QFD application using SERVQUAL for private ...

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QFD application using SERVQUAL for private hospitals: a case study Hatice Camgo¨z-Akdag˘ Management Engineering Department, Faculty of Management, Istanbul Technical University, Istanbul, Turkey

QFD for private hospitals

175 Received 7 February 2013 Accepted 8 February 2013

Mehves¸ Tarım Department of Health Management, Faculty of Health Sciences, Marmara University, Istanbul, Turkey

Subash Lonial Department of Marketing, University of Louisville, Louisville, Kentucky, USA, and

Alim Yatkın Fatih University Hospital, Istanbul, Turkey Abstract Purpose – The purpose of this paper is to describe how quality function deployment (QFD) methodology was employed for translating customer needs and expectations into the quality characteristics in a private healthcare setting. This case study illustrates how an existing approach of SERVQUAL and QFD integration can be applied for quality improvement. Design/methodology/approach – Integrating SERVQUAL into QFD to set the success factors to improve quality in the healthcare industry is the main aim of this paper. A privately-held university hospital, within the city of Istanbul in Turkey, was selected as the sampling frame. A SERVQUAL-type of questionnaire was used and a total of 250 questionnaires were distributed and 210 of them were received. Usable responses were 170, comprising a response rate of 68 percent. Findings – From the results of the QFD application it is seen that behavior and attitude of staff has the highest weight score, meaning that when behavior and attitude of staff is improved there will be almost 25 per cent of improvement in the hospital. Another finding was that there is strong relationship among skills of physician, behavior and attitude of staff, and having enough modern equipment. Research limitations/implications – QFD technique is able to provide hospitals with a better understanding of customers’ expectations to translate these expectations into appropriate service specifications and perform existing process assessment. Originality/value – The case study was a first attempt to apply this integrative approach to a service sector and thus offers practical and applied information useful to both academicians and practitioners. Keywords Health care, Turkey, Private hospitals, Customer requirements, Quality, SERVQUAL, Quality function deployment Paper type Case study

1. Introduction Quality of healthcare has become the latest hot topic everywhere. It is one of the fastest growing industries in the service sector. It is also widely known for its huge concerns

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about the quality of service. In the healthcare industry, all hospitals provide the same type of service, but they do not provide the same level of quality of service (Lim and Tang, 2000). The quality of services-both technical and functional- is a key ingredient in the success of service organizations. With increasing pressure of competition and necessity to deliver satisfaction demanded or expected by the patients, the elements of quality control, quality assurance and effectiveness of medical treatments have become a vitally necessity. It is difficult for patients to identify and prioritize their expectations and for management to include these expectations in the service package (Lim et al., 1999). Quality function deployment (QFD) technique is available to provide hospitals with a better understanding of customers’ expectations translate these expectations into appropriate service specifications and perform existing process assessment. This study employed Quality Function Deployment methodology for translating customer needs and expectations into the quality characteristics. The paper suggests an approach which is integrating SERVQUAL into QFD to set the success factors to improve quality in the healthcare industry. 2. Literature survey Service quality has received a significant amount of attention by both researchers and practitioners. The interest in service quality has been influential in contributing significantly to the growth of the general service marketing field. In business literature, the customer’s perception of quality has been the major focus in studies completed on service quality. Hence service quality is often conceptualized as the comparison of service expectations with actual performance perceptions (Bloemer et al., 1999). Customers evaluate service quality by comparing the service level they receive, against both the service level that they would have preferred (or desired) and the service level they are willing to accept (Tan and Pawitra, 2001). On an operational level, research done on service quality has been dominated by the SERVQUAL instrument, which is based on a so-called gap model. Gap model recognized today as a major contribution to the service management literature (Parasuraman et al., 1985). SERVQUAL is designed by Parasuraman et al. (1988) to measure service quality as perceived by the customer. Through an empirical test, Parasuraman et al. developed SERVQUAL from a modification of ten dimensions proposed in 1985 to five dimensions in 1988. These are tangibles, reliability, responsiveness, assurance, and empathy. In their study, the data on the 22 attributes were factor analyzed and resulted in five dimensions (Parasuraman et al., 1991). After Parasuraman et al. proposed SERVQUAL, James Carmen adapted the original SERVQUAL instrument for use in the hospital industry. The original 22 questions were extended to 34 questions. As stated by Tan and Pawitra (2001), SERVQUAL is not designed to address the element of innovation and even though it provides important information on the gaps between predicted service and perceived service, it is not able to address how the gaps can be closed. Tan and Pawitra (2001) also added that it would be good if SERVQUAL can be integrated with other service quality tools that are more focused on reducing the service gaps. Quality Function Deployment (QFD) is a literal translation of the Japanese words hinshitsu kino tenkai, but was initially translated as quality function evolution in 1978

(Mizuno and Akao, 1978). At the first QFD seminar in the USA (Akao et al., 1983), Masaaki Imai felt that the term evolution inappropriately connoted the meaning of “change” and that hinshitsu tenkai was better translated as quality deployment (Akao and Mazur, 2003). QFD is an established and well-known methodology which translates the “voice of the customer” or customer needs (the “whats”) into its means of accomplishment within an organization (the “hows”) (Hamilton and Selen, 2004). In the literature, there have been many examples of combining SERVQUAL. Kano’s model and QFD have been used in different ways and in different industries. Tan and Pawitra (2001) propose and integrated approach involving SERVQUAL and quality function deployment for evaluating the image of Singapore from the Indonesian tourist’s perspective. The approach aims to help organizations to evaluate customer satisfaction, to guide improvement efforts in strengthening their week attributes, and to expedite the development of innovative services through the identification of attractive attributes embedding them into future services. Franceschini and Terzago (1998) determined the needs of all actors playing different roles in industrial training courses within the Kano model and converted these needs into design characteristics using QFD. Matzler and Hinterhuber (1998) followed a similar methodology for the ski industry. Literature also includes many examples of integration of SERVQUAL and QFD in different ways. Lim et al. (1999) adopted SERVQUAL and QFD performance measurement in Singapore and used the empirical findings as an input for QFD in the process of designing services based on customer expectations for hospitals. Sahney et al. (2004) applied SERVQUAL to identify the gap between customer expectations and perceptions of the actual service received. Afterwards the QFD technique was then used to identify the set of minimum design characteristics/quality components that meet the requirements of student as customers of the educational system. In addition Baki et al. (2009) used SERVQUAL and Kano model to see how well the service quality attributers are able to satisfy customer needs and findings were transferred to QFD. As the present case study was held in a private university operating in Istanbul, Turkey; some valuable information on this industry is given at first, as follows. 3. Healthcare in Turkey The healthcare delivery system in Turkey faces serious challenges: among them improving service quality, being more customer-focused, increasing access and reducing costs are at top ranks. Since the 1990 s, the healthcare market in Turkey has been undergoing a gradual change from a seller-oriented to a buyer-oriented market due to the increasing influence of insurance companies, consumer organizations and public pressure. The healthcare organizations are public, quasi-public, private and philanthropic organizations, but relations among them are not well structured or regulated. Private hospitals and clinics are mostly collected in major cities and luxury neighborhoods. About two third of hospitals are located in Istanbul. Even though there are plenty of rules and regulations for hospitals and clinics it should be stressed that there is no single standard to audit these systems and evaluate the quality of healthcare in Turkey. In addition to this neither the state nor the private hospitals are audited or controlled by real means for their medical applications (Cetik et al., 2004). According to Cetik et al. (2004), the absence of standards, control, audit and


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evaluation results in the reality that the patients’ diagnosis and treatment processes are minimized to only the capacity, information, and ethics of the doctor and hospital staff. Cetik et al. (2004) include that as there is no standard for healthcare in Turkey; success is perceived as the relative quality of paramedical service. 4. Methodology In order to achieve a proper understanding of the concept and a concrete evaluation of the previously-mentioned targets, at first a literature review was carried out and a questionnaire was constructed and used. 4.1 The case study A privately-held university hospital within the city of Istanbul in Turkey was selected as the sampling frame of this study to translate the customer expectation and needs. Participants were selected randomly by using simple random sampling. The respondents that were eligible to be selected were customers being admitted as in-patients. There were no diagnostic limitations on patient selection. However, customers who were in a critical state of health or those who were unable to respond to the questionnaires and did not have any family members to assist in answering the questionnaires were excluded. Total of 250 questionnaires were distributed and 210 of them were received. Usable responses were 170, comprising a response rate of 68 percent at the hospital level. The majority of the respondents completing the questionnaire were in fact patients present in the hospital. 4.2 Survey instrument A survey was conducted to measure service quality in the private healthcare setting in Istanbul Turkey. To enable this study to be conducted, the survey instrument used is the SERVQUAL 5 dimensions model, adapted as recommended by Parasuraman et al. (1985). The SERVQUAL-type of questionnaire for use in the private healthcare sector is constructed by retaining some items from the updated SERVQUAL dimensions. Selected items are refined and paraphrased in both wording and contextual applications as appropriate for this research. The questionnaires were designed in a Likert scale five-point format ranging from “completely disagree” (1) to “completely agree” (5). This instrument includes 25 items for the expectations scale and the same 25 items for the perceptions scale. The results of the questionnaire were then used to integrate the findings from the SERVQUAL instrument into QFD to set the success factors to improve quality in the healthcare industry. 5. Analysis and results Application of QFD to healthcare satisfaction is described step by step as follows: (1) This step focuses on understanding the customer. This information is refined and then a second subset of the information becomes the input for the second step. For this paper, customer (patient) expectations were determined by 170 patients with survey. (2) This step involves gathering the voice of the customer and understanding the context in which customer makes statements. The purpose of this activity is to establish a clear understanding of all customers’ needs and expectations,

(3)

(4)

(5)

(6)

particularly the subjective performance. After understanding all customers’ needs and expectations, these customer needs, expectations and weights must be rated over 9. In this step, technical requirements related to customer expectation were determined and explained. Technical requirements are very important for QFD analysis because engineers and experts consider these requirements when they struggle to meet the customer expectations (Kurtay, 2005). To determine the requirements, experts from different departments should work together. After determining the technical requirements, experts constructed the relationships between customer expectations and technical requirements keeping in mind the importance of ratings and direction of improvement that were crucial points for QFD analysis. This information was evaluated and determined by experts. Physicians and experts of the hospital defined which customer expectations were related with which technical requirement. The resulting relationships, direction of improvement and importance degrees are shown in Figure 1. In the sixth step, experts calculated the technical importance degree of each requirement. These values are calculated for each technical requirement as summation of the importance degree of customer expectation which has relationship with the technical requirement multiplied with the weight of relationship. The formula is as follows: S Technical Importance Degree ¼ S ðImportance degree of customer satisfaction £ Weight of customer expectationÞ

As the questionnaire was formed with seven Likert scale, the response to each question was giving the important degree for each related customer expectations. The relative weight of customer expectations were the percentage explained for each importance degree response. (7) Maximum relationship degree is the degree of relationship between the customer expectation(s) and technical requirement(s). If no relationship is found between customer expectation and technical requirements, the components of customer expectations are deleted from the matrix to save space. Direction of improvement for technical requirements are symbolized with an upward triangle, downward triangle and an X. Upward triangle means needs improvement by increasing the relationship. While a downward triangle means for improvement one should decrease for example the waiting time of patient. If it is decided that there is no need for improvement then that requirement direction of improvement is shown with an X. Also provided are the calculated degrees of importance, relative weights and maximum relationship degree and matrix and direction of improvement. (8) In addition to the information given in the house of quality matrix, it should be realized that there can be a relationship between each technical requirements in itself. Improvement for one technical requirement can also


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Figure 1. House of quality for a private hospital

indirectly or directly affect another technical requirement positively or negatively or vice versa. These correlations among technical requirements are described in Figure 1, using a correlation matrix which also forms the roof of the quality house. Four different symbols are used in the correlation matrix to illustrate the relationship. For a strong positive correlation a double positive symbol (þ þ ), for a positive correlation a single positive symbol (þ ), for a strong negative correlation two negative symbols (2 ) and for a negative correlation a downward triangle symbol is used. After the relationship is figured out among technical requirements the symbols are placed on the roof of the house of quality. The house of quality matrix illustrates which technical characteristic has positive or negative relationship with other technical requirements. This approach helps identify the minimum set of technical requirements of hospitals to meet the various customer requirements, in turn leading to a cost-effective means of improving quality – quality as perceived by the customers.

Application of QFD to healthcare satisfaction is shown in the house of quality (HOQ) illustrated in Figure 1. Figure 1 shows the customer requirements, technical requirements, maximum relationship degree, relative weight of relationships, improvement direction and correlation among technical requirements. For example; it is obvious that there is strong relationship among skills of physician, behavior and attitude of staff, and having the modern equipment available have impacts in the final results. There is a lower relationship between doctor attitudes and modern equipment used in hospital, but still it must be realized that there is a relationship, which means the modernization of equipment has a slight effect on doctor attitude. When the relative weight of column is analyzed, it is seen that behavior and attitude of staff has the highest weight score; meaning that when behavior and attitude of staff is improved there will be almost 25 percent of improvement in the hospital. The second highest relative weight score is calculated to be the attitude of nurses towards patients which states that an improvement in nurse attitude will improve the hospital by 18 percent. And finally the third highest relative weight score is given to the doctor attitude towards patient as it has a score of 15 percent. All three are related to behavior and attitude toward patients. When all three are combined, the hospital will realize improvement and customer satisfaction by total 58 percent. The correlation among technical requirements indicate that doctor attitudes towards patients has a strong positive relationship with attitude and behavior of nurses, attitude and behavior of other staff and modern and enough number of equipment used. Skills of doctors have a strong positive relationship with skills of nurses. Attitudes and behavior of nurses has a strong positive relationship with other staff attitude, modern and enough number of equipment and also with attitudes of doctors. The general atmosphere of hospital also has a strong positive relationship with hygiene and cleanliness of hospital. This is logical since waiting time will decrease if atmosphere is positive, nice and helpful. Waiting time also has strong negative relationships which are related to attitude and behavior of other staff and with modernization and availability of enough number of equipment. 6. Conclusion This case study illustrates how an existing approach of SERVQUAL and QFD integration can be applied to a private university hospital. As a first attempt to applying this integrative approach to a different sector and thus offering practical and applied information, it will be useful for both academicians and practitioners. The authors have experienced that the integrated usage of two methods gives a systematic and efficient approach in translating customer needs into technical requirements in the present case study of a private hospital. Although such integration, service quality position of the hospital was evaluated by SERVQUAL, service quality attributes of analyzed factors show which attributes of service quality have a strategic significance on customer satisfaction and expertise of qualified professionals and how they are linked to these strategic service needs of patients. From a methodological perspective, it can be concluded that the ability of correlating technical requirements with customer satisfaction makes this approach a powerful tool for healthcare sector just like other manufacturing sectors.


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In order to stay competitive, designing the technical services in according with customers expectations has become an increasingly important necessity for hospitals. In this context, the approach provides hospitals a deep understanding of their service quality levels from customer satisfaction perspective. Also, highlighting the most important customer requirements (service attributes) which are highly attractive for their patients, the approach helps hospitals to develop innovative ideas in both strategic and tactical point-of-views. Furthermore, using two methods in a complementary way creates some methodological and practical advantages. Integrating QFD to SERVQUAL successfully identifies and optimizes internal capabilities and addresses specific customer opportunities by improving hospitals’ services design in parallel with the customer needs (Killen et al., 2005). Even though using these two methods has benefits of their own, it should be mentioned that there are limitations involved in each method. For SERVQUAL, limitations such as measuring the expectations of excellence which might not exist, weak discrimination between the dimensions can result, and the results of gap analysis which cannot be easily generalized to the other areas can become somewhat tedious (Alves and Vieira, 2006). Since QFD is sensitive to the measurement of customer needs and expectations, the success of the method largely depends on the power of data collections on each level. Also, the procedure of aggregating customer demands and identifying their relative importance can be problematic in some situations (Poel, 2007). The limitations, however, have not affected the use of the integrative model since its advantages are far greater than its limitations. In summary, since none of the methods separately can achieve total benefits of this integrative approach, a minimal amount of adaptation is required for either method (Tan and Pawitra, 2001). This methodology can be evaluated as being sufficient in response to the main goal of this study. The ease of applying this methodology to different sectors constitutes a very practical benefit and makes it desirable for use in all healthcare sectors. References Akao, Y., Kogure, M. and Furukawa, Y. (1983), Company-wide Quality Control and Quality Deployment Seminar, Arlington Park Hilton, Chicago, IL, 31 October-3 November, sponsored by the Cambridge Corporation and co-sponsored by ASQC. Akao, Y. and Mazur, G.H. (2003), “The leading edge in QFD: past, present and future”, International Journal of Quality and Reliability Management, Vol. 20 No. 1, pp. 20-35. Alves, A.R. and Vieira, A. (2006), “SERVQUAL as a marketing instrument to measure service quality in higher education institutions”, paper presented at the Second International Conference: Product Management-Challenges of the Future, Poznan. Baki, B., Basfirinci, C.S., Cilingir, Z. and Ar, I.M. (2009), “An application of integrating SERVQUAL and Kano’s model into QFD for logistics services: a case study from Turkey”, Asia Pacific Journal of Marketing and Logistics, Vol. 21 No. 1, pp. 106-126. Bloemer, J., de Ruyter, K. and Wetzels, M. (1999), “Lining perceived service quality and service loyalty: a multi-dimensional perspective”, European Journal of Marketing, Vol. 33 Nos 11/12, pp. 1082-1106. Cetik, M.O., Ogulata, S.N. and Kocak, M. (2004), “Hastanelerde Tani ve Tedavi Surecleronde Kalite Engellerinin Hizmet Kalitesi Uzerine Etkilerinin Incelenmesi”, YA/EM’2004-Yoneylem Arastirmasi/Endustri Muhendisligi-XXIV Ulusal Kongresi, 15-18 Haziran, Gaziantep, Adana-Turkey.

Franceschini, F. and Terzago, M. (1998), “An application of quality function deployment to training courses”, International Journal of Quality & Reliability Management, Vol. 15 No. 7, pp. 753-768. Hamilton, J. and Selen, W. (2004), “Enabling real estate service chain management through personalised web interfacing using QFD”, International Journal of Operations & Production Management, Vol. 24 No. 3, pp. 270-288. Killen, C.P., Walker, M. and Hunt, R.A. (2005), “Strategic planning using QFD”, International Journal of Quality & Reliability Management, Vol. 22 No. 1, pp. 17-29. Kurtay, E. (2005), QFD, available at www.scribd.com/doc/6570018/Muterinin-Sesi-QFD (accessed on 10 December 2010). Lim, P.C. and Tang, N.K.H. (2000), “A study of patients’ expectations and satisfaction in Singapore hospitals”, International Journal of Health Care Quality Assurance, Vol. 13 No. 7, pp. 290-299. Lim, P.C., Tang, N.K.H. and Jackson, P.M. (1999), “An innovative framework for health care performance measurement”, Managing Service Quality, Vol. 9 No. 6, pp. 423-433. Matzler, K. and Hinterhuber, H.H. (1998), “How to make product development projects more successful by integrating Kano’s model of customer satisfaction into quality function deployment”, Technovation, Vol. 18 No. 1, pp. 25-38. Mizuno, S. and Akao, Y. (1978), Quality Function Deployment: A Company-wide Quality Approach, JUSE Press, Tokyo (in Japanese). Parasuraman, A., Zeithaml, V.A. and Berry, L.L. (1985), “A conceptual model of service quality and its implications for future research”, Journal of Marketing, Vol. 4 No. 4, pp. 41-50. Parasuraman, A., Zeithaml, V.A. and Berry, L.L. (1988), “SERVQUAL: a multiple-item scale for measuring consumer perceptions of service quality”, Journal of Retailing, Vol. 64, pp. 12-37. Parasuraman, A., Zeithaml, V.A. and Berry, L.L. (1991), “Refinement and reassessment of the SERVQUAL scale”, Journal of Retailing, Vol. 67 No. 4, pp. 420-450. Poel, I. (2007), “Methodological problems in QFD and directions for future development”, Research in Engineering Design, Vol. 18 No. 1, pp. 21-36. Sahney, S., Banwet, D.K. and Karunes, S. (2004), “A SERVQUAL and QFD approach to total quality education: a student perspective”, International Journal of Productivity and Performance Management, Vol. 53 No. 2, pp. 143-166. Tan, K.C. and Pawitra, T.A. (2001), “Integrating SERVQUAL and Kano’s model into QFD for service excellence development”, Managing Service Quality, Vol. 11 No. 6, pp. 418-430. Corresponding author Hatice Camgo¨z-Akdag˘ can be contacted at: [email protected]

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