Int. J. Advanced Operations Management, Vol. 6, No.

4, 2014 309

Effects of service quality dimensions including

usability on perceived overall quality, customer
satisfaction, and return intention in different hospital
types

Fethi Calisir*, Ayse Elvan Bayraktaroglu,

Cigdem Altin Gumussoy and Burcu Kaya
Industrial Engineering Department,
Management Faculty,
Istanbul Technical University,
34367 Macka, Istanbul, Turkey
Email: calisirfet@itu.edu.tr
Email: ayseelvan@gmail.com
Email: altinci@itu.edu.tr
Email: burcukaya29@gmail.com
*Corresponding author

Abstract: A modified SERVQUAL approach, including usability as the sixth

service quality dimension, has been used to evaluate the effect of service
quality dimensions on perceived overall quality, customer satisfaction, and
return intention for four different hospital types operating in Turkey: public,
private, university, and military hospitals. The proposed research model was
tested with 284 patients from different hospital types, and results indicated that
usability is an insignificant factor in perceived overall quality, customer
satisfaction, and return intention prediction for all hospital types. Results
revealed that service quality dimensions having an impact on perceived overall
quality, customer satisfaction, and return intention vary among hospital types.

Keywords: service quality; SERVQUAL; usability; hospital types; Turkey.

Reference to this paper should be made as follows: Calisir, F.,

Bayraktaroglu, A.E., Gumussoy, C.A. and Kaya, B. (2014) ‘Effects of service
quality dimensions including usability on perceived overall quality, customer
satisfaction, and return intention in different hospital types’, Int. J. Advanced
Operations Management, Vol. 6, No. 4, pp.309–323.

Biographical notes: Fethi Calisir is a Professor of Industrial Engineering at

Istanbul Technical University. He graduated with a BS from Istanbul Technical
University in 1989, an MS from the University of Miami in 1993, and a PhD
from Purdue University in Industrial Engineering in 1996. His current research
interests include service quality, intellectual capital, IT project management,
usability, and human-computer interaction. His research papers have appeared
in Computers in Human Behavior, Computers & Industrial Engineering,
Total Quality Management, Accident Analysis & Prevention, Technovation,
Managing Service Quality, International Journal of Information Management,
Management Research News, and Internet Research.

Copyright © 2014 Inderscience Enterprises Ltd.

310 F. Calisir et al.

Ayse Elvan Bayraktaroglu is a PhD student and Research Assistant at the

Department of Industrial Engineering at Istanbul Technical University. Her
interests are intellectual capital, human computer interaction, and usability.

Cigdem Altin Gumussoy is an Assistant Professor of Industrial Engineering

Department at Istanbul Technical University. Her current research interests are
intellectual capital, IT project management, and technology acceptance. Her
research papers have appeared in Technovation, International Journal of
Information Management, Management Research News, and Computers in
Human Behavior.

Burcu Kaya graduated with a BS in Industrial Engineering from Istanbul

Technical University. Her current research interests include service quality and
usability.

This paper is a revised and expanded version of a paper entitled ‘Effects of

service quality dimensions on customer satisfaction and return intention in
different hospital types’ presented at International Conference on Industrial
Engineering and Operations Management, Istanbul, Turkey, 3–6 July 2012.

1 Introduction

Employment numbers in the service sector have been regularly growing in Turkey since
the early 1990s (Rep. of Turkey – Ministry of Industry and Trade, 2010). As a result of
the increased role of the service sector in countries’ economies such as in Turkey, the
quality of promised service has been attracting increased attention. Since the 1990s,
service quality has become a hot topic due to current recognition of its effects on
competitive advantage, increased patronage, and long-term profitability (Pakdil and
Harwood, 2005; Dean, 1999). In the literature on service quality, it is frequently
mentioned that service quality is related to customer satisfaction and customer loyalty,
both of which are essential for survival in the highly competitive service sector. To
achieve high levels of customer satisfaction and loyalty, it is decisive to meet customers’
needs and expectations or even to exceed them. However, service quality is “an elusive
and abstract construct to measure” (Lee et al., 2000; Ladhari, 2009), and it is essential to
measure it to be able to manage it. SERVQUAL was proposed by Parasuraman et al.
(1985, 1988) as a tool which measures service quality, based on the acceptance that
service quality is distinguished from objective quality by containing ‘an overall
impression’ and not being based on “predetermined standards that are measurable and
verifiable” (Ladhari, 2009). Service quality is dependent on the customers’ individual
perceptions and expectations. Thus, SERVQUAL leans on the concept that service
quality is driven by the difference between expectations from the system and actual
performance of the system (Cronin and Taylor, 1992).
As indicated by Drury (2003) “(service) encounter clearly is an interaction between a
person and a system”. In service sector customers’ involvement in the transaction process
is decisive, meaning in service transaction this interaction between customer and system
is the context where customers’ needs may be matched with attainable offerings (Drury,
2003). This interaction necessitates an approach that also includes human factors’
perspective to evaluate the service quality. In this sense, SERVQUAL constitutes a
reliable basis scale to add human factors perspective on.
 Effects of service quality dimensions 311

Due to a continuous increase of the elderly population around the globe and the rising
expenses for healthcare correspondingly, the healthcare sector has become a constantly
growing part of the service industry. Since the quality of the healthcare service directly
affects the well-being of consumers, the importance of service quality is especially high
in this sector (Pakdil and Harwood, 2005). One way of improving the quality of the
healthcare service is by using consumers’ perceptions of the provided healthcare service
to develop improvement plans (O’Connor et al., 1994). SERVQUAL has also been
largely used in studies conducted on the quality of healthcare service (Pakdil and
Harwood, 2005; Babakus and Mangold, 1992; Lonial et al., 2010; Camilleri and
O’Callaghan, 1997; Curry and Sinclair, 2002; Wisniewski and Wisniewski, 2005).
Similar to the trend around the globe, in Turkey also, the elderly population and
healthcare expenditures are increasing (Aykac et al., 2009); however, quality problems
have always been an issue in the Turkish healthcare system. In the previous decade and
even today, the Turkish healthcare system has been in a transition. The private sector has
begun showing more interest in the healthcare industry, and governments have tried to
reconfigure the healthcare system to decrease the expenditures. In this changing
environment, service quality is important not only for “issues related to competition” but
also for “increasing rationalisation, restructuring, and demands for accountability of
public services” (Dean, 1999). In the Turkish healthcare system, mainly four hospital
types are operating these days. These are public hospitals, private hospitals, university
hospitals, and military hospitals. Public hospitals are financially supported by the state;
patients usually do not pay or pay a small amount for the received service. University
hospitals are affiliated mostly to state universities; however, since one of their main
functions is research and education, university hospitals are perceived to be more
specialised in the treatment of some serious/advanced diseases. In private hospitals,
patients usually pay for the services they get, especially in case of not having a social
security. Military hospitals are run by Turkish Armed Forces, all of their healthcare
personnel are military personnel, and most of their patients are military personnel or their
family members. It can be said that customers have common perceptions toward different
hospital types. For example, public hospitals are generally perceived as hospitals working
with overcapacity due to shortage of equipment or staff, where patients have to wait for a
long time to be treated. Although a similar situation is valid for university hospitals,
longer waiting time seems to be a willingly paid price for the expertise one can get in
university hospitals. On the other hand, since in private hospitals patients have to pay for
services that they can get in public hospitals free of charge, patients of private hospitals
might have higher expectancy levels in terms of service quality.
Due to these varying expectations customers may have towards different hospital
types, our objective is to reveal the relationship between service quality dimensions
defined by Parasuraman et al. (1988) and Strawdermann and Koubek (2008), including a
human factors perspective, and perceived overall quality, customer satisfaction and return
intention for different hospital types operating in Turkey. By conducting this research we
aim to reveal whether usability is a service quality dimension for each hospital type and
by determining affecting quality dimensions to introduce the improvement areas to
ensure high levels of quality and customer loyalty for each hospital type, which might
differentiate from each other by managerial aspects, perceived expertise and customers’
quality expectations.
312 F. Calisir et al.

2 Background

SERVQUAL was developed as an instrument intended for quality measurement in the

service sector generally and has been used in various service industries such as travel
(Ryan and Cliff, 1997; Lam and Zhang, 1999), insurance (Tsoukatos and Rand, 2006),
banking (Newman, 2001; Angur et al., 1999), food and beverage (Lee and Hing, 1995),
telecommunications (Van der Wal et al., 2002), library services (Cook and Thompson,
2000), education (De Oliveira and Ferreira, 2009), and accommodation (Albacete-Saez,
2007) in several countries such as New Zealand, Hong Kong, Greece, South Africa,
Brazil, and the USA. SERVQUAL leans on the concept that the gap between consumers’
perceptions of the actual performance executed by the service provider and consumers’
expectations of the ideal performance of the service provider defines the perceived
service quality (Cronin and Taylor, 1992).
Along with SERVQUAL, the other most widely used service quality scale is
SERVPERF (Cronin and Taylor, 1992), which differs from SERVQUAL by considering
consumers’ perception as the only driver of service quality. In a study conducted on the
performance of different service quality measures in banking sector (Angur et al., 1999)
it has been claimed that SERVQUAL provides “greater diagnostic information”
compared to SERVPERF (Angur et al., 1999). Creators of SERVQUAL claimed that
SERVQUAL shows good reliability and validity and if necessary, offers a good basis for
the customisation for specific needs of a service sector/organisation (Parasuraman et al.,
1988). As reported by Seth et al. (2005), in the service quality literature, there have been
service quality measurement models that are based on SERVQUAL or its alterations
(Cronin and Taylor, 2002; Teas, 1994; Sweeney et al., 1997; Zhu et al., 2002;
Strawdermann and Koubek, 2008; etc.). The generally used form of SERVQUAL
consists of five determinants representing 22 items. These five determinants are
tangibles, reliability, responsiveness, assurance, and empathy. In his study on 20 years of
SERVQUAL research, Ladhari (2009) indicated that although SERVQUAL has received
numerous criticisms since it was developed, it still abides as a useful tool for service
quality studies (Ladhari, 2009).
In their study on the importance of human factors in service quality measurement,
Strawdermann and Koubek (2008) argued that human factors should be considered as an
integral part of service quality. They pointed out that human factors relate to “behaviour,
limitations and abilities” of both customers and service providers which may affect the
process and success of the service transaction (Strawdermann and Koubek, 2008). They
considered the usability dimension as a means of human factors in services and proposed
an altered SERVQUAL model, namely SERVUSE, which included usability as the sixth
service quality dimension. Since some sub-dimensions of usability, meaning efficiency,
errors, and satisfaction, coincide with responsiveness, reliability and tangibles dimensions
of service quality, usability, and service quality are reconcilable. The usability dimension
used in the SERVUSE model translates only learnability and memorability notions.
Similar to Cronin and Taylor’s (1992) study, they also examined not only gap scores
between customers’ expectations and perceptions but also the perception scores’
predictive ability on customer satisfaction and return intention. The results of their study
showed that addition of the usability dimension supported the performance of their model
in the case of return intentions examined using the difference between perception and
expectation scores (Strawdermann and Koubek, 2008).
 Effects of service quality dimensions 313

In the literature, there is an amount of studies on the service quality of Turkish

hospitals of different types. Most of them have used original SERVQUAL model as their
proposed quality assessment tool for different hospital types. For example, Caha (2007)
assessed patients’ perception of service quality in private hospitals using original
SERVQUAL; Taner and Antony (2006) compared public and private hospitals in terms
of service quality and concluded that private hospitals scored better; Bakar et al. (2008a,
2008b) applied the SERVQUAL survey to the patients of a university hospital network
and revealed the relationships between patients’ profiles and patients’ expectation scores;
Pakdil and Harwood (2005) used an ‘early-period’, 10-dimension version of
SERVQUAL scale in their study conducted in a preoperative assessment clinic. In the
literature there are also studies using service quality assessment tools inspired by
SERVQUAL. For example, in their 2004 dated study, Yıldız and Erdogmus (2004)
developed a patient satisfaction measurement tool based on SERVQUAL and
implemented it in 31 different hospitals, without mentioning the hospital types. Similarly,
Yagci and Duman (2006) have developed a service quality measurement tool based on
dimensions of the SERVQUAL method. They have focused their study on university,
public, and private hospitals. They defined four dimensions for measurement of service
quality in hospitals. In some studies ‘courtesy’ is added as the sixth dimension to the
original SERVQUAL model. Employing courtesy as the sixth dimension of
SERVQUAL, Lonial et al. (2010) tried to evaluate the reliability and validity of
SERVQUAL in the Turkish context without mentioning the type of the hospital where
they conducted the study. They found that, although service quality has an effect on
overall quality, there is no significant relationship between service quality and customer
loyalty. Similarly, Aykac et al. (2009) used courtesy as the sixth dimension in their study
conducted in a university hospital. Also Kara et al. (2005) employed ‘courtesy’
dimension and found out that in Turkish public healthcare services, intangible dimensions
have more importance than the tangible dimensions in terms of service quality and
customer satisfaction. However, to our knowledge, there is no study adopting a model
which comprises also human factors’ point of view to determine the affecting quality
dimensions for four different hospital types operating in Turkey. Similar to
Strawdermann and Koubek (2008), our research objective is to evaluate the effect of
service quality dimensions, including usability, on perceived overall quality, customer
satisfaction, and customer loyalty for four different hospital types operating in Turkey.

3 Methodology

3.1 Model
Our research model is given in Figure 1. Definitions of the service quality dimensions,
adopted from Strawdermann and Koubek (2008), are listed next. It is assumed that a
person’s perception of service quality is the composition of that person’s perception of all
these dimensions. Items under each dimension were constructed according to healthcare
service context.
• reliability (REL): “delivering the promised performance dependably and accurately”
• tangibles (T): “appearance of organization’s facilities, employees, equipment, and
communication materials”
314 F. Calisir et al.

• responsiveness (RES): “willingness of the organization to provide prompt service

and help customers”
• assurance (A): “ability of an organization’s employees to inspire trust and
confidence in the organization through their knowledge and courtesy”
• empathy (E): “personalized attention given to a customer”
• usability (U): “ease of learning and memorizing of where, how and from whom to
receive the offered service”.
In the literature, it is frequently argued that service quality affects customer satisfaction
and/or return intentions positively (‘repatronage intention’/‘purchase behaviour’/‘return
behaviour’) (Pakdil and Harwood, 2005; Cronin and Taylor, 1992; Lonial et al., 2010;
Aykac et al., 2009; Strawdermann and Koubek, 2008). To evaluate this effect on a
different hospital-type basis, along with overall perceived quality, we selected customer
satisfaction and return intentions as dependent variables.

Figure 1 Proposed model (see online version for colours)

3.2 Instrument
The instrument was constructed in accordance with Strawdermann and Koubek’s (2008)
study. Six dimensions, five from the original SERVQUAL scale and usability as the sixth
dimension as proposed by Strawdermann and Koubek (2008), and three dependent
variables, meaning perceived quality, return intention, and customer satisfaction, are
addressed in the instrument. Item selection for the scale was based on the items
customised for healthcare services by Strawderman and Koubek (2006). At the end, a
total of 18 items adopted from Strawdermann and Koubek (2006) were included in the
scale: three for tangibles, two for reliability, three for responsiveness, three for assurance,
three for empathy, and four for usability. Items for each dimension are given in
Appendix. The questionnaire designed for this study consisted of 4 parts. The first part
included demographic questions regarding gender, age, and education level. The second
and third part of the questionnaire contained questions based on selected items that
measure the expectations of patients from a health service and their perceptions of the
actual service they received. Respondents answered the questions on a seven-point Likert
scale, with 1 representing the lowest agreement level and 7 representing the highest. The
difference between the perceptions of actual experience and expectations has been used
to evaluate the service quality. A negative difference means that the actual performance
failed to reach the expectations. A positive score means that their actual experience was
 Effects of service quality dimensions 315

better than their expectations. In the last part, respondents also evaluated their
satisfaction, return intention to the same hospital in the future, and their overall
perception of the quality of the hospital on a seven-point Likert scale, with 7 representing
the highest agreement level.

3.3 Sample
Data used in this study were collected from patients being served in four different
hospital types mentioned earlier. The execution took place in internal medicine services
of public, university, military, and private hospitals. Executers had permission from the
heads of the services to conduct the survey only in a limited time. Randomly selected
patients from different hospital types were asked to fill in a questionnaire. A response
rate of 71% was achieved with 284 participants, with 75 participants from private and
military hospitals each, 69 participants from public hospitals, and 65 participants from
university hospitals. The demographic profile of the participants is presented in Table 1.
As seen from the table, 64% of the participants from military hospitals are men and on
average, they are younger than the participants from other hospital types, where
participants from other hospital types show similar results in terms of age and gender.
With regard to education level, participants from public hospitals are less educated
compared with patients of other hospital types, with only 16% of participants having a
bachelor degree. Participants from university hospital show a more homogenous
distribution with as much participants having a graduate or undergraduate degree as the
ones having a high school degree.
Table 1 Characteristics of the sample for each hospital type

Public H. University H. Private H. Military H.

# of participants 69 65 75 75
Gender Female 49% 55% 56% 36%
Male 51% 45% 44% 64%
Age Min 14 17 17 17
Max 80 82 77 80
Mean 42.7 44.3 44.6 35.9
Education Primary school 45.3% 25.3% 14.7% 12%
High school 38.7% 38.7% 48% 49.3%
Bachelor’s degree 16% 30.7% 36% 32%
Master’s degree 0% 2.7% 1.3% 4%
PhD degree 0% 2.7% 0% 2.7%

4 Results

Before continuing with the regression analysis, the reliability of the measurement scale
was checked. For expectation subscales, all Cronbach’s Alpha values ranged from 0.608
to 0.874, showing good reliability. In case of difference and perception subscales, all
Cronbach’s Alpha values were higher than 0.7. To reveal the effect of service quality
dimensions on customer satisfaction, perceived overall quality, and return intention,
316 F. Calisir et al.

regression analysis was planned to be conducted via SPSS. First, multicollinearity among
the variables was checked via variance inflation factor (VIF). For all VIF values in our
study that were much smaller than 10, which was proposed as a cut-off value (Pallant,
2007), multicollinearity was not present.
Subsequently, a hierarchical regression analysis was employed to see whether
usability is a significant predictor of the dependent variables, after the SERVQUAL
dimensions had been controlled for. Since it is presented in Dean’s (1999) and Lam’s
(1997) studies that perceived overall quality and return intention are correlated with
perception and perception–expectation difference scores higher than the expectation
scores, the analysis was conducted only from the perception and perception–expectation
difference perspectives. The results are presented in Table 2. As consistent with Dean’s
(1999), Lam’s (1997), and Strawdermann and Koubek’s (2008) findings, in all cases,
regression models that used perception scores as an input source had higher adjusted R-
square values compared with ones which used difference scores, except the cases of
satisfaction-related models for university and private hospitals and return intention-
related ones for military and university hospitals. Although there seems to be some
incremental R-square change in case of adding usability as the sixth dimension to the
original SERVQUAL model, according to the F-change significance values presented in
the last column of Table 2, usability does not seem to have a predictive effect on any
dependent variable for any hospital type as the sixth dimension. The contribution of
usability dimension in the prediction of perceived overall quality, satisfaction, and return
intention is statistically insignificant.
However, since the standard multiple-regression approach was used, for some
hospital types, SERVQUAL dimensions as a group did not seem to have any predictive
power on some dependent variables. In that case, to further explore the factors
contributing to the customers’ perception of overall quality, satisfaction, and return
intention, a stepwise-regression analysis was conducted for each hospital and data source
type. Results are given in Table 3.
According to the results presented in Table 3, usability is the only dimension that
seemed to be insignificant in all regression models. The highest adjusted R-square values
were obtained from the models analysing the relationship for customer satisfaction and
perceived overall quality in public hospitals. In both cases, regression models explained
more than half of the variance in dependent variables, and dimensions with a predictive
impact are the same for both perceived overall quality and customer satisfaction. These
are empathy and assurance for perception data and empathy and reliability for difference
data.
Empathy seems to have a predictive impact on the perceived overall quality and
customer satisfaction for both data types and for all hospital types except university
hospitals. It also has an effect on return intention along with tangibles for military
hospitals. In addition to the adjusted R-square differences between two data types used in
the analyses, significant variables for models using perception or difference scores as a
data source are different for some cases. For example, empathy and tangibles have an
effect on perceived overall quality when perception scores are used in the analysis;
whereas empathy and reliability seem to be predictive in case of difference scores.
Similarly, a military hospital has similar dimensions in regression models predicting both
customer satisfaction and return intention, and perceived overall quality with perception
data. These dimensions are empathy and tangibles. Interestingly, the tangibles dimension
has a predictive impact on all dependent variables only in the case of military hospitals.
 SERVQUAL adjusted SERVQUAL+usability adjusted R-Square Sig. F
Dependent variable Hospital type Data type R-square R-square change F change change Table 2
Perceived overall M ilitary Perception 0.445 0.441 0.004 0.584 0.447
quality
Difference 0.370 0.379 0.017 1.986 0.163
Public Perception 0.701 0.698 0.002 0.511 0.477
Difference 0.549 0.545 0.003 0.496 0.484
University Perception 0.420 0.426 0.014 1.573 0.215
Difference 0.405 0.397 0.002 0.202 0.655
Private Perception 0.467 0.460 0.001 0.104 0.748
Difference 0.434 0.426 0.000 0.024 0.879
Satisfaction M ilitary Perception 0.374 0.365 0.000 0.000 0.995
Regression model comparison

Difference 0.354 0.345 0.000 0.019 0.892

Public Perception 0.666 0.661 0.000 0.000 0.988
Effects of service quality dimensions

Difference 0.616 0.619 0.009 1.559 0.217

University Perception 0.381 0.372 0.001 0.073 0.788
Difference 0.381 0.374 0.003 0.301 0.585
Private Perception 0.384 0.382 0.007 0.821 0.368
Difference 0.384 0.382 0.007 0.793 0.376
Return intention M ilitary Perception 0.400 0.394 0.002 0.272 0.604
Difference 0.432 0.429 0.005 0.598 0.442
Public Perception 0.394 0.387 0.003 0.312 0.578
Difference 0.381 0.385 0.013 1.455 0.232
University Perception 0.231 0.221 0.003 0.238 0.627
Difference 0.287 0.278 0.003 0.266 0.608
Private Perception 0.328 0.319 0.000 0.006 0.940
Difference 0.297 0.287 0.000 0.023 0.880
317
 p value for
318
Dependent variable Hospital type Data type Adjusted R-square regression model Equation
Table 3
Perceived overall quality M ilitary Perception 0.449 0.000 POQ = 0.575 + 0.428*E + 0.430*T
Difference 0.372 0.000 POQ = 6.203 + 0.557*E + 0.254*REL
Public Perception 0.699 0.000 POQ = -0.545 + 0.548*E + 0.535*A
Difference 0.543 0.000 POQ = 6.214 + 0.504*E + 0.406*REL
University Perception 0.426 0.000 POQ = 1.407 + 0.700*RES
F. Calisir et al.

Difference 0.413 0.000 POQ = 6.128 + 0.676*RES

Private Perception 0.469 0.000 POQ = 1.883 + 0.384*RES + 0.346*E
Difference 0.431 0.000 POQ = 6.751 + 0.395*E + 0.333*REL
Customer satisfaction M ilitary Perception 0.398 0.000 CS = 1.236 + 0.460*T + 0.326*E
Stepwise regression models

Difference 0.370 0.000 CS = 6.278 + 0.400*E + 0.313*T

Public Perception 0.681 0.000 CS = 0.294 + 0.607*E + 0.370*A
Difference 0.610 0.000 CS = 6.455 + 0.573*E + 0.309*REL
University Perception 0.381 0.000 CS = 1.708 + 0.741*A
Difference 0.399 0.000 CS = 6.686 + 0.348*RES + 0.346*A
Private Perception 0.395 0.000 CS = 2.302 + 0.313*RES + 0.351*E
Difference 0.372 0.000 CS = 6.632 + 0.613*E
Return ıntention M ilitary Perception 0.420 0.000 RI = 0.941 + 0.496*E + 0.337*T
Difference 0.443 0.000 RI = 6.339 + 0.478*E + 0.334*T
Public Perception 0.380 0.000 RI = 1.874 + 0.710*A
Difference 0.402 0.000 RI = 6.424 + 0.368*A + 0.315*RES
University Perception 0.244 0.000 RI = 2.919 + 0.539*A
Difference 0.281 0.000 RI = 6.507 + 0.536*A
Private Perception 0.339 0.000 RI = 3.825 + 0.701*RES - 0.287*T
Difference 0.322 0.000 RI = 6.700 + 0.584*RES
 Effects of service quality dimensions 319

5 Discussion and conclusions

The effect of SERVQUAL dimensions along with usability as the sixth dimension on
perceived overall quality, customer satisfaction, and return intention has been assessed
for each hospital type on a two different data source basis, meaning perception scores,
and the difference between perception and expectation scores. According to the results,
usability does not have any impact on perceived overall quality, customer satisfaction,
and return intention for all hospital types. This result is inconsistent with the results
presented by Strawdermann and Koubek (2008), who exhibited that usability has a
significant role in consumer satisfaction and return intention prediction. However, it
should be kept in mind that in the proposed model ‘usability’ addresses only learnability
and memorability of the general usability sub-dimensions and other usability
sub-dimensions, meaning efficiency, errors and satisfaction are covered by
responsiveness, reliability and tangibles dimensions. This stresses that the affect of
human factors perspective on overall perceived quality, satisfaction and return intention
should not be ignored.
Consistent with the literature defending the use of perception scores for service
quality evaluation (Babakus and Mangold, 1992; Cronin and Taylor, 1992; Brady et al.,
2002) also in this study, for most of the hospital types, perception scores seem to explain
more variance in the perceived overall quality and customer satisfaction. However, in
case of return intentions only for private hospitals, perception scores have higher
explanatory power. Although this result supports the approach of using perception scores
as the basis for service quality measurement, there is argument in the literature that using
difference scores may lead to the “loss of richer, more accurate diagnostics” (Dean,
1999), as difference scores exhibit the weaknesses and strengths of each SERVQUAL
dimensions by indicating “the direction and the amplitude of the difference between
expectation and perception” (Ladhari, 2009). So, the type of data source to be used might
depend on the focus of the implementers of the service quality measurement.
Results revealed that service quality dimensions having an impact on perceived
overall quality, customer satisfaction, and return intention vary among hospital types.
This underlines the fact that customers might have different kinds of expectations and
judgments toward distinct hospital types. Results indicating that empathy has an
influence on customer satisfaction and perceived overall quality for all hospital
types, except university hospitals, show that customers expect and appreciate a
customer-focused service concept. This might be a result of the general perception that
due to high demand (high patient numbers), heavy workload, and performance
considerations (it is generally expected that healthcare workers treat a certain number of
patients in a certain time period), healthcare employees do not give patients personalised
attention, especially in public hospitals, where the variance explained in perceived overall
quality and customer satisfaction is relatively high. For patients served in university
hospitals instead of empathy, responsiveness and assurance seem to be more of a concern
in terms of perceived overall quality, customer satisfaction, and return intention. Since
most patients of university hospitals look for special care for their chronic/rare/serious
diseases, they might have higher expectations for medical and organisational expertise
and professionalism from a hospital, which is also a practice area of an academic
institution. Both responsiveness and assurance have an effect on the return intention of
public hospitals’ patients. For private hospitals’ patients, responsiveness is influential on
return intentions for both data sources. This might be due to the perception that if they
320 F. Calisir et al.

pay for the promised service, then they might expect to receive more attention and
information from employees when they need it.
Tangibles are important for customer satisfaction and return intention for military
hospitals’ patients. This is partially consistent with Kara et al.’s (2005) study, which
suggested that in Turkish public healthcare services, intangible dimensions have more
importance than the tangible dimensions in terms of service quality and customer
satisfaction. Strict rules on order, formation, and appearance in military hospitals might
have an impact on this result. Since most of the patients of military hospitals are military
personnel and their families, they might expect increased care with regard to the
appearance of the hospital environment.
The regression models for different hospital types produced varying adjusted R-
squared values, most of which indicated that more than half of the variance had not been
explained by the proposed dimensions. Only for public hospitals in case of perceived
overall quality and customer satisfaction the adjusted R-squared values are higher than
0.5. Similarly, in other studies addressing the relationship between SERVQUAL
dimensions and satisfaction and loyalty for healthcare organisations using linear
regression (Aykac et al., 2009; Strawdermann and Koubek, 2008), the adjusted R-squared
values are lower than 0.4. In Yagci and Duman’s (2006) study, where items of original
SERVQUAL method had been used to define new dimensions to measure overall
perceived quality in public, university and private hospitals, the adjusted R-squared
values are higher than 0.5. This shows that factors other than the dimensions proposed in
this study should have an effect on the dependent variables used in our study for different
hospital types and for further investigation SERVQUAL model needs to be improved to
address the needs in healthcare sector in Turkey and to be customised for different
hospital types.
There are some other limitations of this study. First, the respondents were selected
from one example of every hospital type. To be able to generalise the results, future
studies should include more respondents from several randomly selected hospitals from
each type. Second, respondents of the questionnaire were outpatients only. There might
be differences between the outpatients and inpatients in terms of service quality
expectations and perceptions. Future studies should also take inpatients’ perspectives into
account.

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 Effects of service quality dimensions 323

Appendix

Dimensions and scale items

Reliability (REL)
Rel1 Hospital should provide services at the time they promise to do
Rel2 When patients have problems, hospital should show sincere interest in solving it.

Tangibles (T)
T1 Hospitals should have up-to-date equipment
T2 Hospital’s physical facilities should be visually appealing
T3 Hospital employees should appear neat.

Responsiveness (RES)
Res1 Hospital employees should tell patients exactly when services will be performed
Res2 Hospital employees should give prompt service to patients
Res3 Hospital employees should always be willing to help patients.

Assurance (A)
A1 Patients should be able to feel safe in their interactions
A2 The behaviour of employees should instil confidence in patients
A3 Hospital employees should be polite.

Empathy (E)
E1 Hospital should have operating hours convenient to all patients
E2 Hospital should have employees who give patients personal attention
E3 Hospital should have the patients’ best interests at heart.

Usability (U)
U1 Hospital should be easy to use
U2 Patients should be able to learn how to use the system easily
U3 Information regarding hospital should be easy to find
U4 Information regarding hospital should be easy to understand.