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Service quality factors and outcomes in dental care

Article  in  Journal of Service Theory and Practice · June 2003

DOI: 10.1108/09604520310476472

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 Introduction
Service quality When considering the availability of prior
factors and outcomes in studies into this topic, Bush and Nitse (1992,
dental care p. 39) identify that ‘‘very little empirical
information is available about consumers’
acceptance of retail dental practices’’, while
Alan Baldwin and Laslett (1994, p. 21) confirms that ‘‘Despite the
Amrik Sohal consensus that patient satisfaction surveys are
important for quality assurance in medical
services and hospitals, little work has been
focussed on patient satisfaction with dental
services’’. Bryce (1999, p. 41), when discussing
the availability of customer satisfaction
indicators pertaining to in-hospital medical
treatment, comments ‘‘the sort of data currently
The authors being sought by some funders (e.g. health
insurance funds and governments) is not yet
Alan Baldwin is Manager, Dental and Healthcare
available anywhere in the world’’.
Centres, Austrailian Unity, Cranbourne, Victoria, Australia.
Berman-Brown and Bell (1998) confirm that
Amrik Sohal is Professor, Monash University,
much research into customer-oriented service
Caulfield East, Australia.
quality perceptions exists in areas other than
health care, producing a yet-to-be-met need in
Keywords the health quality arena. The published
Service quality, Dentists, Health care, Australia literature contains many references to quality
and customer service concepts pertaining to the
Abstract dental and medical professions from a clinical
perspective. It has been proposed that a
The research question developed for this study was:
significant variation exists between a patient’s
``Which aspects of the delivery of dental care impact most
expectations of treatment quality and the
significantly on patients’ perceptions of the service quality
perceived service quality of the treatment
of the care received?’’. The research methodology used a
received, due to a number of factors related to
questionnaire based upon the SERVQUAL instrument. A
number of implications are identified that impact
the service quality of the treatment delivered
significantly upon the service quality perceptions of dental
(Strasser et al., 1995; Butler et al., 1996;
patients. Amongst these are patient fear and anxiety,
Berry et al., 1988).
patients’ appreciation of punctual and convenient service
This paper examines the strength of the
delivery, and the positive advantages of involving patients
relationship between service quality practices
in the development of treatment plans. Dental and service quality outcomes in dental care.
practitioners are encouraged to develop strategies within The research question developed for this
their practices that are designed to build upon the study was: ‘‘Which aspects of the delivery of
advantages identified within the study. dental care impact most significantly on
patients’ perceptions of the service quality of
the care received?’’ This question resulted in
Electronic access
the identification of four factors relating to
The Emerald Research Register for this journal is distinct areas of dental service quality:
available at (1) Responsiveness. The relationship between
http://www.emeraldinsight.com/researchregister dentists keeping scheduled appointments
The current issue and full text archive of this journal is while accommodating patients at short
available at notice and their patients’ perceived level of
http://www.emeraldinsight.com/0960-4529.htm service quality, is positive and significant.
(2) Empathic assurance. The relationship
between treatments that maintain
patients’ comfort, ‘‘self-respect’’ and that
Managing Service Quality
involve minimal pain and the patients’
Volume 13 . Number 3 . 2003 . pp. 207-216
# MCB UP Limited . ISSN 0960-4529 perceived level of service quality, is
DOI 10.1108/09604520310476472 positive and significant.
207
 Service quality factors and outcomes in dental care Managing Service Quality
Alan Baldwin and Amrik Sohal Volume 13 . Number 3 . 2003 . 207-216

(3) Reliability. Practitioners who display traits patients that related to their perceptions of the
that are consistent with the patient’s service quality that they received. While the
perception of ‘‘professionalism’’ have a questions were finalised from data collected
significant positive effect on the patients’ during qualitative focus-group interviews, the
perceived level of service quality. issues of prior expectations and the degree of
(4) Tangibles. The physical characteristics of importance placed on each dimension by the
the practice (i.e. the décor, look, ambience, sample were not addressed, limiting the
etc. of the offices, surgeries, rooms, and effectiveness of the survey.
reception areas, including the technology With a study based on the SERVQUAL
and equipment used within them) have a method, Camilleri and O’Callaghan (1998)
significant positive effect on the patients’ paired patients’ expectations to their
perceived level of service quality. perceptions of the outcomes of service quality
delivery in the Maltese public and private
The findings of this research provide valuable
hospital systems. The three most significant
insights for dental practitioners into the non- service quality indicators were related to the
clinical aspects of service quality delivery that hospital environment, personalised service
are most valued by patients receiving and professional care. While the main focus of
treatments within their practices. the study was to compare the public system
against the private, the validity of the
Service quality expectation/perception pairing methodology
A popular definition of quality proposed by bodes well for future studies.
Berry et al. (1988, p. 35) is ‘‘conformance to Andaleeb’s (1998) study proposes and tests
specifications’’, however, they go on to claim a five-factor model that assesses the variation
that this definition can be improved for in customers’ satisfaction with hospitals. The
service quality: ‘‘conformance to customer study asserts that the most powerful
specifications; it is the customer’s definition indicators of customer satisfaction are the
of quality, not management’s, that counts’’. staffs’ competence, their demeanor and the
patients’ perceived cost of hospitalisation.
Customer satisfaction Carman (1990) attempts to build on and
Evans and Lindsay (1999, p. 176) proffer the replicate the research conducted by the
view that ‘‘Customer satisfaction results from authors of the SERVQUAL instrument by
providing goods and services that meet or exceed attempting to replicate their original studies in
customers’ needs’’. Linder-Pelz (1982) defined three separate situations: a tyre store, an
patient satisfaction as ‘‘Positive evaluations of employment placement centre and a dental
distinct dimensions of the health care’’. As clinic. The author confirms that the
customer satisfaction is customer/patient based, SERVQUAL instrument may be adapted for
an accurate analysis of the patients’ perceptions use in any industry. It appears, however, that
of the service delivery (outcomes) is critical to adaptations should only be made within the
the success of this research. stated guidelines, if the integrity of the
instrument is to be maintained.

The SERVQUAL expectation-perception Prior Australian research

gap Laslett’s (1994) research into patient
satisfaction at the Royal Dental Hospital
The patient-centred audit as described by Melbourne (RDHM) was based on the
Berman-Brown and Bell (1998) is hailed as the Davies and Ware (1981) instrument and
first instrument that is ‘‘totally grounded in assumed that there were a number of factors
patients’ views’’. The audit as described is that contribute to patient satisfaction. Laslett
indeed patient oriented, it appears to be (and is measures this satisfaction and makes
later recognised in the article to be) no more recommendations regarding improving the
than an adaptation of Parasuraman level of patient access to services. As Laslett’s
et al.’s (1988, 1991) SERVQUAL framework. study is conducted within the publicly funded
Utilising tangibility, reliability, responsiveness, RDHM, the issue of access differs to that
assurance and empathy, the service quality explored within this research report, given
dimensions that are contained in the that to be included in the sample frame, all
SERVQUAL instrument, as the foundations the respondents must have visited a dentist in
for the survey, 22 questions were presented to private practice over the previous 12 months.
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Alan Baldwin and Amrik Sohal Volume 13 . Number 3 . 2003 . 207-216

Research methodology Limited. The responses numbered 357,

representing a response rate of 24.2 percent.
The primary data gathering medium When considering the sample as a proportion
employed within this research was a written of the population, Krejeie and Morgan
self report survey questionnaire. The (1970), recommend that for the population
questionnaire collected both quantitative and considered within this survey - 4,500 people -
qualitative data and was adapted as a sample of 354 persons is required if ‘‘the
recommended by Parasuraman et al. (1991, sample proportion will be within §0.05 of the
p. 41) in that only ‘‘minor customisation of population proportion with a 95 per cent level
the wording of items’’ was used from the of confidence’’ (Krejeie and Morgan, 1970,
SERVQUAL instrument originally developed p. 608). The 357 responses received during
and subsequently refined to improve the the research have met this criterion.
instrument’s reliability and validity by
Parasuraman et al. (1991).
Only data that a dental practitioner could
Quantitative data analysis
reasonably expect to gather from patients
were sought within the demographics section The Statistical Package for Social Sciences
of the survey. Questions relating to education (SPSS) for Windows version 10.0 software
and income levels were deliberately not package was used to conduct most data
sought as these would not typically be analysis, while Microsoft Excel 2000 was used
collected by a dental practitioner and would to produce the tables and graphs from data
therefore reduce the perceived worth of the supplied by SPSS outputs. The first analyses
study to its intended audience (dental considered the demographics of the sample,
practitioners). Two sets of questions, one and where appropriate, compared the
relating to the respondents’ perceptions, the respondents’ profile to those that comprised
other relating to their expectations of a the sample frame. Descriptive statistics,
particular aspect of service quality, comprised primarily frequencies, provided an
Section Two (see Appendix). Each question understanding of the respondents’ gender,
was formed on a Likert scale, ranging between age, location, time elapsed since last visit,
1 and 7, with 1 representing ‘‘strongly traveling distance and appointment time
disagree’’ and 7 being ‘‘strongly agree’’. distributions. Data on the practitioners that
The relative importance of each of the five they visited were also collected, including
dimensions of service quality was assessed gender, age, type of practitioner and practice
through a ranking process adapted from composition, enabling t-tests to be conducted
Parasuraman et al.’s (1991) questions related to verify any links between the respondent’s
to this aspect, which appeared in the third demographic profile, the practitioner’s
section of the questionnaire (see Appendix). profile, and the service quality levels received
The final section of the questionnaire invited (i.e. the gap between the respondents’
respondents to share their views about the perceptions and their expectations).
service quality they had received from their Three batteries, of 22 questions each,
dental practitioners. Questions were open- relating to the aforementioned perceptions of
ended and covered the respondents’ feelings service quality received, the respondents’
relating to visiting their dental practitioner, the prior expectations of service quality, and the
pleasing and displeasing aspects of visits, perceived gaps between expectation and
important indicators of service quality, aspects delivery were analysed. These three sets of 22
that indicate ‘‘professionalism’’, together with results were factor analysed to ascertain their
suggestions about how practitioners might congruence with the service quality
improve their level of service delivery, as dimensions originally established by
perceived by their patients. Parasuraman et al. (1991) during a number of
An explanatory statement, consent form studies using the SERVQUAL instrument.
and survey questionnaire, together with a Factor analysis is defined by Hair et al.
reply paid envelope, were mailed to the (1998, p. 90), as ‘‘address(ing) the problem of
sample frame of 1,485 people selected from a analysing the structure of the interrelationships
cohort of people who held private health (correlations) among a large number of
insurance that provided cover for dental variables by defining a set of common
treatment with Australian Unity Health underlying dimensions, known as factors’’.
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Alan Baldwin and Amrik Sohal Volume 13 . Number 3 . 2003 . 207-216

The standard deviations of the independent troublesome correlation was that between the
variables comprising the factors, together with gap responses for question 3 (‘‘my dentist’s
the reliability and validity measures, were employees are neat-appearing’’) and question
analysed to ensure that the multi-item scale 7 (‘‘my dentist performs the service right the
items were consistent and to confirm the first time’’), which returned an abnormally
validities established by Parasuraman et al. low correlation of 0.111, with a significance of
(1991) when the SERVQUAL instrument was 0.023. While still acceptable at 95 percent
finalised. One sample t-tests were conducted significance, this low correlation value
to confirm the independent strength of the indicates that the two questions appeared to
weighted gap factors’ components and that be substantially unrelated to most
none of the individual factors had an overly respondents.
dominant effect on the overall measure of
service quality gleaned from the perception/ Total variance explained
expectation gap results. The percentage of the total variance within
the data that is explained by each model
ranged between 65.92 percent for the four
factor ‘‘gap’’ version (4Fq) to 74.33 percent
Factor analysis
for the five factor ‘‘expectations’’ model (5Fe).
As recommended by Parasuraman et al.
(1991), a factor analysis was performed on Reliability coefficients - internal
the data that interpreted the respondents’ consistency
levels of satisfaction with the 22 questions Internal consistency within a survey
relating to their expectations (Fe) and the 22 instrument is assessed by measuring the
questions pertaining to their perceptions, of reliability of the questionnaire’s items and
the level of service received (Fp). A further scales through a process used to ‘‘measure the
factor analysis was then performed on the gap internal consistency of a measure [by analysing
between these expectations and perceptions how well] scores on subsets of the items within
(Fq), as reported by each respondent. a scale are correlated’’ (Zikmund, 1997,
p. 341). Reliability coefficients were computed
Standard deviations for the independent variables (IVs) that
All analyses were first screened for abnormal formed each group of factors, with Cronbach’s
standard deviations, with those variables alpha (Cronbach, 1951) calculations
producing outlier values indicating that the producing the values shown in Table I, by
wording of the question may have confused factor, within each factor type.
the respondents. Of the ‘‘perceptions’’ battery
Table I Reliability coefficients with Cronbach’s alpha
the standard deviations fell in the range 0.87
to 1.35, while within the ‘‘expectations’’ n
battery the standard deviations ranged from Expectation factors (4Fe )
0.80 to 1.46. The ‘‘gap’’ analysis’ standard Fe 1 – Skill and ability 0.8781
deviations ranged from 0.85 to 1.61 - this Fe 2 – Punctuality 0.8577
greater range does not, however, indicate that Fe 3 – Personal attention 0.8729
there was confusion regarding the wording of Fe 4 – Tangibles 0.8594
questions (as it would have done for the Overall (4Fe ) Cronbach’s alpha 0.9466
expectations and perceptions batteries).
Perception factors (4Fp )
Fp 1 – Skill and ability 0.8959
Correlations
Fp 2 – Punctuality 0.8567
The correlation matrices were checked next
Fp 3 – Personal attention 0.8348
to ensure that the correlation between
Fp 4 – Tangibles 0.8261
individual variables was neither too high, nor
Overall (4Fp ) Cronbach’s alpha 0.9514
too low, overall. The values appeared evenly
Quality gap factors (4Fq )
distributed, indicating that there is neither an
Fq 1 – Responsiveness 0.9052
indication that their explanatory power is
Fq 2 – Empathic assurance 0.8844
diminished by being too highly correlated, nor
Fq 3 – Reliability 0.7796
that there is little likelihood of there being a
Fq 4 – Tangibles 0.8113
suitable range of dimensions of service quality
Overall (4Fq ) Cronbach’s alpha 0.9321
within the spread of variables. The only
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While alpha values will always fall between 0 - understandable considering the
and 1, the above values are all in excess of the intimate and intrusive nature of the
‘‘generally agreed on lower limit for service being provided.
Cronbach’s alpha of 0.70’’ recommended by (2) Factor two - punctuality. Punctual, timely
Hair et al. (1998, p. 118). This result can be delivery of service with minimal waiting
partially attributed to the number of IVs time and delays, and practitioners that are
(questions) in the questionnaire, as Cronbach’s responsive to their patients’ needs form
alpha has a ‘‘positive relationship to the the essential elements of this factor.
number of items in the scale’’ (Hair et al., (3) Factor three - personalised attention. Chair-
1998, p. 118). As the self report questionnaire side ability, knowledge of the required
contained 22 items, it is to be expected that a procedures, personalised attention and
high value would be achieved, however, the the ability to anticipate the needs of
magnitude of the alpha values obtained does patients, all feature strongly.
constitute positive proof of the internal (4) Factor four - tangibles. The equipment,
consistency of the items forming the self-report décor, waiting room, physical appearance
questionnaire’s scale. Additionally, when the of employees’ uniforms, and the
individual 4Fe, 4Fp and 4Fq factors’ alpha attractiveness or otherwise of promotional
values are analysed they too indicate significant materials contribute to this factor’s success
levels of reliability and internal consistency. as a predictor of service quality.

Nomological validity - perceptions and Nomological validity - quality gaps

expectations 4Fq model
The SERVQUAL instrument’s two batteries The four factor model, 4Fq, (see Table II)
of questions are designed to interrogate adopts the five factors proposed by
respondents’ experiences of levels of service Parasuraman et al. (1991) in the modified
quality on five dimensions: tangibles, SERVQUAL instrument, however, the factors
reliability, responsiveness, assurance and labelled ‘‘assurance’’ and ‘‘empathy’’ by
empathy. The authors’ (Parasuraman et al., Parasuraman et al. (1991) have been merged
1991) claim that the SERVQUAL by the SPSS factor analysis process to form one
instrument’s strength in the areas of scale factor. Considering the very personal nature of
reliability and validity is well proven, as the service being assessed within a dental care
assessed by a number of published studies, environment, it is not surprising that
that include Babakus and Boller (1991), dimensions of service that represent assurance
Brensinger and Lambert (1990); Carman and empathy become closely aligned. All IVs
(1990) and Finn and Lamb (1991). The have factor loadings of greater than 0.45,
results from this study further demonstrate ensuring that there is sufficient evidence to
the instrument’s strength in the areas of scale group them within their allocated factor.
reliability and validity.
Construct validity - quality gaps
Construct validity - perceptions and The factors emerging from the 4Fq ‘‘gap’’
expectations analysis can be defined by noting the aspects
The 4Fe4Fp model, in containing factors that of each factor that featured most frequently in
differed from each other and that are distinctly the responses to the qualitative questions.
identifiable, is said to have discriminant
Factor one - responsiveness Fq1.
validity (Carman, 1990). Another aspect of
A recognisable willingness to help promptly,
validity is the ability of factors to accurately
to respond readily to the demands of patients,
reflect the dimensions or constructs originally
to instil confidence and advise patients of
proposed by the hypotheses, referred to as
their rights and obligations in a timely
construct validity (Hair et al., 1998, p. 584).
manner, are all principal conditions of
The individual factors contributing to the
this factor.
4Fe4Fp model are as follows:
(1) Factor one - skill and ability. This factor Factor two - empathic assurance Fq2.
can best be described as representing the Major features of this factor incorporate a
‘‘craft’’ skills that dental practitioners feeling that the practitioner understands and
have studied and practiced. Safety, recognises the needs of patients to be treated,
reliability, and technical ability are at times that suit the patients and in an
incorporated within this composite factor environment that encourages the patients to
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Alan Baldwin and Amrik Sohal Volume 13 . Number 3 . 2003 . 207-216

Table II Four factor ``gap’’ model the quality and accuracy of any
Factor
promotional or other material provided by
1 2 3 4 the practitioner.

Responsiveness
Q12 0.82 0.25 0.24 0.14
Q11 0.81 0.27 0.25 0.19 Limitations
Q13 0.81 0.21 0.15 0.15 Expectation/perception gaps
Q14 0.77 0.27 0.25 0.16 The measurement of ‘‘gaps’’ between the
Q10 0.63 0.15 0.32 0.18 respondents’ expectations and perceptions of
Q8 0.46 0.28 0.34 0.25
the quality of the service received that was
Assurance and empathy conducted in Section two of the self-report
Q18 0.19 0.75 0.38 0.10 questionnaire would ideally have been
Q19 0.12 0.73 0.12 0.20 measured by assessing the respondents’
Q20 0.57 0.64 0.03 0.16
expectations prior to visiting their dentist.
Q22 0.44 0.62 0.15 0.16
Their perceptions of the quality of the service
Q17 0.42 0.59 0.05 0.06
that they had received would then be
Q16 0.53 0.58 0.12 0.14
measured immediately following the visit. For
Q21 0.25 0.57 0.51 0.09
the purposes of this research, however, given
Q15 0.11 0.55 0.54 0.20
time and resource constraints, such an
Reliability
approach was impractical.
Q7 0.22 0.11 0.80 0.03
Q6 0.22 0.14 0.75 0.13
Moderating variables
Q9 0.52 0.15 0.55 0.11
The attempt to identify moderating variables
Q5 0.27 0.21 0.52 0.38
such as age, gender and location as having an
Tangibles
effect on patients’ levels of service satisfaction
Q2 0.11 0.08 0.16 0.84
was not successful, there being no significant
Q1 0.15 0.04 0.10 0.80
Q4 0.07 0.15 0.15 0.72
effects measurable from the data produced by
Q3 0.27 0.23 ±0.01 0.69 the project.

Notes: Rotated component matrix. Extraction method: principal component

analysis. Rotation method: Varimax with Kaiser normalization. Rotation Inter-rater reliability
converged in eight iterations. Percentage variance explained by four factors: The qualitative results from this project were
KMO and Bartlett’s test 65.924; Kaiser-Meyer-Olkin measure of sampling not, in the traditional sense, checked for inter-
adequacy 0.935; Bartlett’s test of sphericity: approx chi-square 4,443.923;
df 231; sig. 0.000
rater reliability, principally due to time
constraints. The qualitative results were
feel less anxious. Patients are treated as coded after a gap of two weeks had elapsed
individuals, with their specific needs, since the quantitative results were input to
questions and interests met through the SPSS, and before any analysis had been
ability of employees to enhance the level of performed on the quantitative data. This
security felt by the patients. approach enabled the author to deliver a
reasonably objective coding methodology,
Factor three - reliability Fq3. through a process of adopting a deliberately
Respondents to the qualitative questions impartial classification regime.
indicated that a low failure or re-treatment
rate, high levels of quality control, an
Relevant literature
enthusiastic yet caring nature and skill in The dearth of literature directly pertaining to
performing the agreed procedures, all
the delivery of quality service in a private
contribute to an overall impression that
dental provider’s environment has limited the
the practitioner is dependable and can be
researcher’s ability to compare directly the
relied on.
strength, validity and reliability of this study
Factor four - tangibles Fq4. to other preceding studies, although the
Principal indicators of this aspect include a studies by Carman (1990) and Laslett (1994),
belief that the practitioner’s practice instils provide comparable results, albeit from two
confidence in the patients through its public dental hospitals. It has also not been
appearance, the appearance of the possible to build on previous studies, for the
practitioners and their employees, and same reason.
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Future research weekends (a trend that includes medical

centres, ancillary providers such as
The aspects of service quality delivery in physiotherapists, naturopaths and pharmacists,
dental care that have been identified within but not usually medical specialists), a relevant
this research project as being suitable topics question that should be posed in future surveys
for future research are shown below. is: ‘‘at what time of day, and on which day
would you rather visit the dentist?’’, thereby
Service quality and corporatisation attempting to address any potential imbalance
The issue of access, labelled ‘‘responsiveness’’ between supply and demand within the dental
during this research, is worthy of future marketplace and the potentially negative effects
research. The preference to operate as a single on the responsiveness factor within the service
or two-practitioner practice may be the quality ‘‘mix’’ in dentistry.
product of market forces, such as limited
demand within the practice’s geographic Cancellation and/or missed
(patient) catchment area, or may be based in appointment fees
some other rationale. The structure of a The recent trend - reported anecdotally -
practice can have a direct effect on the ability towards dental practices charging patients a
of the dental practitioner to see patients in a cancellation/missed appointment fee should
timely manner. While the corporatisation of they not provide sufficient notice to the
dental practices was not specifically identified
practice of their (the patients) intention to
as an option for future change during the
cancel an appointment was not investigated
project, the trend within e.g. general medical
within this research project and the
practices indicates that this is a contemporary
acceptability of such a fee should be assessed
option that cannot be ignored. The changes
in future research. Most private dental
possible through alternate practice
practitioners must effect a balance between
configurations, particularly through a
efficiently structuring appointments and
corporatisation model, on the service quality
providing acceptable levels of access for their
factor related to responsiveness and the ability
patients. The ability, however, for a practice
of the practice to see patients in a timely
to be recompensed for structuring
manner, should be investigated during future
appointments less efficiently, while improving
research projects.
patients’ perceptions of the responsiveness
factor, may have a positive effect on the
Gender as an indicator of patient loyalty
overall perception of the service quality
While not reported within this paper,
cross-tabulation analysis of the demographics delivered by dental practitioners.
of the respondents to the research project
indicated that females seem to be three times Relationship between irrational and
more likely to travel greater than 50km to rational anxiety
visit a dentist, with 9 percent of females and This research identified the issue of irrational
3 percent of males falling into this category. fear and anxiety as being a major barrier to
This result should be treated with caution as attending the dentist at the recommended
no attempt has been made within this periodicity. Future research should
research project to discover the reasons investigate the actual level of pain and
behind this result. It is, however, discomfort experienced as compared to the
recommended that the effect of gender and level anticipated prior to receiving the
traveling distance on patient loyalty should treatment. Thomson (2002) identifies
be researched in future research projects as patients that visit their dentist only when they
a possible influencer of patients’ perceptions experience problems as being twice as likely to
of the reliability factor within service quality suffer from dental anxiety as patients that visit
delivery. their dentist on a regular basis. Improvements
in the service quality factor ‘‘empathic
Increased practitioner operating hours assurance’’ may have a significant impact on
This research identified patient attendance how patients experience this phenomenon in
times as principally occurring between the the future, with improved communication
hours of 8 a.m. and 5 p.m. on weekdays. When between practitioner and patient offering the
considering the tendency within the general possibility that elements such as a ‘‘fear of the
retail sector to open longer hours and at unknown’’ may be minimized.
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Alan Baldwin and Amrik Sohal Volume 13 . Number 3 . 2003 . 207-216

Managerial implications Waiting times

With both patient anxiety and lack of
A number of facets of service quality have practitioner punctuality in delivering
emerged as priorities for patients when treatments emerging as facets that impact
analysing the responses provided during this negatively on the respondents’ perceptions of
research, and should be recognized by service quality delivery within the
practitioners as having a significant impact on ‘‘responsiveness’’ factor, it would be valuable
their patients’ overall satisfaction levels: to explore the relationship between the two to
determine the level of causality - if any - that
Fear and anxiety exists between patients’ anxiety levels and the
The issue of fear and anxiety related to the punctual nature of the treatment delivery. If a
pain and discomfort associated with dental causal relationship is inferred and then proven
treatments is worthy of further research. As to exist between a patient’s anxiety level and
this fear or anxiety has been reported by 27 the amount of time they spend in the dental
percent of respondents as being the result of waiting room, the practitioner will be
‘‘irrational paranoia’’ or ‘‘bad past experiences presented with a choice of appropriate actions.
(usually in childhood)’’, this suggests that a A practitioner may, for example, discover that
large proportion of treatments do not result in their practice is such that a large proportion of
the patient actually experiencing any patients are kept waiting for an amount of time
significant levels of physical pain or that causes their anxiety levels to increase.
discomfort. There may well be opportunities
for the dental profession, on an industry-wide Collaborative treatment planning
platform, to address these fears effectively, The collaboration between practitioners and
perhaps by acknowledging and publicising the patients in setting appropriate treatment plans
improved techniques and advanced was felt by many respondents to empower the
technologies available to contemporary patient and enhance their feelings of self-respect.
practitioners. The resultant reduction in Respondents have indicated that they prefer to
demand for un-scheduled emergency visits be provided with choices or options regarding
may result in measurable improvements in the the treatment pathway to be explored, enabling
‘‘responsiveness’’ results, due to the dental them to retain the feeling that they have a degree
practice’s ability to improve appointment of control over their ‘‘dental destiny’’ and
scheduling and the punctuality of dentists enhancing their perceptions of service quality
delivering treatments to patients. within the empathic assurance factor. From the
practitioners’ perspective, obtaining the patient’s
Punctuality imprimatur when establishing the treatment
The importance of punctuality and the ability plan provides a degree of assurance that the
of the practitioner to value their patients’ time patient will be committed to seeing the
equally with their own should also be treatment through to completion, which would
explored. Emergencies and unexpectedly be a desirable outcome for practitioners given
extended appointments are an inevitable and the time and resource-intensive nature of many
unpredictable facet of operating most dental dental treatment plans.
practices. The ability of the practitioner and
the reception staff to communicate effectively Opening times
the nature of any delays, together with the Feedback to the demographic section of the
reasons for the delay, would be greatly questionnaire indicated that on the last occasion
appreciated by a number of respondents to that the respondents had visited the dentist, at
this research, perhaps resulting in enhanced least 90 percent of them had visited their dentist
results within the ‘‘responsiveness’’ factor. between 8 a.m. and 5 p.m. on a weekday.
Modern technology enabling the surgery to be When cross tabulating these data, there were no
linked to the reception desk by means of a significant correlations between the regular and
networked computer system, together with irregular appointees and the timing of their
the appropriate practice management respective appointments. However, only 46
software, provides opportunities for percent of all respondents indicated that they
practitioners to communicate any delays to had visited the dentist within the past six
their front desk personnel in a quiet, effective months, perhaps indicating a latent demand for
and unobtrusive manner. opening hours beyond those currently available,
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 Service quality factors and outcomes in dental care Managing Service Quality
Alan Baldwin and Amrik Sohal Volume 13 . Number 3 . 2003 . 207-216

with the possibility of an improvement in the Department of Social and Preventative Medicine,
results achieved for the ‘‘responsiveness’’ factor Monash University, Melbourne.
Linder-Pelz S. (1982), ``Toward a theory of patient
in the service quality mix.
satisfaction’’, Social Science and Medicine, Vol. 16,
pp. 577-82.
Parasuraman, A., Berry, L.L. and Zeithaml, V.A. (1991),
References ``Refinement and reassessment of the SERVQUAL
scale’’, Journal of Retailing, Vol. 67 No. 4, pp. 420-50.
Andaleeb, S.S. (1998), ``Determinants of customer Parasuraman, A., Zeithaml, V.A. and Berry, L.L. (1988),
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International Journal of Health Care Quality consumer perceptions of service quality’’, Journal of
Assurance, Vol. 11 No. 6, pp. 181-7. Retailing, Vol. 64 No. 1, pp. 12-40.
Babakus, E. and Boller, G.W. (1991), ``An empirical Strasser, S., Schweikhart, S., Welch, G.E. and Burge, J.C.
assessment of the SERVQUAL scale’’, Journal of (1995), ``Satisfaction with medical care’’, Journal of
Business Research, Vol. 24 No. 3, pp. 253-68. Health Care Marketing, Vol. 15 No. 3, pp. 34-43.
Berman-Brown, R. and Bell, L. (1998), ``Patient-centred Thomson, M. (2002), Public Perceptions of Dentistry,
audit: a users’ quality model’’, Managing Service Australian Institute of Health and Welfare Dental
Quality, Vol. 8 No. 2, pp. 88-96. Statistics and Research Series No. 25, AIHW DSRU,
Berry, L.L., Parasuraman, A. and Zeithaml, V.A. (1988), Adelaide, pp. 77-82.
``The service-quality puzzle’’, Business Horizons, Zikmund, W.G. (1997), Business Research Methods,
September-October, pp. 35-43. Dryden Press, Fort Worth, TX.
Brensinger, R.P. and Lambert, D.M. (1990), ``Can the
SERVQUAL scale be generalised to business-to-
business services?’’, Knowledge Development in
Marketing, 1990 AMA’s Summer Educators’ Appendix. Modified SERVQUAL
Conference Proceedings. instrument
Bryce, M. (1999), ``30 percent rebate a good thing’’,
National Healthcare Journal, Vol. 9 No. 3, pp. 39-41. Expectations section
Bush, R.P. and Nitse, P.S. (1992), ``Retail versus private Tangibles
dental practices: do the patients differ?’’, Journal of E1. Excellent dentists will have modern-
Health Care Marketing, Vol. 12 No. 1, pp. 39-47. looking equipment.
Butler, D., Oswald, S.L. and Turner, D.E. (1996), ``The
effects of demographics on determinants of
E2. The physical facilities at excellent
perceived health-care service quality ± the case of dentists will be visually appealing.
users and observers’’, Journal of Management in E3. Employees of excellent dentists will be
Medicine, Vol. 10 No. 5, pp. 8-20. neat-appearing.
Camilleri, D. and O’Callaghan, M. (1998), ``Comparing E4. Materials associated with the service
public and private hospital care service quality’’,
International Journal of Health Care Quality
(such as pamphlets or statements) will be
Assurance, Vol. 11 No. 4, pp. 127-33. visually appealing in an excellent
Carman, J.M. (1990), ``Consumer perceptions of service dentist’s practice.
quality: an assessment of the SERVQUAL
dimensions’’, Journal of Retailing, Vol. 66, Spring, Reliability
pp. 33-5. E5. When excellent dentists promise to do
Cronbach, L.J. (1951), ``Coefficient alpha and the something by a certain time, they will do so.
internal structure of tests’’, Psychometrica, Vol. 16, E6. When customers have a problem,
pp. 297-334.
excellent dentists will show a sincere
Davies, A.R. and Ware, J.E. Jr (1981), ``Measuring patient
satisfaction with dental care’’, Social Science interest in solving it.
Medicine, Vol. 15a, pp. 751-60. E7. Excellent dentists will perform the
Evans, J.R. and Lindsay, W.M. (1999), The Management service right the first time.
and Control of Quality, South-Western College E8. Excellent dentists will provide their
Publishing, Cincinnati, OH.
services at the time they promise to do so.
Finn, D.W. and Lamb, C.W. (1991), ``An evaluation of the
SERVQUAL scales in a retailing setting’’, Advances E9. Excellent dentists will insist on error-free
in Consumer Research, Vol. 18. records.
Hair, J.F., Anderson, R.E., Tatham, R.L. and Black, W.C.
(1998), Multivariate Data Analysis, Prentice-Hall, Responsiveness
Upper Saddle River, NJ. E10. Employees of excellent dentists will tell
Krejeie, R.V. and Morgan, D.W. (1970), ``Determining customers exactly when services will be
sample size for research activities’’, Educational and performed.
Psychological Measurement, Vol. 30, pp. 607-10. E11. Employees of excellent dentists will give
Laslett, A-M. (1994), ``Patient satisfaction among users of
the Royal Dental Hospital of Melbourne’’, Research prompt service to customers.
Report submitted in partial fulfilment of the E12. Employees of excellent dentists will
requirement for the Master of Public Health, always be willing to help customers.
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 Service quality factors and outcomes in dental care Managing Service Quality
Alan Baldwin and Amrik Sohal Volume 13 . Number 3 . 2003 . 207-216

E13. Employees of excellent dentists will P12. Employees of my dentist are always
never be too busy to respond to willing to help you.
customer requests. P13. Employees of my dentist are never too
busy to respond to your requests.
Assurance
E14. The behavior of employees of excellent Assurance
dentists will instill confidence in P14. The behavior of employees of my dentist
customers. instills confidence in customers.
E15. Customers of excellent dentists will feel P15. You feel safe in your transactions with
safe in their transactions. my dentist.
E16. Employees of excellent dentists will be P16. Employees of my dentist are consistently
consistently courteous with customers. courteous with you.
E17. Employees of excellent dentists will have P17. Employees of my dentist have the
the knowledge to answer customer knowledge to answer your questions.
questions.
Empathy
Empathy P18. My dentist gives you individual attention.
E18. Excellent dentists will give customers P19. My dentist has operating hours
individual attention. convenient to all its customers.
E19. Excellent dentists will have operating P20. My dentist has employees who give you
hours convenient to all their customers. personal attention.
E20. Excellent dentists will have employees P21. My dentist has your best interests at heart.
who give customers personal attention. P22. Employees of my dentist understand
E21. Excellent dentists will have the your specific needs.
customers’ best interests at heart.
E22. The employees of excellent dentists will Point-allocation question
understand the specific needs of their Directions
customers. Listed below are five features pertaining to
dentists and the services they offer. We would
Perceptions section like to know how important each of these
Tangibles features is to you when you evaluate your
P1. My dentist has modern-looking equipment. dentist’s quality of service. Please allocate a
P2. My dentist’s physical facilities are total of 100 points among the five features
visually appealing. according to how important each feature is to
P3. My dentist’s employees are neat-appearing. you - the more important a feature is to you,
P4. Materials associated with the service the more points you should allocate to it.
(such as pamphlets or statements) are Please ensure that the points you allocate to
visually appealing at my dentist. the five features add up to 100:
Reliability (1) The appearance of the dentist’s physical
P5. When my dentist promises to do facilities, equipment, personnel, and
something by a certain time, it does so. communications materials: ___ points
P6. When you have a problem, my dentist (2) The ability of the dentist to perform the
shows a sincere interest in solving it. promised service dependably and
P7. My dentist performs the service right the accurately: ___ points
first time. (3) The willingness of the dentist to help patients
P8. My dentist provides its services at the and provide prompt service: ___ points
time it promises to do so. (4) The knowledge and courtesy of the
P9. My dentist insists on error-free records. dentist’s employees and their ability to
convey trust and confidence: ___ points
Responsiveness
(5) The caring, individualized attention the
P10. Employees of my dentist tell you exactly
dentists provides to patients: ___ points
when services will be performed.
P11. Employees of my dentist give you Total points allocated - 100 points (Source:
prompt service. Parasuraman et al. (1999)).

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