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)

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

In Partial Fulfillment
of the Requirements for the Degree
DOCTOR IN PUBLIC ADMINISTRATION

NGUYEN THI LAN ANH
December, 2016


ii

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


iii

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


iv

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


v

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


vi

LIST OF ABRIVIATIONS
E
P
W
t
IT
QI
SD
VN
CV

Expectations
Perceptions
Weighted
Time
Information Technology
Quality Improvement
Standard Deviation
Vietnam
Coefficient of Variation

EHR
GDP

IMS
HIC
PZB
QIP
TNH
JCI
EFA
VND

Electronic Health Record
Gross Domestic Products
Indicator Measurement System
Health Insurance Card
Parasuraman, Zeithaml and Berry
Quality Indicator Project
ThaiNguyen National Hospital
Joint Commission International
Exploratory Factor Analysis
Vietnam Dong

USD
SPSS
TAN
REL
RES
ASS
EMP
SAT
GSO

United States Dollar
Statistical Package for the Social Sciences
Tangible
Reliability
Responsiveness
Assurance
Empathy
Satisfaction
General Statistics Office

WHO
NHS
KMO
VIF
ANOVA
SERVQUAL
SERVPERF

World Health Organization
National Health Service
Kaiser-Meyer-Olkin-Kriterium
Variance Inflation Factor
Analysis of Variance
Service Quality
Service performance


vii

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


viii

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.

1

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


2

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


3

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.


4

Ultimately, the dimensions of quality that relate to client satisfaction affect the health and wellbeing 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.

Thai Nguyen National General Hospital (From October, 2016 has been renamed to 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:

5

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.


6
+ 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


7

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:

STRUCTURE
• Physical and
organizational
charactoristics where
health care occurs

PROCESS

OUTCOME

• Foucus on the care
delivered to patients
(services or treatments)

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

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.
In this research:
 Quality of structure is determined in terms of quality system and ability of quality
assurance.
 Quality of process including quality of monitoring, investigation, intervention, health
education, supervision.
 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


8

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.


9

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.


10

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

Past experience

Personal
Needs

Expected
Service
Gap 5
Perceived
Service
CUSTOMER

PROVIDER

Service
Delivery

External

Gap 4

Communication
To

Customers

Gap 3

Gap 1

Service
Quality Specs

Gap 2
Management
Perceptions of
Customer
Expectation

Figure 1.2. Model of service quality by PZB


11

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.
1.5. Conceptual Framework
In this study, the researcher uses 5 SERVQUAL factors or dimensions to analyze the
overall perceived service quality of patients and level of their satisfaction as well as their intent
to return and recommend the hospital services with 25 item scales.


12

Overall perceived
service quality

SERVQUAL factors
• Tangibility
• Reliability

E. Services
expectation

• Responsibility
• Assurance
• Empathy

P. Service
perception

1. Exceeding
expectations (Eexcellent quality)
2. Meet expectations
(E=P satisfactory
quality)
3. Under expectation
(E>P, low quality)

Figure 1.3. Modified SERVQUAL model in health service

The framework will be presented in the diagram as follows:
ANTECENDENT VARIABLE

INDEPENDENT VARIABLE

DEPENDENT VARIABLE

SERVQUAL GAP 5
Expected Service Quality

DEMOGRAPHIC
S

Overall
Perceived
Service Quality

Perceived Service Quality



Age
 Gender
Ethnic

Patient

Occupation
 Income

Satisfaction






Education
 Using HIC

Retention to
return or
recommend

Figure 1.4. The conceptual Framework


13

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)


14
 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 consumptionrelated fulfillment (adapted from Oliver 1997)
 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


15
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.


16

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.


17

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