International Journal of Health Care Quality Assurance Factors affecting dental service quality Mohammadkarim Bahadori Mehdi Raadabadi Ramin Ravangard Donia Baldacchino

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Article information: To cite this document: Mohammadkarim Bahadori Mehdi Raadabadi Ramin Ravangard Donia Baldacchino , (2015),"Factors affecting dental service quality", International Journal of Health Care Quality Assurance, Vol. 28 Iss 7 pp. 678 - 689 Permanent link to this document: http://dx.doi.org/10.1108/IJHCQA-12-2014-0112 Downloaded on: 01 February 2016, At: 02:39 (PT) References: this document contains references to 54 other documents. To copy this document: [email protected] The fulltext of this document has been downloaded 295 times since 2015*

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Factors affecting dental service quality

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Mohammadkarim Bahadori Health Management Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran

678

Mehdi Raadabadi

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Received 10 December 2014 Revised 1 February 2015 12 April 2015 Accepted 10 May 2015

Health Services Management Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran

Ramin Ravangard Department of Health Services Management, School of Management and Medical Information Sciences, Shiraz University of Medical Sciences, Shiraz, Iran, and

Donia Baldacchino Department of Nursing, Faculty of Health Sciences, University of Malta, Malta Abstract Purpose – Measuring dental clinic service quality is the first and most important factor in improving care. The quality provided plays an important role in patient satisfaction. The purpose of this paper is to identify factors affecting dental service quality from the patients’ viewpoint. Design/methodology/approach – This cross-sectional, descriptive-analytical study was conducted in a dental clinic in Tehran between January and June 2014. A sample of 385 patients was selected from two work shifts using stratified sampling proportional to size and simple random sampling methods. The data were collected, a self-administered questionnaire designed for the purpose of the study, based on the Parasuraman and Zeithaml’s model of service quality which consisted of two parts: the patients’ demographic characteristics and a 30-item questionnaire to measure the five dimensions of the service quality. The collected data were analysed using SPSS 21.0 and Amos 18.0 through some descriptive statistics such as mean, standard deviation, as well as analytical methods, including confirmatory factor. Findings – Results showed that the correlation coefficients for all dimensions were higher than 0.5. In this model, assurance (regression weight ¼ 0.99) and tangibility (regression weight ¼ 0.86) had, respectively, the highest and lowest effects on dental service quality. Practical implications – The Parasuraman and Zeithaml’s model is suitable to measure quality in dental services. The variables related to dental services quality have been made according to the model. Originality/value – This is a pioneering study that uses Parasuraman and Zeithaml’s model and CFA in a dental setting. This study provides useful insights and guidance for dental service quality assurance. Keywords Iran, Quality measures, Service quality, Measurement, Confirmatory factor analysis, Quality improvement, Quality assessment, Dental Paper type Research paper

International Journal of Health Care Quality Assurance Vol. 28 No. 7, 2015 pp. 678-689 © Emerald Group Publishing Limited 0952-6862 DOI 10.1108/IJHCQA-12-2014-0112

Introduction In today’s competitive world, quality has become increasingly important in all organizations and is considered an important, strategic lever (Brennan et al., 1991; Groene et al., 2008), which plays a key role in gaining competitive advantages and achieving success (DeMoranville and Bienstock, 2003; Kong and Jogaratnam, 2007). Quality is considered more in industries than in service sectors, whose main characteristics are

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production and consumption intangibility and inseparability (Murphy, 2007) while the current service sectors can have a significant contribution to the economic growth and quality of life (Büyüközkan et al., 2011). Measuring healthcare service quality is the first and most important step to improving care (Davis et al., 2005; Lee and Yom, 2007) and the quality provided plays an important role in patient satisfaction ( John et al., 2011). Additionally, healthcare’s increasing complexity and the rising demand for improved patient safety, monitoring health service quality has become essential (Manias, 2010). The demand for quality is also increasing among health system stakeholders, such as medical insurance organizations, healthcare providers and health policy makers (Beyer et al., 2011; Davies, 2001; Rosenbaum, 2003). Consequently, providing high-quality services in the health sector is considered a desirable goal that leads to development in other areas (Andaleeb, 2000b; Karydis et al., 2001; Youssef, 1996). In hospitals, owing to the different services, quality can be used strategically to create a distinct advantage that will be difficult for competitors to imitate (Lim and Tang, 2000); promoting quality will increase patient satisfaction and loyalty (Arasli et al., 2008; Dawn and Lee, 2004). Furthermore, quality has a great role in patient choice or for future referrals (Jenkinson et al., 2005; Karassavidou et al., 2009; Merle et al., 2009). In the past, goods or service characteristics were defined as the quality measuring criteria. However, based on new methods and attitudes, quality is defined as customer demands and desires (West, 2001). Today, measuring quality from the patient’s perspective is accepted in healthcare and its use is increasing (Lin et al., 2009). The information obtained by gathering patient perspectives is a successful method for strategic evaluation and for improving health service quality (Saeed and Mohamed, 2002). In healthcare, different plans are made to improve and assure quality, especially among dental service providers (Bader, 2009; Greenfield and Braithwaite, 2008; Kenny et al., 1999; Mills and Batchelor, 2011). Patient perceptions, attitudes and satisfaction with the dental services have been recognized as factors and are the main quality assurance programme components (Butters and Willis, 2000; Saeed and Mohamed, 2002). Meeting patients’ dental care needs and expectations may affect patient behaviour towards increasing their utility, reducing cancelled appointments, pain and anxiety (Butters and Willis, 2000; Newsome and Wright, 1999). Analysing service quality enables managers to relate financial resources and performance improvement in areas that have greater effect on customer perceptions (Raju and Lonial, 2002). Market-based mechanisms can reduce dental service costs and another mechanism that has a strong effect on attracting customers is meeting customer demands (Roberts, 1999). Research shows that several factors, including performance (Schoenfelder et al., 2011), environment, support/care and waiting time (Atinga et al., 2011), communication, responsiveness, honesty (Hasin et al., 2001) nursing care, admission process, environment, compassion for family and friends, physician care and discharge process (Otani and Kurz, 2004), affect patient satisfaction. Furthermore, other factors affecting patient satisfaction and dental service quality are technical competence, personal factors, comfort, costs, facilities and equipment (Kress, 1988; Newsome and Wright, 1999), assurance, provider empathy (John et al., 2011), responsiveness (Dewi et al., 2011), communication, consideration, knowledge, abilities, skills (Dewi et al., 2011), high-quality dental care, convenient appointment, friendly staff and modern dental clinics (Al-Hussyeen, 2010). The literature shows that total dental service quality studies are less than other specialties and that there is no clear and reliable information in this area. Several people are referred daily to dental services, so identifying, measuring and improving factors affecting dental service quality can prevent resource wastage

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and increase patient satisfaction. Therefore, this study aimed to identify factors affecting dental service quality as perceived by the patients referred to a Tehran dental clinic, using confirmatory factor analysis (CFA). Method Study design The study population included all patients receiving dental services. This cross-sectional and analytical study was conducted between January and June 2014. Inclusion criteria were patients receiving clinic services at least once, who were familiar with its employees, environment and dental clinic. A sample of 385 patients was determined (maximum CFA size). This sample was selected from morning and evening work shifts across 15 working days in May using the stratified sampling proportional to the size method. Therefore, each work shift was considered as a stratum in which patients were selected considering the total patients in each shift using a random numbers table. Data collection Data were collected using a self-administered questionnaire, designed for the study, based on Parasuraman and Zeithaml’s service quality model (Parasuraman et al., 1985). This questionnaire had two parts: demographics, such as sex, age, marital status, education level and insurance status, and a 30-item questionnaire to measure five service quality dimensions, including tangibility (seven items), reliability (nine), responsiveness (six), assurance (four) and empathy (four). A five-point Likert scale was used to assess each dimension (1 ¼ strongly disagree and 5 ¼ strongly agree). In this study, Parasuraman and Zeithaml’s dimensions did not change, however, their respective items changed according to dental services. The modified questionnaire’s validity was confirmed using six faculty members, including four dentists and two health service management experts. Reliability was confirmed by Cronbach’s α coefficient (α ¼ 0. 95). Data collection lasted 15 days. A researcher was stationed in the clinic and distributed the questionnaire to patients. If patients were illiterate then researchers asked questions and completed the document on their behalf. Approval Permission to conduct our study was obtained from university heads and authorities. Informed consent was obtained from all participating patients and all were assured about data confidentiality. Approval for conducting this study was obtained from Baqiyatallah Medical Sciences University ethical committee (ethical code: CH/7018/100). Data analysis Data were analysed using SPSS 21. 0 and Amos 18. 0 using means, standard deviations and CFA, which was used to determine consistency between patient responses and the proposed structural model. Second-order factor analysis was used for data analysis. The following indices were used in the CFA: comparative fit index (CFI), root-meansquared error of approximation (RMSEA), degrees of freedom (df), incremental fit index (IFI), χ2 and normed χ2. Findings Most patients were male (53.2 per cent), married (79 per cent), 31-40 years (32.5 per cent), had academic and university degrees (53.8 per cent) and insurance coverage (83.1 per cent) (Table I).

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Variables

Frequency (%)

Sex Male Female

205 (53.2) 180 (46.8)

Marital status Single Married

81 (21) 304 (79)

Having insurance coverage Yes No

320 (83.1) 65 (16.9)

Education level Less than high school diploma Diploma Academic and university degrees

48 (12.5) 130 (33.8) 207 (53.8)

Age (years) o20 21-30 31-40 41-50 W50 Note: n ¼ 385

24 99 125 73 64

(6.2) (25.7) (32.5) (19) (16.6)

The 30-item questionnaire means, standard deviations (sd) and Cronbach α are shown in Table II. Cronbach’s α coefficient for each dimension was higher than 0.7. The most important items were: tangibility: cleanliness, materials and supplies (4.87); reliability: dentists’ attention to patient expectations (4.83); responsiveness: easy and quick treatment (4.64); assurance: dental skills (4.83); and empathy: paying attention to the patients’ needs and demands (4.64) (Table II). According to the absolute χ2 index (797.9) and given that the model’s degrees of freedom (270) moved away from zero, and had moved towards the independent model’s degree of freedom (326), the proposed model was deemed appropriate. The normed χ2 index, which is a relative index, showed that if the value was between 1 and 3 then the model would be more appropriate. Therefore, because normed χ2 ¼ 2.95, the proposed model was appropriate and acceptable. Furthermore, because RMSEA ¼ 0.078, which was lower than 0.08, the model was acceptable. Moreover, considering that CFI ¼ 0.930 and IFI ¼ 0.947, which were more than 0.08, the model had a good fit. Generally, the model had a good fit and was acceptable. The results showed that assurance (regression weight ¼ 0.99) and tangibility (regression weight ¼ 0.86) had, respectively, the highest and lowest effects on dental service quality. Also, the results indicated that all variables had acceptable loading factors for measuring latent variables (Figure 1). Discussion Given the healthcare system changes and the dental service providers’ key role in maintaining oral health, our study plays an important part in improving dental services and promoting oral health. Also, since patient satisfaction is closely related to service quality (Alhashem et al., 2011), their perceptions can determine failures and gaps, and

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Table I. Demographics

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Quality dimensions and items Tangibility (α ¼ 0.80)

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Reliability (α ¼ 0.81)

Responsiveness (α ¼ 0.91)

Table II. Factors affecting dental services from the patients’ perspective

P1. In a good dental clinic, the equipment should be modern P2. The clinic employees should be clean, neat, tidy and appropriate to their professions P3. The waiting room, tables and chairs, bathrooms, toilets and floors should be clean, beautiful, comfortable and desirable P4. The card of patients’ chart numbers, pamphlets and brochures should be appropriate and beautiful P5. The cleanliness and quality of the materials and supplies used for treatment should be appropriate P6. The process of paying the bills should be easy and comfortable P7. The car parking space for patients should be enough around the clinic P8. In a good dental clinic, the patients’ physical examinations and treatments should be provided at the time that has previously been appointed and patients should not be delayed too much on the day of physical examination and treatment P9. The dentist should consider the patients’ expectations and needs and meet them completely P10. When explaining the treatment procedures to the patients, the dentist should speak clear and understandable so that they fully understand him/her P11. In addition to the assistants and secretary, the dentist should also explain the treatment procedures to the patients P12. The patients’ charts should be completed without any mistakes and maintained accurately and can easily be found when needed P13. The dental care costs should not be high P14. Everything should be done correctly and without duplication and reworking at the first time P15. The treatment provided should be of high quality and longterm effectiveness P16. The dentist should give patients useful and necessary advice for preventing them from other diseases P17. In a good dental clinic, there should not be a long time between patients’ physical examinations and their treatment procedures P18. The treatment process should be provided quickly and conveniently P19. The employees should behave towards patients such that they can trust in the dental clinic and its employees P20. A secretary should always be accountable for arranging the time of treatment session by phone or in person P21. The dentist should clearly explain the problems and diseases to the patients during the first visit and physical examination P22. The employees should constantly be willing to help the patients referred to the clinic and be ready at any time to answer their questions

Mean

SD

4.81

0.44

4.75

0.43

4.71

0.54

4.28

0.77

4.87

0.33

4.34

0.77

4.37

0.90

4.72

0.56

4.83

0.37

4.74

0.43

4.61

0.52

4.53 4.55

0.57 0.61

4.74

0.48

4.81

0.44

4.74

0.48

4.49

0.61

4.64

0.48

4.62

0.56

4.51

0.70

4.63

0.52

4.60

0.49

(continued )

Quality dimensions and items

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Assurance (α ¼ 0.71)

Empathy (α ¼ 0.86)

P23. In a good dental clinic, the employees should always behave towards patients with respect and courtesy and ensure their privacy P24. The dentist should be familiar with the newest treatment methods, as well as the modern technologies P25. The dentist should have sufficient skills and be good at his/ her job P26. A good dental clinic should have a good reputation among the people so that they offer it to each other P27. In a good dental clinic, the admission process for consultation and initial physical examination should be carried out quickly and easily P28. The clinic employees should listen to the patients’ comments and opinions P29. The clinic employees should understand and pay attention to the patients’ needs P30. The clinic employees should pay particular attention to each patient’s costs of dental services and should be assured that they are affordable for patients

Mean

SD

4.74

0.43

4.72

0.44

4.83

0.42

4.53

0.57

4.60

0.53

4.57

0.57

4.64

0.60

4.57

0.53

develop effective strategies to improve quality. Therefore, we aimed to identify factors affecting dental service quality as perceived by patients referred to a Tehran dental clinic. Based on CFA, all factors were highly correlated with service quality; assurance had the highest correlation. The Wisniewski and Wisniewski (2005) and Karydis et al. (2001) studies confirm our results. The assurance item, “The dentist should have sufficient skills and be good at his/her job” had the highest mean, indicating that dental skills and abilities, both technical and medical, are important according to patients. A teaching hospital study in Ireland (McCabe, 2004) found that nursepatientcentred communication training was poor so that the patients were dissatisfied with improper communication and the nurses’ task-centred communication. Thus, nurses’ poor communication appeared to contribute towards a decline in nursing quality (McCabe, 2004). High assurance scores indicate that having an ability to do things right, an updated knowledge, high competence and employee behaviour are considered by patients as important, which increase their security and confidence. These findings were consistent with studies conducted in Asian countries (Butt and de Run, 2010; Lee and Yom, 2007; Lim and Tang, 2000). Generally, improved technical skills may increase the service quality assurance dimension through in-service training programmes and using qualified, experienced and motivated young dentists. Healthcare organizations and hospital managers should attempt to inform patients about employee knowledge and capabilities, so they can trust dental staff. Like the Wisniewski and Wisniewski’s (2005) study, tangibility had the lowest correlation in our study and includes facilities, equipment, employees and communication. However, since tangibility has some effect on service recipients, providing them with suitable physical conditions is important. Physical environment has an important service quality role and an important reason why patients choose a hospital (Arasli et al., 2008; Karydis et al., 2001; Andaleeb, 2000a; Camilleri and O’Callaghan, 1998). Additionally, the “Cleanliness, appropriate materials and supplies” element is an important item as it affected patient perceptions.

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Table II.

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Figure 1. Confirmatory factor model for dental service quality

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Responsiveness had a considerable influence on service quality. This dimension is focused on care processes, whereby patients expect that employees are available when needed and interested in quickly solving their problems (Choi et al., 2005). An important item in the responsiveness dimension was the time between patient examination and treatment; due mainly to the highly specialized clinic wards; i.e. if a patient needs more than one dental service then s/he is referred to a ward to set an examination date and time. Most patients tend to be referred to the clinic only once or twice. This problem may be because most patients experience referrals to a private dental office whereby they receive services in a non-separated and non-specialized ward. Therefore, they usually compare their physical examinations and treatments in the public dental clinics with the private dental office. Andaleeb (2000b) showed that employees’ non-responsiveness and their unwillingness to provide the best services could waste patient time, money and energy. Therefore, clinic managers should schedule and time service delivery appropriately. Also, they should provide opportunities for employees to deliver services to the patient’s satisfaction. Reliability and empathy had relatively similar effects on service quality. In the Anderson and Zwelling’s (1996) study , reliability had the greatest effect on service quality. Reliability is the ability to provide services dependably and accurately so that customer expectations are met. The clinic manager’s decision to cancel the appointment for patients attending more than five minutes late, reduces to some extent patient waiting times. However, most patients attend the clinic on time and even earlier than the appointment, this decision has not helped to solve the patient waiting time problem. Clinic staff should arrange patient appointments so that they are assured that the previous patient’s physical examination and treatment is completed before the next patient. Also, clinic admission unit staff or the ward secretary should remind the dentist about the next patient’s appointment time as each physical examination starts. Empathy effects service quality; i.e. it indicates if clinic employees provide quick services and are sensitive to patient demands, requests and complaints (Sultan and Wong, 2010). Poor empathy can lead to poor communication between staff and patients. Therefore, improving employees-patient communication is recommended. Increasing total specialists and diagnostic equipment can improve patient admission for consultations and initial physical examinations. If services are intangible then interpersonal interactions during service delivery can significantly affect service quality perceptions (Brady and Cronin, 2001). Studies that show the human element’s effects on patient perceptions can demonstrate empathy’s importance (Mohd Suki et al., 2009; Padma et al., 2010; Rose et al., 2004). Our study has limitations, service quality in our study was measured only from patient perspectives. Other stakeholders and interest groups’ views, including dentists, managers and other service providers have not been considered. Conclusions and recommendations To improve dental service quality, paying attention to everyone’s needs and demands plays a major role. Patient preferences should be considered fundamental to providing good quality dental care. Therefore, given the positive effects on dental service quality that we found, service delivery processes should carefully be considered in all quality dimensions, especially assurance and responsiveness.

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Improving service quality requires administrators and managers to meet patients’ reasonable needs and to solve their problems. There are different conceptual models for measuring health services quality; however, we recommend that all models should be tested using CFA.

686

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Corresponding author Dr Mohammadkarim Bahadori can be contacted at: [email protected]; m.bahadori@ bmsu.ac.ir

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