Journal of Dental Sciences (2013) 8, 239e247

Available online at www.sciencedirect.com

journal homepage: www.e-jds.com

ORIGINAL ARTICLE

Patient satisfaction analysis: Identifying key

drivers and enhancing service quality of
dental care
Wen-Jen Chang a*, Yen-Hsiang Chang b

a
Department of Information Management, Chang Gung University, Taoyuan, Taiwan
b
Department of General Dentistry, Chang Gung Memorial Hospital, Taoyuan, Taiwan

Received 17 February 2012; Final revision received 31 October 2012

Available online 22 December 2012

KEYWORDS Abstract Background/purpose: Dental care service quality has received increasing attention
dental service; in recent years. Patient satisfaction is extensively used to evaluate healthcare service quality.
patient satisfaction; The aim of this study was to propose a conceptual framework for identifying the key drivers
service quality of and provide guidance for enhancing dental care service quality.
dental care Materials and methods: The dentistry department of a typical Taiwanese hospital was investi-
gated. In total, 400 adult patients, who subsequently visited the studied hospital for dental
treatment, participated in this study. Donabedian’s structure-process-outcome model was
used to explore the dental care service elements. A Kano-type questionnaire was developed
as the survey instrument.
Results: The response rate was 76% (303/400). Cronbach’s a value to each question was >0.7,
implying that the questionnaire was highly reliable. When investigating 30 quality elements,
based on Kano’s perspective, 12 elements were classified into must-be attributes, which are
regarded as key drivers of patient satisfaction; 10 elements were in the attractive attributes
category; and the remaining were one-dimensional attributes. Patient responses to most
dental service elements ranged from satisfied to very satisfied.
Conclusion: Physical characteristics of structural aspects and administration of process aspects are
regarded as essential dimensions. Patient satisfaction with the surveyed service elements was posi-
tive. Satisfaction with administration-related factors, other than accurate patient records, in the
process aspect was at the lowest level, thus there should be opportunities for improvement.
Copyright ª 2012, Association for Dental Sciences of the Republic of China. Published by Elsevier
Taiwan LLC. All rights reserved.

* Corresponding author. Department of Information Management, Chang Gung University, 259 Wen-Hwa 1st Road, Kweishan, Taoyuan 333,
Taiwan.
E-mail address: [email protected] (W.-J. Chang).

1991-7902/$36 Copyright ª 2012, Association for Dental Sciences of the Republic of China. Published by Elsevier Taiwan LLC. All rights reserved.
http://dx.doi.org/10.1016/j.jds.2012.10.006
240 W.-J. Chang, Y.-H. Chang

Introduction
Patient satisfaction with healthcare services has recently
received increasing attention. Increasing patient satisfac-
tion requires healthcare services to be patient-oriented and
comply with standard and efficient protocols. Analyzing
patient satisfaction and understanding weaknesses, oppor-
tunities, and threats associated with healthcare services,
can enhance the ability of healthcare providers to attract
patients. Identifying key drivers of patient satisfaction and
improving healthcare service quality have become crucial
for hospital operation.
Numerous instruments have been developed to measure
healthcare service quality, but the precise meaning of
“quality of care” remains ambiguous. Numerous studies were Figure 1 The Kano model of customer satisfaction.
developed to assess healthcare service quality. Patient
satisfaction is extensively used to evaluate healthcare
service quality.1,2 The SERVQUAL model, or the so-called gap attributes contrast with one-dimensional attributes and
model, which was developed to assess the service quality of their fulfillment can cause dissatisfaction.12
general businesses and is commonly used to examine The Kano model has attracted considerable attention
healthcare service quality, is useful for calculating the gap among marketing practitioners and researchers interested in
between customer/patient expectations and perceptions.1e4 identifying key drivers of customer satisfaction and dissat-
However, Donabedian5 indicated that healthcare signif- isfaction.14,15 Accordingly, the literature has also adopted
icantly differs from general business services, and patient the Kano model to identify customer/patient requirements
assessments of healthcare quality are more complex than or enhance their satisfaction with healthcare services.16e20
those for other services. Donabedian thus developed Such a model may prove useful in identifying drivers of
a systematic framework, namely the structure-process- patient satisfaction for application to dental services and
outcome model, to evaluate healthcare service quality.6 clarify where there is room for improvement.
The Donabedian framework has been widely adopted to Dental services differ from other medical services, in that
assess healthcare service quality. Those studies demon- they assume a more personal, intimate, and lasting contact
strated a close relationship among the three aspects of with the patient, since even the simplest dental procedure
structure, process, and outcome.7e9 Much literature has demands a relatively long session. Quality assessment of
analyzed the relationships between patient satisfaction and dental services remains relatively primitive.21 This study
these three aspects, and the service elements were thus integrated the structure-process-outcome framework
explored in aggregate. Each service element exerts of Donabedian, and the two-dimensional quality model of
different impacts on patient satisfaction, and their pecu- Kano, to identify the key determinants of patient satisfac-
liarities should be analyzed separately. In most quality tion with dental services.
models, such as the technical functional quality model10 Since 1995, the National Health Insurance (NHI) system has
and gap model,11 the relationship between the levels of provided the population of Taiwan with universal and
customer expectations fulfilled, and their perceptions, was comprehensive health care (including dental care) accessible
assumed to have a linear relation. However, Kano et al12 at a low cost. From 1998 to 2011, the number of dentists grew
exhibited potential nonlinear product/service perfor- rapidly to reach 5.16 dentists/10,000 residents. The NHI
mance impacts on customer satisfaction, and proposed Bureau contracted with 97% of the 6358 private dental service
a two-dimensional quality model to separately classify providers in Taiwan.22 Intense market competition has made
service element attributes and formulize their relationship the best means of promoting service quality23 and attracting
based on the motivator-hygiene theory of Herzberg.13 The patients key issues for dental service providers. This study
two-dimensional quality model, shown in Fig. 1, assumes investigated a typical Taiwanese hospital, a medical center
asymmetrical relationships between the level of customer about which patients had high expectations. To fulfill the
expectations fulfilled and customer satisfaction. Depending expectations of the government and the general population,
on the influence of individual service elements on customer the studied hospital emphasizes and strives to promote
satisfaction, product/service elements are classified as healthcare service quality and patient satisfaction.
must-be, attractive, one-dimensional, indifferent, and
reverse attributes.
Must-be attributes are essential requirements that do not Materials and methods
positively impact satisfaction, if expectations are exceeded,
but generate dissatisfaction if they are not satisfactory. Identification of service quality elements
Attractive attributes are excitement factors that do not
impact dissatisfaction but can enhance satisfaction. One- A comprehensive set of service elements was identified,
dimensional attributes are performance factors that based on the literature and suggestions from dentists at the
symmetrically impact both satisfaction and dissatisfaction, studied hospital. Thirty service elements, shown in Fig. 2,
in proportion to their level of fulfillment. Indifferent attri- were examined and classified in terms of three aspects,
butes do not impact satisfaction or dissatisfaction. Reverse structure, process, and outcome, based on the framework
Patient satisfaction with dental services 241

of Donabedian.6 The structure aspect included both a dysfunctional question, were formulated for each service
physical (five elements) and staff characteristics (three element with respect to dental services. For example,
elements); moreover, the process aspect examined convenient access to the facility is considered an element
professionalism (five elements), interactions (four of dental service. Table 1 lists the sample questions
elements), reactivity (four elements), and administration developed for the Kano-type questionnaires. Accordingly,
(six elements). The outcome aspect, which was neglected patients (respondents) should select a state from “I like it
in the literature in terms of dental services,21 was explored that way”, “It must be that way”, “I am neutral”, “I can
to evaluate patient perceptions after visiting the hospital. live with it that way”, and “I dislike it that way” from the
This investigation proposed three elements, posttreatment functional and dysfunctional questions. Patient perceptions
pain relief, increased confidence, and acceptable fees for of the service quality level were explored using a five-point
dental services, and used them as outcome measures. Likert scale, that ranged from “strongly dissatisfactory” to
“strongly satisfactory” to assess patient satisfaction with
Questionnaire design each service element. This study thus adopted three survey
types of classifying quality attributes, identifying the
A questionnaire was designed based on the perspectives of importance of service elements, and evaluating patient
Kano. Pairs of questions, comprising a functional and satisfaction.

Figure 2 The framework of investigated dental service attributes based on Donabedian’s perspective.
242 W.-J. Chang, Y.-H. Chang

patient answers “I like it that way” in response to the

Table 1 Sample questions of Kano-type questionnaires.
question “How would you feel if the location of the facility
Sample questions Possible responses is convenient?” (the functional form of the question) and
Functional question: , I like it that way answers “It must be that way” or “I am neutral” in response
If the facility is convenient , It must be that way to the question “How would you feel if the location of the
arrival, how would you feel? , I am neutral facility was not convenient?” (the dysfunctional question),
, I can live with it that way the combination of questions in the evaluation table yields
, I dislike it that way category “A”. A convenient location thus becomes an
Dysfunctional question: , I like it that way attractive attribute for that respondent. For a service
If the facility is not , It must be that way element, the category is derived from calculating the
convenient arrival, , I am neutral frequencies of the difference categories appearing in the
how would you feel? , I can live with it that way responses. For example, if 55/100 patients respond that
, I dislike it that way a service element is a must-be attribute and 25 patients
respond that it is an attractive attribute, the results suggest
that the service element being inquired about is viewed as
a must-be attribute.
The content validity of the survey determined whether The Kano model can improve the understanding of how
the survey was appropriate for measuring issues related to patients evaluate services and can help service providers
patient attitudes. Content validity testing of this study was focus on those quality attributes in most need of improve-
performed using a panel consisting of personnel who served ment. The patient satisfaction (PS) coefficient, which indi-
as administrators of the dental care sector of the studied cates how strongly a service element influences satisfaction
hospital and a professor with extensive experience in the or dissatisfaction, can serve as an indicator in ranking patient
field. The reliability appropriate in the context is an esti- requirements. The PS coefficient of a service element
mation of the internal consistency or homogeneity. Cron- comprises positive (better) and negative (worse) numbers.
bach’s a statistic was widely used in previous studies, and The former denotes the relative value of meeting this service
was also used in this study to measure the reliability. element requirement or its impact on satisfaction, while the
latter represents the extent to which this requirement
Study participants and setting remains unfulfilled.25 The calculation can be written as
follows, where A, O, M, and I denote the frequencies of
attractive, one-dimensional, must-be, and indifferent
This study was reviewed and approved by the Institute
attributes of each service element, respectively:
Review Board (IRB) at the studied hospital. All question-
naires included a separate section with informed consent AþO OþM
and description of the study aims. The study population was BetterZ ; WorseZ 
AþOþMþI AþOþMþI
comprised of patients who had visited the Department of
Dentistry at the studied hospital once in the past 3 months. A minus sign is placed in front of the Worse number to
The study surveyed 400 adult patients, who subsequently emphasize the negative influence on patient satisfaction
visited the Department of Dentistry of the studied hospital associated with this service requirement not being fulfilled.
for dental treatment. The range of absolute values of the PS coefficients is 0w1;
The service element category was derived using two values close to 1 are associated with stronger influences on
steps of identifying the categorization of an individual patient satisfaction or dissatisfaction.24
respondent and calculating the frequencies of categories to Rational allocation of scarce resources is important to
analyze the categorization result of a service element. For optimize patient satisfaction. This study used patient
an individual respondent, the category of a service element satisfaction and PS coefficients to more accurately consider
was derived from his/her answers to a pair of questions, the ranking of service elements being evaluated to enhance
comprised of a functional and a dysfunctional question their performance. Service elements with lower satisfac-
referring to Kano’s evaluation table (Table 2).24 The Kano tion and higher absolute values of both Better and Worse
evaluation lists the different combinations of potential numbers of the PS coefficients need to be improved and
answers and associated categories. For example, if the should be prioritized.

Table 2 Kano evaluation table with the possible combinations and resulting categories.
Quality attribute Dysfunctional
1. Like 2. Must-be 3. Neutral 4. Live with 5. Dislike
Functional 1. Like Q A A A O
2. Must-be R I I I M
3. Neutral R I I I M
4. Live with R I I I M
5. Dislike R R R R Q
A Z attractive; I Z indifferent; M Z must-be; O Z one-dimensional; Q Z questionable; R Z reverse.
Patient satisfaction with dental services 243

Statistical analysis To effectively manage the influence of patient charac-

teristics on the six less satisfactory service elements, the
Data were analyzed using SPSS 18.0 software (SPSS, Chi- statistical significance of the demographic variables
cago, IL, USA) and Microsoft Office Excel 2007 (Redmond, (gender, age, education, and occupation) were analyzed
WA, USA). To assess the internal consistency of the inves- using a one-way ANOVA. Table 4 lists the details of the
tigation, Cronbach’s a statistic was calculated. A one-way results. Two of the six elements, clearly stating the item
analysis of variance (ANOVA) examined the statistical charge list and a short duration of hospital stay, signifi-
significance of patient satisfaction, based on demographic cantly differed between genders (P < 0.05).
variables using the SPSS statistical package. Microsoft Service elements with lower satisfaction should be
Office Excel 2007 was used to classify the attributes of improved to promote overall patient satisfaction. Rationally
dental service elements. optimizing the allocation of limited resources is important.
This study took the level of patient satisfaction and the PS
coefficient of service elements as indicators to prioritize
Results service element improvement. As shown in Fig. 3, patient
satisfaction and the PS coefficient of the service elements
Characteristics of the sample were plotted against each other in the form of a scatter
diagram. Two different charts were drawn up. Fig. 3A shows
Four hundred questionnaires were distributed to adult patient satisfaction and Better numbers of PS coefficients of
patients, who subsequently visited the dental section of the the service elements; Fig. 3B shows patient satisfaction and
studied hospital for dental treatment. After removing Worse numbers of PS coefficients of the service elements.
incomplete samples, 303 questionnaires were further
analyzed. Conservatively, this would give a 95% confidence
interval (and so precision) of the estimate of the percentage
Discussion
of patients aware of dental service quality of 5.6%. Over
half of the sampled patients (57.25%) were female, approx- This study focused on identifying key drivers of patient
imately 18% were aged <30 years, and 6.5% had received no satisfaction and prioritizing service elements to improve
more than 9 years of education (junior high school). The the Department of Dentistry of the studied hospital.
criterion of reliability, namely an estimate of the internal Compared to previous investigations,2,3 this study classified
consistency and homogeneity, was evaluated using Cron- service elements for which researchers reported higher
bach’s a statistic. The value of Cronbach’s a for all questions expectation scores as must-be attributes. Notably, the
exceeded 0.7, indicating reasonable internal reliability. highest score awarded by patients surveyed in the previous
study was “clean and hygienic appearance” and “thorough
sterilization of instruments”, which most patients in the
Analysis of service attributes present study regarded as crucial attributes. This is prob-
ably why elements classified in this study as must-be
The attribute of each service element was derived attributes are basic requirements and are regarded as
according to the relative frequency of participant answers. crucial services that dental care providers must offer.
The results are summarized in columns four to eight of Failure to fulfill the requirements associated with these
Table 3. From the patient’s perspective, most service elements induces high patient dissatisfaction.
elements were classified as must-be attributes (12 Based on the Donabedian framework,6 service elements
elements). Moreover, 10 elements were classified as in the physical characteristics category of structural
attractive attributes; the remaining were classified as one- aspects, other than convenient arrival, were classified as
dimensional attributes. must-be attributes. This result indicates that good hygienic
The last three columns of Table 3 summarize patient facilities and up-to-date equipment are essential. This
satisfaction and give the PS coefficient of the service finding is consistent with those of Palihawadana and
elements. The mean scores of patient satisfaction for most Barnes2 and Karydis et al3 who found that these patient
service elements exceeded 4.0. Patient satisfaction expectations were placed at the top of patients’ priorities
regarding service elements thus ranged between satisfied and should be fulfilled for all dental services. Additionally,
and highly satisfied. This finding indicates positive patient those elements in the one-dimensional category were
satisfaction with most service elements. However, six important attributes, and the presence or absence of
service elements revealed lower satisfaction, including particular service elements and patient satisfaction were
ease of making appointments, a short duration of hospital proportionately related. Hospital managers should provide
stay, convenient arrival, clearly stating the item charge a good performance of these service elements to promote
list, meeting patients on time, and soliciting patient opin- overall patient satisfaction. Meanwhile, attributes in the
ions, in decreasing order of mean scores of patient satis- attractiveness category were less important than those in
faction. Among the six service elements, clearly stating the the must-be and one-dimensional categories. These attri-
item charge list, and meeting patients on time, were butes are also called excited factors, which do not impact
regarded as must-be attributes. A short hospital stay dissatisfaction but can enhance satisfaction, and should be
duration and ease of making appointments were considered enhanced to attract patients and promote patient loyalty.
one-dimensional attributes. Convenient arrival and solicit- Associations between respondent characteristics and
ing patient opinions occupied the attractive attribute their satisfaction with the six less-satisfactory service
category. elements were analyzed, and the results are listed in
244 W.-J. Chang, Y.-H. Chang

Table 3 The classification of dental service attributes in this study.

Aspects Dental service elements Frequency Attribute Patient PS coefficients
satisfaction (%)
A O M I Better Worse
number number
Structure Physical 1. State-of-the-art equipment 47 99 139 15 M 4.25 48.7 79.3
characteristics 2. Visually appealing 60 92 130 21 M 4.21 50.2 73.3
facilities
3. Clean and hygienic 18 63 200 22 M 4.33 26.7 86.8
appearance
4. Thorough sterilization 3 50 249 1 M 4.24 17.5 98.7
of instruments
5. Convenient arrival 124 83 63 33 A 3.72 68.3 48.2
Staff 6. Well dressed staff 80 83 172 26 M 4.23 45.2 70.6
characteristics 7. Sufficient dentists 118 70 48 67 A 4.10 62.0 38.9
for selection
8. Reputation of dentist 151 39 74 39 A 4.29 62.7 37.3
Process Professionalism 9. Healthy appearance 128 59 68 48 A 4.20 61.7 41.9
of dentist
10. Performing services 12 49 242 0 M 4.10 20.1 96.0
right the first time
11. Sense of security 31 87 172 11 M 4.13 39.2 86.0
with surgery staff
12. Subside pain during 83 143 52 24 O 4.02 74.8 64.6
treatment
13. Look over the teeth 126 76 71 30 A 4.13 66.7 48.5
actively
Interaction 14. Reliable oral health 151 77 48 24 A 4.05 76.0 41.7
instructions
15. Courtesy of dentist 124 95 64 20 A 4.22 72.3 52.5
16. Explain diagnosis 57 63 120 62 M 4.16 39.7 60.6
and treatment
17. Concern with patient’s 98 111 74 20 O 4.10 69.0 61.1
questions and worries
Reactivity 18. Prompt patient service 68 78 139 18 M 4.09 48.2 71.6
19. Sympathetic attitude 88 103 95 17 O 4.02 63.0 65.3
with patient’s problems
20. Effectiveness in 111 52 107 31 A 4.01 54.2 52.8
handling patient complaints
21. Good service attitude 90 97 93 23 O 4.24 61.7 62.7
Administration 22. Short duration of 77 112 91 20 O 3.79 63.0 67.7
hospital stay
23. Meet patient on time 20 106 167 10 M 3.87 41.6 90.1
24. Soliciting of patient 144 26 68 65 A 3.93 56.1 31.0
opinions
25. Accurate patient 34 72 173 24 M 4.21 35.0 80.9
records
26. Ease in making 95 115 69 24 O 3.66 69.3 60.7
appointment
27. Clearly stated item 65 113 119 6 M 3.82 58.7 76.6
charge list
Outcome Outcome 28. Pain relief after 120 71 88 24 A 4.08 63.0 52.5
treatment
29. More confidence 52 138 79 33 O 4.27 62.9 71.9
after treatment
30. Acceptable fees 29 140 123 11 O 4.04 55.8 86.8
for dental service
A Z attractive quality; I Z indifferent quality; M Z must-be quality; O Z one-dimensional quality.
The unclassified and reverse quality was <1%, omitted.
The shaded parts revealed relative higher cumulated frequencies and the service attributes belonged to the two-dimensional quality
classification.
Patient satisfaction with dental services 245

Table 4 Patient satisfaction by respondent demographic variables.

Service elements Patient satisfaction P
Mean  SD Gender Age Education Occupation
Easily making appointments 3.66  0.78 0.982 0.653 0.702 0.872
Convenient arrival 3.72  0.72 0.079 0.158 0.775 0.366
Clear and itemized list of charges 3.82  0.73 0.030* 0.504 0.590 0.101
Short duration of hospital stay 3.79  0.73 0.046* 0.510 0.424 0.549
Prompt and timely service delivery 3.87  0.61 0.181 0.856 0.823 0.400
Soliciting of patient opinions 3.93  0.70 0.152 0.445 0.259 0.118
* Denotes significant difference at a Z 0.05.

Table 4. Only two of the six elements, clearly stating the resources. Fig. 3 shows that service elements in the upper-
item charge list and a short duration of hospital stay, left corner are those with the most room for improvement,
significantly differed between genders (P < 0.05). Males while those in the bottom-right corner have the lowest
and females were compared in terms of their perceived priority. That is, to foster patient satisfaction, priority
satisfaction with the two service elements, and mean should be given to improving service elements with lower
scores of both elements perceived by males were higher patient satisfaction and higher Better numbers of the PS
than those of females. This result indicates that male coefficient. Fig. 3A shows that the first five service
patients were more satisfied with dental services, while elements that should be improved to promote patient
female patients had higher service requirements. This satisfaction, are easily making appointments, convenient
finding is similar to that of Karydis et al,3 who found that arrival, a short hospital stay duration, clearly stating the
patient gender and socioeconomic characteristics affect item charge list, and meeting patients on time. Conversely,
their satisfaction. decreasing patient dissatisfaction requires prioritizing
Patient satisfaction can be enhanced, and dissatisfac- service elements with lower patient satisfaction and higher
tion substantially reduced, by rationally allocating limited absolute Worse numbers of the PS coefficient. Fig. 3B shows
that the items identified as priorities for reducing patient
A 100 dissatisfaction coincide with those identified as priorities
for increasing patient satisfaction. Only a low priority
High priority
80 should be assigned to improving service elements with
Impact on satisfaction

12 14
26 5 17 15 higher satisfaction and smaller PS coefficients.
13
22 19 28 7 9
29
8 As mentioned previously, administrators are respon-
60 27 21
24 30
20 2
sible for improving the first five service elements. Three of
18 1
40 23 16
6 the five service elements whose improvement should be
11 25 prioritized, belong to the process aspect of the adminis-
3
20 10
tration category. To promote overall patient satisfaction
4
or reduce patient dissatisfaction, hospital managers
Low priority
should focus on improving “scheduling related” areas and
0
3.5 3.7 3.9 4.1 4.3 4.5 streamlining the business process to increase facility
utilization. Such streamlining can allow patients to make
Patient satisfaction
appointments more easily, shorten hospital stays, and
B 100 10
4 thus, increase patient satisfaction. This result is a little
High priority 23
30 11 3
different from that of Kaldenberg et al,26 who found that
80 25 1 the lowest level of patient satisfaction was related to
Impact on dissatisfaction

27
18
2
6 29 scheduling areas; however, improving those areas would
22 12
26
19
17 16 21 not dramatically reduce patient dissatisfaction. In their
60
20 28 15
study, factors of “providing services as promised” and
5 13
“instilling confidence in patients” were most likely to
14 9
40 7 8 have the greatest impacts on improving patient
24
satisfaction.
20 From this investigation, we found that patients were less
Low priority satisfied with the service element of clearly stating the
0
item charge list. The NHI program of Taiwan provides
3.5 3.7 3.9 4.1 4.3 4.5 universal and comprehensive health insurance with low
Patient satisfaction copayment for dental care, but excludes cosmetic services
such as dentures, orthodontics, and implants.22 The sums of
Figure 3 (A) The impact of the service attributes on patient money involved differ with the materials used. For
satisfaction; (B) the extent of non-fulfilled service require- example, the cost of dental crowns range from New Taiwan
ments being improved to reduce patient dissatisfaction. Dollars (NT$)4000 to >NT$10,000 (in 2011, the average
246 W.-J. Chang, Y.-H. Chang

exchange rate was US$1 z NT$29.464).27 This study thus Acknowledgements

suggests that dentists of the studied hospital should inform
patients of the costs of fee-charged service before This research was supported by grant NSC99-2410-H-182-
providing those services. 033 from the National Science Council, Taiwan.
Overall patient satisfaction was investigated and evalu-
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