,000 Vietnamese people go overseas for treatment every year They spent more than 5 billion USD for their treatment in developed countries such as Singapore, South Korea, the US, France, and Thailand This figure is estimated to rise to 50,000 people by 2016 Doctors in Vietnam are considered as not inferior to the advanced countries mentioned above It is caused by overworked staff, poor service quality, and complex administrative procedures; cumbersome A survey of over

700 patients taken by VN Express in Vietnam showed that 57 % Vietnamese people do not want to use the services of hospitals in the country by the attitude and ethics of the medical staffs It is raising a question of ―Does the medicine of our country have won the confidence

of the patient?‖

Medical service is a very special service In essence, health service includes activities performed by medical staff as health examination and treatment for patients and families (Journal of Marketing, 2009)

Institute of Medicine (2001) defines quality of health care is the degree to which the health services are provided to individuals and the population to increases the desire of health outcomes and match current professional knowledge Quality of health services will determine the existence of hospital and can be measured through the patients‘ satisfaction

Previously, it is thought that the evaluation and quality assurance is limited in developed countries (Thomason & Edwards, 1991), in the developing countries; the problem of improving

medical quality received little interest until recently (Reerinks and Sauerborn, 1996) For public services, the quality assessment has also received little attention (Narang and Ritu, 2011) The quality of medical services is assessed from two points of view: technical and functional (Institute of Medicine, 2001) Technical quality refers to aspects related to the diagnosis and procedures while functional quality refers to aspects related to the way services are provided to the patients (Narang and Ritu, 2010) To be successful in long term a health care organization must effectively monitor and manage both technical and functional quality (Babakus and Mangold, 1992) Functional quality is often considered as the main key to determine the quality

by customer perception because it is difficult to precisely assess the technical quality due to lack

of professional experience (Donabedian, 1980)

Thai Nguyen is a large mountainous province in northern area of Vietnam with 1.2 billion inhabitants It is nationally known as a No 3 center for training human resources after Hanoi and Ho Chi Minh City with 6 universities, 11 colleges, 9 vocational center, training nearly 100,000 workers each year This unique demographic situation has led to a marked diversity of public health agencies in Thai Nguyen province There are one national general hospital, 08 provincial hospitals and more than fifteen medical centers at district level For this reason, public health agencies in Thai Nguyen were classified differently from other cities of Vietnam According to General Statistic Office of Vietnam, in 2013 the province had 520 health establishments with 23 hospitals and 4719 patient beds; The number of medical staffs was 4219 persons, doctors per thousand populations was 7.6, number of beds per thousand populations was 31.6 beds, and the percentage of children under age 1 fully injected vaccine was 98% Specifically, the State own unit account for 42% but served 98% of patient bed The national health program was implemented and performed relatively well, the state of food safety and hygiene has been improved However, the quality of services in some health facilities was not high due to lack of technical facilities and doctors (Thainguyen Statistic Office)

Public health services are more favorable with reasonable price for most people in Thainguyen city Community pharmacy is recognized as an easily accessible source of advice in primary health care and pharmacists as competent and well-trained health professionals An essential factor to consider when analyzing the quality of health care in facilities is the perspective of the clients For clients and communities, quality care is something that meets their perceived needs Since a client's needs often differ from one and other, his/her personal satisfaction ultimately depends on the individual perception, attitude and expectations Patient satisfaction is a strong influencing factor in determining whether a person seeks medical advice, complies with treatments and maintains a relationship with the provider/health facility

Ultimately, the dimensions of quality that relate to client satisfaction affect the health and being of the community The results of the literature review suggest that the most important dimensions of quality for the client are technical competence, interpersonal relations, accessibility and amenities

well-Thai Nguyen National General Hospital (From October, 2016 has been renamed to well-Thai Nguyen National Hospital) is located at Phan Dinh Phung ward, right center of Thainguyen City

The hospital was established in 1951, this is a state own hospital – one of the largest hospital in Thai Nguyen province and in North mountainous area Thainguyen National Hospital (TNH) is maintained the first class hospital with bed size of 1200 units, the highest level of treatment is responsible for direct health care for more than 1.2 million people in Thainguyen province, and the ultimate treatment venue in North mountainous provinces The hospital has 40 wards, department and centres with high quality medical staffs In order to reach the mission of deploying advanced techniques of thoracic surgeries, tumours, resuscitation, heart disease; the satellite clinics of leading Central hospital in Northern mountainous area of Vietnam, the completion of human resources and enhancing quality of hospital‘s health services is necessary Especially, in the coming competitiveness and higher demand as well as quality for health services boost all hospital to a number of opportunities and threats

Today for the healthcare services market in Thainguyen city, there is a need for a healthcare service quality model that takes into consideration a complete coverage of the dimensions that consumers use in evaluating healthcare service quality Hence, the evaluations of health services through the patients‘ satisfaction as well as health provider‘s perspective of awareness and managing quality were needed Provision of health service quality is the top

priority in hospital management, especially in public sector That is why the topic ―Public health

service quality at Thai Nguyen National Hospital‖ was chosen as the dissertation title The

research was conducted with focus on services quality, patient satisfaction and intentions to return, as well as the patient role in the healthcare service encounter

1.2 Objectives of the Study

1.2.1 General objective

This study concentrates on quality assessment of the public health services at Thai Nguyen National Hospital Thus, improving health service quality as well as the competition ability of hospital and contributing to meet the strategic objectives of Vietnam in terms of public health services quality up to 2020

1.2.2 Specific objectives

Specifically, this study seeks to:

1 Describe the current status of health services quality at Thai Nguyen National Hospital – a public hospital in Thai Nguyen city;

2 Determine factors affecting functional quality of health service at Thai Nguyen National Hospital

3 Examine the overall perceived quality of patients toward the quality of health services

at Thai Nguyen National Hospital;

4 Determine relationships between overall patient satisfaction and factors affecting their satisfaction level including tangibility, reliability, responsiveness, assurance, and empathy;

5 Determine relationships between patient demographics characteristics and their overall level of satisfaction;

6 Propose recommendations for a better healthcare quality improvement at Thai Nguyen National Hospital

1.3 Hypothesis of the study

Major Research Questions

Q1: What is the model in measuring health service quality?

Q2: What are the factors affecting functional health service quality?

Q3: Do patient demographic (Age, Gender, Occupation, Educational level, Income level) have different effects on patient‘s overall perceived service quality?

Q4: Does the service quality of five certain dimensions (tangibles, reliability, responsiveness, assurance, and empathy) have significant impact on the overall patient perception of service quality?

Q5: What is the relationship between overall patient satisfaction and behavioral intentions to return and recommend?

Research Hypothesis

- Hypothesis 1 (H1): There are no significant effects of SERVQUAL dimensions as Tangibles, Reliability, Assurance, Responsiveness, and Empathy on patient‘s overall perceived of health service quality

+ H1.1 There is no significant effect of “Tangibility” on patient’s overall perceived

of health service quality

+ H1.2 There is no significant effect of “reliability” on patient’s overall perceived of health service quality

+ H1.3 There is no significant effect of “Assurance” on patient’s overall perceived of health service quality

+ H1.4 There is no significant effect of “Responsiveness” on patient’s overall perceived of health service quality

+ H1.5 There is no significant effect of “Empathy” on patient’s overall perceived of health service quality

- Hypothesis 2 (H2): There are no significant different in overall perceived hospital service quality of patient according to their personal characteristics as age, gender, occupation, income and educational level

+ H2.1 There is no significant different in overall perceived hospital service quality

of patient according to their age

+ H2.2 There is no significant different in overall perceived hospital service quality

of patient according to their gender

+ H2.3 There is no significant different in overall perceived hospital service quality

of patient according to their occupation

+ H2.4 There is no significant different in overall perceived hospital service quality

of patient according to their income

+ H2.5 There is no significant different in overall perceived hospital service quality

of patient according to their educational level

- Hypothesis 3 (H3): The higher patients‘ perceive of overall quality of health service is, the better their satisfaction would be

- Hypothesis 4 (H4): There is no significant correlation between overall patient satisfaction and the patients' intention to return and to recommend other for coming to hospital

1.4 Theoretical Framework

1.4.1 Donabedian’s Model (1988)

The Donabedian model is a conceptual model that provides a framework for examining health services and evaluating quality of health care According to the model, information about quality of care can be drawn from three categories: ―structure,‖ ―process,‖ and ―outcomes ―Structure describes the context in which health care is delivered, including hospital buildings, staffs attitude, financing, and equipment Process denotes the transactions between patients and providers throughout the delivery of healthcare Finally, outcomes refer

to the effects of healthcare on the health status of patients and populations Avedis Donabedian, a physician and health services researcher at the University of Michigan, developed the original model in 1966.While there are other quality of care frameworks, including the World Health Organization (WHO) - Recommended Quality of Care Framework and the Bamako Initiative, the Donabedian model continues to be the dominant

paradigm for assessing the quality of health care Donabedian developed his quality of care framework to be flexible enough for application in diverse healthcare settings and among various levels within a delivery system

This framework consists of improving the quality of care into three fundamental parts

of health care services:

Figure 1.1 Donabedian’s model in assessing quality of health services

This model can be used to category quality indicators and frame the outcomes of an EBP implementation program In the Donabedian model, structure refers to the setting in which care is delivered, and includes the attributes of material resources (e.g facilities, equipment), of human resources (e.g number and characteristics of personnel), and of organizational structure (e.g medical staff organization, methods of peer review) Process refers to the approaches or means of providing health care which includes the services and treatments the patients receive Outcome refers to the result or impact of care on the health status of patients and populations It may also involve improvements in patient‘s knowledge

& behavior and degree of patient satisfaction

 Quality of outcome is considered as quality of services

Quality has not happen by chance; it needs to be systematically developed with objective planning, staff involvement and considering patient need

At its most basic level, the framework can be used to modify structures and processes within a healthcare delivery unit, such as a small group practice or ambulatory care center, to improve patient flow or information exchange For instance, health administrators in a small physician practice may be interested in improving their treatment coordination process

OUTCOME

• Effects of health care on the status of patients and populations

through enhanced communication of lab results from laboratory staffs to provider in an effort

to streamline patient care The process for information exchange, in this case the transfer of lab results to the attending physician, depends on the structure for receiving and interpreting results The structure could involve an electronic health record (EHR) that a laboratory staff fills out with lab results for use by the physician to complete a diagnosis To improve this process, a healthcare administrator may look at the structure and decide to purchase an information technology (IT) solution of pop-up alerts for actionable lab results to incorporate into the EHR The process could be modified through a change in standard protocol of determining how and when an alert is released and who is responsible for each step in the process The outcomes to evaluate the efficacy of this quality improvement (QI) solution

might include patient satisfaction, timeliness of diagnosis, or clinical outcomes

In addition to examining quality within a healthcare delivery unit, the Donabedian model is applicable to the structure and process for treating certain diseases and conditions with the aim to improve the quality of chronic disease management

Donabedian‘s model can also be applied to a large health system to measure overall quality and align improvement work across a hospital, group practice or the large integrated health system to improve quality and outcomes for a population In 2007, the US Institute for Healthcare Improvement proposed ―whole system measures‖ that address structure, process, and outcomes of care These indicators supply health care leaders with data to evaluate the organization‘s performance in order to design strategic quality improvement planning The indicators are limited to 13 non-disease specific measures that provide system-level indications of quality, applicable to both inpatient and outpatient settings and across the continuum of care In addition to informing the quality improvement plan, these measures can

be used to evaluate the quality of the system‘s care over time, how it performs relative to stated strategic planning goals, and how it performs compared to similar organizations

1.4.2 Measuring service quality: SERVQUAL model

Service quality is an approach to manage business processes in order to ensure full satisfaction of the customers and quality in service provided It works as an antecedent of customer satisfaction Measuring service quality has been one of the most recurrent topics in management literature (Parasuraman et al., 1988; Gronroos, 1984; Cronin et al., 1992)

SERVQUAL is a service quality framework, developed in the eighties by Zeithaml, Parasuraman & Berry, aiming at measuring the scale of quality in the service sectors It has emerged as perhaps the most popular standardized questionnaire to measure service quality The concept of SERVQUAL model is generally based on GAP theory of Parasuraman, 1985

Parasuraman et al (1988, p.15) define perceived quality as a form of attitude, related but not equal to satisfaction, and results from a consumption of expectations with perceptions of performance Therefore, having a better understanding of consumer‘s attitudes will help know how they perceive service quality in grocery stores We have adopted the definition by Parasuraman et al (1988, p.5), which defines service quality as the discrepancy between a customers‘ expectation of a service and the customers‘ perception of the service offering

Service quality = Perception - Expectation (of the attribute performance)

Weighted SERVQUAL model:

∑( )

Where: is service quality or overall perceived quality of stimulus i

k is the number of attributes

Wj is weighting factor if attributes have differentiated weights

Pij is performance perception of stimulus i with respect to attribute j

Eij is expectation for attribute j that is the relevant norm for stimulus i

The original scale consisted of a 97-item instrument, which was further divided into

10 dimensions and 54 items using item-to-item correlations and coefficient alpha computations This was followed by factor analysis reducing the items further to 34 items and five of the original 10 dimensions These included reliability, responsiveness, competence, access, courtesy, communication, credibility, security, understanding the customer, and tangibles, which remained distinct After that, they found that there was an overlap between the ten criteria the customer should be able to distinguish only five one The remaining five dimensions: communications, credibility, security, competence and courtesy collapsed into 2 distinct dimensions, each consisting of items from the original five dimensions This 37-item scale was following another step of purification was reduced into the final 22-item scale, divided into five dimensions including tangibles, reliability, responsiveness, assurance and empathy The last two dimensions containing items representing the seven original dimensions: communications, credibility, security, competence, courtesy, understanding the consumer and access (Parasuraman et al., 1988, 1991) Of all these dimensions, reliability has emerged as the most important one from the customers‘ viewpoint regardless of the service being studied (Berry, 1988)

Parasuraman et al developed 22-scale instrument with which to measure customers‘ expectations and perceptions (E and P) of the five rater dimensions Four or five number of items is used to measure each dimension The instrument is administered twice in different forms, first to measure expectations and second to measure perceptions

From the SERVQUAL model, it has showed that the key to ensuring good service quality is meeting what customers expect from the service and that judgement of high and low service quality depends on how customers perceive the actual performance in the context of what thay expected

Word-of-mouth

Communications

Personal Needs

Past experience

Expected Service

Perceived Service

Service Delivery

External Communication

To Customers

Service Quality Specs

Management Perceptions of Customer Expectation

PROVIDER

Gap 1

Gap 4 Gap 5

Gap 3

Gap 2 CUSTOMER

Figure 1.2 Model of service quality by PZB

The use of the SERVQUAL model makes it easier to access the service quality from the customer‘s perspective and also helps in tracking the customers‘ expectations over time and also differences between them

In the SERVQUAL model, there are five different gaps which show the weakness of the company in fulfilling customer needs Gap analysis is used to identify and correct gaps between the desired level of the customers and the actual level of performance provided by the organizations

Gap 1: not knowing customer expect

This is the difference between consumer expectations and management perceptions of consumer expectations;

Gap 2: not selecting the right service designs and standard

It is the difference between management perceptions of consumer expectations and service quality specifications;

Gap 3: not delivering to service standards

This gap reflects the difference between service quality specifications and the service actually delivered;

Gap 4: not matching performance to promises

This is the difference between service delivery and what is communicated about the service to consumers;

Gap 5: Service gap

Close gaps 1 to 4 to meet customer expectations consistently This is on the consumer side, and it shows the difference between a consumer‗s actual and perceived about quality of service

Closing the gap between what customers expect and what they perceive is critical to delivering quality service It forms the basis or the starting point for the GAPS model

Figure 1.3 Modified SERVQUAL model in health service

The framework will be presented in the diagram as follows:

Figure 1.4 The conceptual Framework

1 Exceeding expectations (E<P, excellent quality)

2 Meet expectations (E=P satisfactory quality)

3 Under expectation (E>P, low quality)

E Services expectation

P Service perception

Overall Perceived Service Quality DEMOGRAPHIC

Expected Service Quality

Perceived Service Quality

The conceptual framework including 3 types of variables: antecedent, independent and dependent variables Dependent variable is the overall level of perceived service quality by patients; Independent variables are all the factors affecting the overall level of perceived service quality by patients in terms of 5 dimensions follow by SERVQUAL model The services include: Physician Medical Service; Hospital employees and premises; Admission; other patient supported Services

Firstly, the author gathered information about the demographic characteristics of the respondents Then evaluated the patient‗s expectations (E) and Perception (P) of the hospital service quality and the answers are on a five-point Likert Scale

After that statements to measure the feelings of importance/weighted (W) that each expert assigns to each of the features measured above and the answers are on a five-point Likert Scale

1.6 The Operational Definition of Variables and other Terms

 Age: refers to years of living of patients (as last birthday of them) Dividing the market into 5 different age groups from 1 to 5 (1 = Under 18; 2 = 18 - under 30; 3 = 30 - 60; 4

= more than 60)

 Gender: Refer to know the patients male or female (0 = male; 1 = female)

 Ethic: Whether patient is minority ethnic people or not (0: Kinh; 1: Minority)

 Occupation: Refers to respondents‘ job (1 = state official; 2 = self - employed; 3 =

worker; 4 = famer; 5 = Students; 6 = other jobs)

 Income: Level of respondents‘ income monthly (in VND) Dividing the market into

different income groups: Group 1: ≤ 2.0 million; Group 2: 2.1 – under 5.0 million;

Group 3: 5.1 - under 10 million; Group 4: ≥ 10 million)

(2 million VND/month is poverty standard in Vietnam from 2016 - 2020; 5.0 million VND/month is estimated average income per month of Thainguyen in 2020, equivalent

to 2200 USD per year)

 Education: The highest level of education that respondent attained Dividing the market

into different education groups: It is express in terms of number of year that patient had been studied at school or college (1 High school and under; 2: Diploma/Some College;

3: Completed College/University; 4: Ph.D or Master‘s Degree)

 Using HIC: Whether the patient using health insurance card or not (1: Using HIC; 0:

Not using HIC)

 Satisfactions: is as a judgment following a consumption experience-it is the consumer‘s

judgment that a product provided (or is providing) a pleasurable level of related fulfillment (adapted from Oliver 1997)

consumption- Patient Satisfaction: Allows the patient to personally evaluate their interpersonal

aspects of their care (Medicine, Admission, Food Services, Physical Setting)

 Patient expectation: means uncontrollable factors including past experience,

personal needs, word of mouth, and external communication about

healthcare services Patient expectations are standards or reference points that patients bring into the service experience

 Patient perception: means patient‘s feelings of pleasure/displeasure or the

reaction of the customers in relation to the performance of the hospital

staffs in satisfying/dissatisfying the services These are subjective assessment of actual service experience

 Tangibility: is defined as external representation of the physical facilities, equipment,

medical staffs and materials, information tools In this study, tangibility is measured by

a five - items question on tangibility which is answerable by 5 level of satisfaction from

1 to 5 as described in the Likert scale The mean value for the tangibility items is the measure for tangibility The higher the mean, the higher will be the perceived tangibility

of the respondents

 Reliability: is defined as the ability to make appropriate service and exactly what

commitment, promise; the ability to perform the promised service dependably and accurately In this study, reliability is measured by a six - items question on reliability which are answerable by 5 level of satisfaction from highly satisfied to highly dissatisfied The mean value for the reliability items is the measure for reliability The higher the mean, the higher will be the perceived reliability of the respondents

 Responsiveness: is defined as the desired level and the willing of serving patients in a

timely manner It is also reflect in terms of the willingness to help patients and provide prompt services In this study, responsiveness is measured by a five- item question on this aspect which is answerable by 5 level of satisfaction from 1 to 5 as described in the Likert scale The mean value for the responsiveness items is the measure for responsiveness The higher the mean, the higher will be the perceived responsiveness of the patients

 Assurance: is defined as the knowledge and courtesy of the physicians and their ability

to convey trust and confidence that will ensure freedom from physical risk and instill

the patient‗s confidence in a successful medical outcome It can be expressed in terms

of knowledge and courtesy of medical staff and their ability to inspire trust and confidence In this study, assurance is measured by a four-item question on this aspect which is answerable by 5 level of satisfaction from 1 to 5 as described in the Likert scale The mean value for the assurance items is the measure for assurance The higher the mean, the higher will be the perceived assurance of the respondents

 Empathy: is defined as the interest and interaction the physician has with his patient

and their willingness to help the patient and provide prompt service as well as the caring, individualized display of professional ability to the patient- physician reliability: The ability to perform the promised service dependably and accurately In this study, empathy is measured by a five - items question on the questionnaire which are answerable by 5 level of satisfaction from highly satisfied to highly dissatisfied as described in the Likert scale The mean value for the empathy items is the measure for empathy The higher the mean, the higher will be the perceived empathy of the respondents

The author try to access the overall service quality of the hospital through patients‘ expectation and perception directly The answers are based on a five-point Likert scale of patients‘ overall satisfaction and their intention to return and recommend to others

1.7 Significance of the study

Significance to Theory: The study findings help to build on the body of the existing

literature and knowledge This can help to provide reference for future researchers and they can carry out research with ease since this study provides secondary data to the researchers The study helps to build on the researcher‘s knowledge and understanding of the study variables It also helps the researcher to gain more skills of conducting research It is a reference the researcher to appreciate the concept of health care services

Significance to Practice: The study findings help to identify and highlight the weaknesses

in health care service of hospital and how is patients ‗satisfaction The analysis of SERVQUAL model indicates that all patient satisfaction dimensions positively and significantly contributes

to patient satisfaction and which also act as an important mediating factor between the satisfaction dimensions and service quality Hospital‘s board of manager can find their strengths and weakness in delivering health services, improving their services quality and enhancing competition capacity of hospital to utilize resources and meet the need of patients The patients would have chance to express their opinion to contribute to the continuously improvement of health care services in public hospital

Significance to Social Change: The study is also expected to add knowledge about health

care services to the public This will help the public recognize and appreciate health care services

In general, the research has both theoretical and practical implications On a practical note, healthcare providers need to measure health service quality and patients ‗satisfaction due to its high correlation with issues essential to the hospital bottom-line and the reputation of the hospital

in the market By identifying defective areas through implementation of the scale and the model, the service provider could address each need and reallocate resources accordingly thus aiming to improve patients‘ perceptions and eventually satisfaction with the services provided by the hospital And since patient‗s satisfaction has been strongly linked to future purchase and recommendation behavior in the current research, this stresses the importance of measuring patient satisfaction in hospitals in accordance with the hospital quality

1.8 Scope and Delimitation

1.8.1 Scope of the study

Content scope: The study focuses on assessing the overall perceived service quality of

patients and their satisfaction with health care services at Thai Nguyen National Hospital

Time scope: Research was conducted from 2015 to 2016

- Secondary data was collected for the period 2010-2015

- Primary data was collected during 15th, June - 31st, August, 2016

Space scope: The research was conducted at Thai Nguyen National Hospital, Thai

Nguyen city, Vietnam

1.8.2 Delimitation

The quality of health care is reflected through outcomes, which is an end point of interest in care delivery, public policy, or evaluation of services In general, there exits three types of outcomes are studied in health care evaluations: those related to patients, those related to treatments, and those related to the system Patient-related outcomes represent the effects of delivering care In this research, the author only concentrates on the outcomes related to patients and the system, and set aside the outcomes which are related to treatments because of technical issues

Patient-related outcomes represent the effects of delivering care in a particular system

on the patient‘s ability for self-care, physical function and mobility, emotional and intellectual performance, and self-perception of health System-related outcomes represent the effect on the health care system produced by the provision of medical services to a patient population Examples of the outcomes studied in health services research include performance benchmarks, requirements for pain medication, length of hospital stay, waiting times, frequency of read mission, and frequency and severity of secondary health complications

CHAPTER II REVIEW OF RELATED LITERATURE AND STUDIES

2.1 Review of related literature

2.1.1 The concept of public health service

 Public services

A study carried out by Johns (1998, p.954) points out that the word ‗service‘ has many meanings which lead to some confusion in the way the concept is defined in management literature, service could mean an industry, a performance, an output or offering or a process

He further argues that services are mostly described as ‗intangible‘ and their output viewed as

an activity rather than a tangible object which is not clear because some service outputs have some substantial tangible components like physical facilities, equipment and personnel

According to economics view, public services related with these basic characteristics: (1) Non-excludable: is the attribute that was created when it is difficult to exclude anyone from using it These goods do not have to rule are those goods that everyone can access and use it that cannot be prevented

(2) Non-competitive: is this person's consumption does not reduce the consumption of others In other words, such services when a user or multiple users it is the same

In terms of the two criteria of public goods do not exclude non-competitive and the health services are a commodity -specific public service nature of public goods has, both private nature For public health services, the nature of many more, for health services as required, the nature of goods to more investment The approach based on the role of the State and the market in the provision of public goods and services Accordingly, there are all kinds

of goods and services the core of the public sector and public sector expansion (Truong Bao Thanh, 2013)

From the above characteristics, in my view, public services can be understood as an activity essential to meet the needs of society, for the common good of the community, society and the State is directly assumed or authorized and facilitated the private sector implementation For this type of goods and services expanded public sector can apply the mechanism of competition in this area to improve efficiency in the provision of services to better meet the needs of society

Edvardsson (1998, p.142) thought that the concept of service should be approached from the customer‘s perspective because it is the customer‘s total perception of the outcome which is the ‗service‘ and customer outcome is created in a process meaning service is

generated through that process He pointed out the participation of the customer in the service process since he/she is a co-producer of service and the customer‘s outcome evaluated in terms of value added and quality meaning the customer will prefer service offered to be of high value and quality Service process is that which consists of either, delivery of service, interpersonal interaction, performance or customer‘s experience of service

 Public health services

In life, people always have health care needs not only of themselves but of the whole family Not only when the disease occurred, people need to be running but we still need health care services when we are in good health

According to the World Health Organization (WHO): Health services include all services related to the diagnosis and treatment of disease and the care and rehabilitation of health These include personal health services and public health services

Health services are professional services offered by doctors This is considered as pure services with the service being produced and consumed simultaneously for both the consumer and the provider and the consumer is an integral part of the service process

According to Dr Le Chi Mai: Medical services including medical services, immunization, and prevention of disease This is seen as a fundamental human right, so unable to dominate the market for which it is the responsibility of the state In summary, there are many concepts of health services stated under different angles but the overall gains: Medical services are a commodity-specific public services, to meet the basic needs of the people and the community, including two groups of public sector service expansion: group services and treatment on demand (nature of capital goods can be applied more competitive mechanisms in this market) and the group of public health services such as disease prevention (nature of public goods more) by the State or private undertook

 Characteristics of health services

On the health care market there exists a monopoly position of the hospital has many specialists, a good doctor with the material and technical basis of modern, especially the medical equipment makes modern diagnosis and treatment is accurate and efficient

For medical services market, the demand for medical services and treatment of people dependent on the disease status of the population and the health care needs of the people On the regular market imbalance between supply and demand, status nation‘s uncontrolled epidemic situation to spread disease, uncontrolled environmental pollution may cause mass illness for the population in residential areas of environmental contamination

According to the U.S Department of Health and Human Services, Public health practices across the entire system should reflect the following characteristics:

 Population-centered–protecting and promoting healthy conditions and the health of the entire population

 Equitable–working to achieve health equity

 Proactive–formulating policies and sustainable practices in a timely manner while rapidly mobilizing to address new and emerging threats and vulnerabilities

 Health-promoting-ensuring policies and strategies that advance safe practices by providers and the population and that increase the probability of positive health behaviors and outcomes

 Risk-reducing-diminishing adverse environmental and social events by implementing policies and strategies to reduce the probability of preventable injuries and illness or other adverse outcomes

 Vigilant-intensifying practices and enacting policies to support enhancements to surveillance activities (e.g., technology, standardization, systems thinking/modeling)

 Transparent-ensuring openness in the delivery of services and practices with particular emphasis on valid, reliable, accessible, timely, and meaningful data that are readily available to stakeholders, including the public

 Effective-justifying investments by using evidence, science, and best practices to achieve optimal results in areas of greatest need

 Efficient-understanding costs and benefits of public health interventions and facilitating optimal use of resources to achieve desired outcomes

2.1.2 Quality of public health services

Quality can be defined as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge Quality can also refer to services evaluated at the individual or population level of analysis.According to Hardie and Walsh (1993, p.75); Sower and Fair (2005, p.8); Wicks and Roethlein (2009, p.82), quality has many different definitions and there is no universally acceptable definition of quality They claim it is because of the elusive nature of the concept from different perspectives and orientations and the measures applied in

a particular context by the person defining it In our study, quality must be well defined in the context of grocery stores and must focus on various dimensions of both product and service This therefore means the definition of quality varies between manufacturing and services industries and between academicians and practitioners

The quality of service – both technical and functional – is a key ingredient in the success of service organizations (Gronross, 1984) Technical quality in health care is defined primarily on the basis of technical accuracy of the diagnosis and procedures Functional quality, in contrast, relates to the manner of delivery of health-care services

Health care quality is a very difficult concept to define This is the definition that was originally used during the landmark reports of the Institute of Medicine starting with Lohr (1990) It is still widely used in studies of health care quality because it places an appropriate emphasis on both individual and population levels of analysis, links health care services (and their constituent processes) with desired health outcomes and focuses upon the gap between current versus desired practices

Public health service is a part of the public sector related to medical examination and treatment, convalescence and rehabilitation of object‘s physical and mental to provide services consistent with the interests of the community and society It consists of three elements: structure, process and outcome (Donabedian, 1996) The structure related to technology, infrastructure and capacity; the process is the interaction between service providers and patients; results can be assessed by the deaths, patient satisfaction and respond (Narang and Ritu, 2011)

Quality assessment in public health is the measurement of achievement of population health objectives and practices Public health agencies worldwide have increasingly recognized the potential benefits of quality assessment and the need of formal assessing and improving the quality of their services Measuring quality can help monitoring progress toward public health goals and become more accountable to the populations they serve Public health quality indices are quantitative statements of quality assessment about the capacity, actions, or results of public health practices (Zhao et al., 2015) It is important to develop a framework of quality assessment indices for public health services

In health care sector, quality can be defined as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge Quality can also refer to services evaluated at the individual or population level of analysis Health care quality is a very difficult concept to define This is the definition that was originally used during the landmark reports of the Institute of Medicine starting with Lohr (1990) It is still widely used in studies of health care quality because it places an appropriate emphasis on both individual and population levels of analysis, links health care services (and their constituent processes) with desired health outcomes and focuses upon the gap between current versus desired practices

Figure 2.1 Health care environment – setting system regulation

- Whose Perspective Should Be Addressed In Quality Assessment?

 Practitioners: Technical knowledge, interpersonal skills, amenities of care

 Patient: Above considerations plus any felt gap between personal experiences

versus expectations

 Community: Access to care, technical performance, monetary costs.

- Essential Elements of High Quality Health Care

 Provision of appropriate services in a technically competent manner

 Effective communication

 Shared decision making

 Cultural sensitivity

- The necessary To Improve Health Care Quality

 High costs of health care services

 Regulatory pressures

 Excessive variation in practice

 Growing power of the purchaser

 Malpractice incidents

 Declining morale among health care workers

If quality-of-care criteria based on structural, process, or intermediate outcomes are to be credible, it must be demonstrated that variations in the attribute they measure lead to differences in health status outcomes

In the Nordic model of service quality, popularized by Christian Grönroos total perceived service quality is the outcome of an evaluation process where the customer compares context specific expectations of quality with the experienced quality The expectations of quality are context specific to the firm under consideration and not based

on the total class of service providers, as is the case in the Anglo-Saxon model The expected service is influenced by the marketing activities of the service provider and external influences, such as word-of-mouth, corporate image and customer needs

Third quality dimension identified by Grönroos is the image of the service provider, which moderates both technical and functional quality to arrive at a perceived level of service The public image of the service provider appears in both sides of the total perceived quality equation as it is also considered to moderate expected quality Grönroos indicated that technical and functional quality are interrelated, but argued that functional quality was more important to the quality of the service, as perceived by customers, than the other factors and that the performance of staff in direct contact with customers can compensate for a lower technical quality

 Define service quality and health care service quality

Because of increasing competition and more demanding consumers, service quality has become an important issue for virtually all businesses and in the medical field in particular due to the high importance of excellent service quality in a field where poor service quality could ultimately lead to morbidity However, quality is difficult to measure for service providers in the medical field

Healthcare service quality has been regarded as a multi-dimensional construct It has been envisioned to be composed of two main parts: quality as perceived by the consumer and quality in fact Although many researchers argue the point that the 'real' quality of a service cannot be accurately portrayed in patient's perceptions, however patients will always continue to draw their own conclusions about the quality of the service In healthcare especially, perception for the patient is the reality and it is the perceived quality as opposed to the actual or absolute quality that is important for healthcare professionals to manage This is the basis on which consumers make purchase, repurchase and recommendation decisions (Paul, 2003)

According, Parasuraman et al (1985), the intangible elements of a service (inseparability, heterogeneity and perishability) are the critical determinants influencing service quality perceived by a consumer

As Lewis and Booms (1983) have put it, ―service quality is a measure of how well the service level delivered matches customer expectations Delivering quality service means confirming to customer expectations on a consistent basis‖

―Because of intangibility, the firm may find it difficult to understand how consumers perceive their services & evaluate service quality‖ (Zeithaml, 1981) In order for a company‘s offer to reach the customers there is a need for services These services depend on the type of product and it differs in the various organizations Service can be defined in many ways depending on which area the term is being used An author defines service as ―any intangible act or performance that one party offers to another that does not result in the ownership of anything‖ (Kotler and Keller, 2009, p.789) In all, service can also be defined as an intangible offer by one party to another in exchange of money for pleasure

According to Kendrick and Michael (1994), there are thirty ingredients of quality services Thirty points demonstrated as a long time of assembling the observations, researching and study from the suggestion of W Wolfensberger in 1983 Generally, thirty elements listed mentioned to two main objectives: customers and service providers To provide the best services, the providers need to have understanding of the service and standards as well as the demanding for their customers They also need to be provided the good materials These are mentioned as ―appropriate acknowledgment and support for the existential, emotional and spiritual struggles of the person served‖ (Thirty elements of service quality, Michael J Kendrick, 1994)

Many researchers have researched service quality and considerable findings and progress has been achieved in the measurement of service quality (Zeithaml et al., 1988; Gronroos, 1984) strong findings as well as opposing critique against the usefulness of the existing satisfaction measures (Peterson and Wilson, 1992; Carman, 1990; Cronin and Taylor,

1992, 1994) has emerged A brief overview on the relevant literature will be tackled in the following section

Due to intangibility, inseparability, heterogeneity, and perishability characteristics of services, it is very difficult to define service quality Various researchers have defined health care service quality in their study which is given in table below:

Table 2.1 Summary of service quality (SQ) definition

1 Christian Gronroos 1984 SQ is usually evaluated in terms of technical

quality and functional quality

2 Leonard Berry et al 1988 SQ is defined as ―conformance to customer

specifications‖

3 Avais Donabedian 1988

Quality has also been defined as ―The abilities

to reach the desired objectives using legitimate means‖

7 Sachdev and Verma 2004

SQ can be measured in terms of customer perception, expectation, satisfaction, and attitude due its characteristics of services

SQ is considered as an important tool for a firm‘s struggle to differentiate itself from its competitors

The quality of service is an important determinant of population health and in this respect Vietnam is far behind Though health is regarded as a fundamental human right, uniform dispensation of health service facilities to the entire population has not yet been observed in Vietnam The number of government hospitals in Vietnam was 910, from national

to provincial level, account for 85.4% of total hospital over the country (General Statistics Office of Vietnam, 2014) Hospitals are health establishments which having specialized departments, surgeon rooms, testing room, equipment for disease diagnosis and health staff like doctors, physicians, nurses, etc

In this research, health service quality is defined as the degree and direction of discrepancy between patients‘ service perceptions and expectations It is a comparison of

perceived expectations (E) of a service with perceived performance (P) Thus if the perception

is higher than expectation, then the service is said to be of high quality Likewise, when expectation is higher than perception, the service is said to be of low quality

2.1.3 Factors affecting health service quality

Various models have been developed to measure service quality following these approaches either attitude-based measures or disconfirmation models It is very important to measure service quality because it allows for comparisons before and after changes, identifies quality related problems, and helps in developing clear standards for service delivery

The SERVPERF model developed by Cronin and Taylor, (1992), uses the performance approach method which measures service quality based on customer‘s overall feeling towards service This model is good to measure service quality but does not provide information on how customers will prefer service to be in order for service providers to make improvements

Teas (1993) developed the Evaluated Performance model which measures the gap between perceived performance and the ideal amount of a dimension of service quality, rather than the customer‘s expectation This was to solve some of the criticism of some previous models Gronroos (1984) and Parasuraman et al (1985, 1988)

The American scholar: Zeitham VA, Parasuraman A and LB Leonard have launched the decisive factor in the quality of services, including 10 factors or dimensions as follow:

Gap 5

Figure 2.2 Factors affecting services quality of Parasuraman

The first is reliability: the consistency in operating, performing correctly the function

from the outset, complies with promises made to customers reliable

The second is a sense of responsibility: the zealous or the willing of providing service

at the right time, timely of the supply staff

The thirst is the capacity: Employees must have the necessary skills and knowledge to

work in this service

The fourth is the excusableness: It is easy to access, with the waiting time, with

opening hours

The fifth is the behavior: the polite, respect, caring and friendly of staff in the

enterprise with customers

Expectation

Perception

Perceived Service Quality

The sixth is the communication: Inform with the customers by their own words, listen to

the opinions of our customers, adjusted for how to communicate with different groups of clients, explain that the service process itself will cost how much and it help solve what problem

The seventh is the credibility: honesty, trustworthy, reputation of the enterprise, the

personal qualification of the servants

The eighth is the safety: Client felt no danger, no risk or doubt, safe in physic, in

finance, maintain the client‘s confidentiality

The ninth is the customer insights: the efforts of understanding the customer's needs,

keeping in mind the specific requirements of each individual, creating the attention to the individual, identifying the regular and loyal customers of the enterprise

The tenth is the visible: the physical evidence of the service, the facilities, the

appearance of staff, and the equipment to conduct services, physical symbol of service

The model shows the relationship of 10 quality factors and the customer‘s expectations The difference between health care and customer service from the above definition can be seen the concept of health care consists of two parts: Firstly, health care is customer service in a way that they want to serve Secondly, health care aiming to hold the existing customers, create customer loyalty This makes the main difference between the two concepts of health care and customer service

In Vietnam, a set of quality criteria for evaluating hospitals (including 83 criteria under 5 sections: Navigate to the patient, human resource development, professional activities, quality improvement, and specialty criteria)

Health care as well as many other marketing activities are geared towards satisfying the needs and expectations of customers Actually there are many different factors to satisfy the customer These factors are divided into three main groups:

 The factor of product: diversity of product, price, quality

 The factor of convenience: location, delivery terms and conditions of change, opening times, payment methods

 The human factor: the skill level of sales, attitude of staff behavior

2.1.4 Measuring the quality of healthcare service

Measuring the quality of health care is important because it tells us how the health system is performing and leads to improved care With some special characteristics of health service quality such as quality associated with health; This is a special services that people have to use even if they don‘t have money; Service do right at the first time, don‘t have chance to try; Patients do not control services they used, quality measures can take many

forms, and these measures evaluate care across the full range of health care settings, from doctors‘ offices to imaging facilities to hospital systems

Quality measurement in health care is the process of using data to evaluate the performance of health plans and health care providers against recognized quality standards (Families USA, 2014) Measuring the quality of health care is a necessary step in the process

of improving health care quality

 Types of service quality measures

Although the aims above suggest how one might measure quality, there are multiple approaches to measuring different aspects of quality One of the first comprehensive works that focused on quality of care was published in a series of three books by Avedis Donabedian (Donabedian, 1980, 1982, 1985) A subsequent article (Donabedian, 1965) summarized that work Donabedian proposed that one could assess whether high quality care is provided by examining the structure of the setting in which care is provided, by measuring the actual

process of care, and/or by assessing what the outcomes of care are

Table 2.2 Types of quality measures

1

Structure Assesses the characteristics of a care setting, including

facilities, personnel, and/or policies related to care delivery

2

Process Determines if the services provided to patients are consistent

with routine clinical care

3 Outcome Evaluates patient health as a result of the care received

4 Patient Experience Provides feedback on patients‘ experiences of care

Structure: refers to the characteristics of the setting in which care takes place Measures

of the setting used might include characteristics of:

 Physicians and hospitals (e.g., a physician's specialty or the ownership of a hospital);

 Personnel; and/or

 Policies related to care delivery

Increasingly, we view structure as not just the way clinics and hospitals are organized and operated, but by the policies they have in place that affect care quality For example, processes for monitoring and promoting quality, incentives for high quality care, etc can have an influence on how well care is delivered A motivation for focusing on structure is the premise that the setting can be a strong determinant of care quality and given the proper system, good care will follow For example, one would expect care to be

of higher quality when all staff are clear about their roles and responsibilities, when there are strategies for monitoring adherence to recommended procedures, and there are systematic approaches to continuously improving care quality

Process: measures assess whether a patient received what is known to be good care

They can refer to anything that is done as part of the encounter between a physician and another health care professional and a patient, including interpersonal processes, such as providing information and emotional support, as well as involving patients in decisions in a way that is consistent with their preferences, etc

Process measures are used to determine the extent to which providers consistently give patients specific services that are consistent with recommended guidelines for care These measures are generally linked to procedures or treatments that are known to improve health status or prevent future complications or health conditions (Jerry Cromwel at el, 2011)

Outcomes: refer to a patient's health status or change in health status (e.g., an

improvement in symptoms or mobility) resulting from the medical care received This includes intended outcomes, such as the relief of pain and unintended outcomes, such as complications Although the term ―outcomes‖ is sometimes used loosely to refer to results such as mammography rates, such measures are actually process measures in the Donabedian sense There is also a category of measurement called intermediate outcomes This includes measures like Hemoglobin, A1 levels for people with diabetes and blood pressure measurements These intermediate outcomes are often closely related to other health outcomes

Outcome measures evaluate patients‘ health as a result of the care they have received More specifically, these measures look at the effects, either intended or unintended, that care has had on patients‘ health, health status, and function They also assess whether or not the goals of care have been accomplished Outcome measures are where the rubber meets the road: Patients are interested in surviving illness and improving their health, not the clinical processes that support these outcomes

Patient Experience:

Patient experience measures provide feedback on patients‘ experiences of their care, including the interpersonal aspects of care But these measures assess many other aspects of care, ranging from the clarity and accessibility of information that doctors provide, to whether doctors tell patients about test results, to how quickly patients are able to get appointments for urgently needed care

Research shows that positive patient experiences have a well-documented relationship

to clinical quality: Patients with better care experiences are often more engaged in their care, more committed to treatment plans, and more receptive to medical advice

Experts are increasingly advocating for the inclusion of patient experience as a key measure

of quality as the movement to improve health care quality continues to develop and evolve

2.1.5 Patients’ satisfaction

Researchers have tried to define patient satisfaction and in general they have defined it

as transaction process Oliver (1981) defined satisfaction ―as a summary of psychological state resulting when the emotion surrounding disconfirmed expectations is coupled with the consumer's prior feelings about the consumption experience" (pp 24) Kotler (2000) defined satisfaction as: ―a person‘s feelings of pleasure or disappointment resulting from comparing a product perceived performance (or outcome) in relation to his or her expectations‖ Parasuraman et al (1991) divide customer service expectations into two levels: desired and adequate Desired level of service expectations is a state of service the customer desires to receive, whereas adequate level of customer expectation is the level of service the customer can only ―accept‖ without being too satisfied with it

Awareness of patients is becoming more important in assessing the quality of health services for their opinions may use for meaningful change in the health system Moreover, the perceptions of the users can be added for the evaluation of medical staff, public health establishments ultimately leading to "an optimal balance between the services supply and expectations use"(Narang and Ritu, 2011) Trends emphasized the patient's perspective in order to improve the quality of health services is concerned in the US and Northern Europe and become strategies in many other countries with different levels (Narang and Ritu, 2011)

Patient satisfaction is considered the in the last stage of the buyer decision process which is constituted of need recognition, information search, evaluation of alternatives, purchase decision and the post-purchase behavior (Kotler and Armstrong, 1999) Satisfaction

is important since a company's revenue comes from two basic groups, new customers and retained customers It costs much more to attract new customers than it does to retain older ones thus it makes sense for marketers to strive to retain their customers through achieving patient satisfaction since satisfied customers re- purchase, talk favorably to others about the brand, pay less attention to competing brands and advertising thus are less likely to switch and but products and alternatives from other companies (Kotler and Armstrong, 1999) Some marketers go beyond merely meeting the customers' expectations to aiming to delight the

customer thus ensuring that they are more likely to re-purchase, talk favorably of the product and pay premium prices (Kotler and Armstrong, 1999)

The hospital marketer is now concerned in how to build an increase in demand for his organization versus other organizations Building customer loyalty through satisfaction with the offered services as well as attracting new customers is one of the main targets of a hospital To ensure patient satisfaction, hospital marketers used patient surveys to ask patients

to rate their satisfaction with the services offered Surveys are a useful and simple management tool that gives a direct reflection of patient satisfaction with hospital services (Swan et al., 1985)

It is believed that increases in patient satisfaction can be achieved with improving the services that rated low in the satisfaction surveys or in services that patient relate strongly with future intentions to revisit the hospital thus enters the importance of measuring consumer satisfaction with the service quality (Anderson, 1981)

Another important aspect of the healthcare industry is a hospital is composed of both

a technical (medical service) and functional (hospitality service) aspect Steven D Wood, PhD, Executive Director of JD Power and Associates Healthcare Division states that - we believe patients can separate their personal medical outcome from their service experience during their hospital stay With that in mind, hospitals can definitely differentiate themselves

on the basis of the service aspects of the patient experience

Patients enter the hospital in a heightened state of anxiety, making empathy and relevant information both welcome and highly valued Patients also place a high value on the service aspects of their hospital experience – such as food, comfort of the bed, room amenities, and the responsiveness of the staff-just as a hotel guest would do‖ (Managed Care Weekly Digest, 2003) A hospital marketer should focus on improving both aspects of the hospital service and not just one or the other

2.1.6 Service quality and Relationship with Customer Satisfaction

The study of consumer satisfaction has always been one of the central issues in marketing in today‗s competitive marketplace, where companies needs to satisfy its customers to ensure its profitability Briefly, the work of the foremost authors in the subject will be highlighted in the following section

One of the earliest concepts of consumer satisfaction literature is the confirmation/disconfirmation concept The majority of studies in consumer satisfaction are based on this paradigm This is traced back to the early consumer behavior models (Nicosia,

1966; Engel et al., 1968; Howard and Sheth, 1969) These theories incorporate purchase evaluation as an integral part in mapping the consumer decision process

post- Confirmation: Occurs when performance matches the standard The patient experiences a neutral feeling

 Positive Disconfirmation: Occurs when performance is better than the standard and this leads to satisfaction

 Negative Disconfirmation: Occurs when performance is worse than the standard and this leads to dissatisfaction

Also prominent in consumer satisfaction literature is the equity theory that states that consumers will analyze the purchase process to determine the extent to which it is fair Dissatisfaction is the result of a perceived unfavorable ratio of outcomes to inputs in an exchange process in relation to the other party in the exchange (Fisk and Young, 1985; Cadotte et al., 1987; Murfin et al., 1995)

Furthermore, there is also the - Attribution Theory that focuses on the way people identify causes of actions (Folkes et al., 1984) In addition, the Attribution-Based Affective Feelings (Westbrook, 1987) deals with the affective feelings associated with the product or service after purchase that can influence the level of satisfaction and states that both positive and negative feelings can exist simultaneously about a purchase An example of this is on purchase of a new product there is excitement about the purchase while there might be irritation during the purchase process stemming from unfriendly sales personnel (Murfin et al., 1995)

Service literature has left confusion as to the relationship between consumer satisfaction and service quality This is important because service providers have a need to know and distinct between having customers who are satisfied with their performance or to deliver the maximum level of perceived service quality Several researchers have tried to clarify this relationship Parasuraman et al (1985, 1988) proposed that higher levels of perceived service quality resulted in increased consumer satisfaction Other researchers conclude that satisfaction is an antecedent of service quality Bitner, 1990 demonstrated a causal pathway between satisfaction and service quality Bolton and Drew, 1991 assuming that service quality is an attitude suggested that satisfaction is an antecedent of service quality They posed that ATTITUDEt (perceived service quality) is a function of consumer‗s residual perception of the service quality from a prior period (ATTITUDEt-1) and the consumer‗s level of (dis)satisfaction with the current level of service (CS/Dt)

Consumers have become more quality-conscious in the past era and the benefits of quality in contributing to market shares and the return-on-investment of firms has been clearly demonstrated (Philips et al., 1983) The definition of quality is essential before any