Shu - Te University

College of Management

Graduate School of Business Administration

Master

A Relationship Study between healthcare

quality and patient’s key caretaker satisfaction

for Hai Duong children’s hospital in Viet Nam.

Student: Nhu Ngoc Thanh

ID: 99733427

Advisor: Dr.Jau-Shyong Wang

Co-Advisor: Dr. Pham Vu Thang

September, 2013

Shu-Te University

Graduate School of

Business A

dministration

Thesis

A

relationship study between healthcare quality and

patient’s key caretaker satisfaction for Hai D

uong children’s hospital in V

iet Nam

Nhu N

goc Thanh

September, 2013

A relationship study between healthcare quality and patient’s key

caretaker satisfaction for Hai Duong children’s hospital in

Viet Nam.

Student : Nhu Ngoc Thanh

Advisor : Dr.Jau-Shyong Wang

Co-Advisor : Dr. Pham Vu Thang

A Thesis

Submitted to the

Graduate School of Business Administration

College of Management

Shu-Te University

In Partial Fulfillment of the Requirements

For the Degree of

Master of Science in

Business Administration

September, 2013

i

Shu-Te University

Graduate School of Business Administration

A relationship study between healthcare quality and patient’s key

caretaker satisfaction for Hai Duong children’s hospital in

Viet Nam. Student : Nhu Ngoc Thanh

Advisor : Dr.Jau-Shyong Wang Co-advisor : Dr. Pham Vu Thang

Abstract

The main purpose of this thesis is to research on the satisfaction of the patients

with factors of service quality in SERVQUAL model in Hai Duong Children’s Hospital

in Vietnam.

The research method used in this thesis is quantitative research with some

statistical step of data analysis and processing such as: descriptive statistics, scale

verification, factor analysis, correlation analysis, and regression analysis. The

supporting software is SPSS 20.0.

The research results showed that the satisfaction of patients with disease diagnosis

and treatment of the hospital was affected by four factors including: (1) assurance, (2)

empathy, (3) responsiveness, and (4) tangibles. The factor “reliability” has no impact on

general satisfaction of the patients. These factors positively influence the satisfaction of

the patients with services.

The research results also showed no differences between groups of different age,

income, job and education level.

In addition, the research also pointed out the limitations and directtions for further

researches.

Keywords: the satisfaction of patients, healthcare, service quality, SERVQUAL.

ii

Acknowledgements

I am so happy having chance to express my gratitude and my deep thanks to those

who have supported and encouraged me to complete this study. Without them it could

be difficult for me to fulfill this thesis.

Firstly, I would like to thank and appreciate the advices of Dr. Jau-Shyong Wang

and Dr. Sheng-Jung Li in the Faculty of the School of Business Administration, Shu-te

University and Dr. Pham Vu Thang, who have enthusiastically guided me in this

research process. Hints and tips by Dr. Wang, Dr. Li and Dr. Thang have great

importance for me to perform this research. Dr. Wang, Dr. Li and Dr. Thang are willing

to help me at any time and in any situation.

Secondly, I would like to thank the team of doctors, hospital staffs at Hai Duong

Hospital as well as my colleagues and especially the patients who took the time to

discuss and complete the questionnaire and gave advices for my research.

Finally I would like to express my sincere gratitude to my family, wife and

children, who have always encouraged me during the course of this study.

Nhu Ngoc Thanh

September, 2013

iii

Table of Contents

Abstract ......................................................................................................................... i

Acknowledgements ....................................................................................................... ii

Table of Contents ......................................................................................................... iii

List of Tables ............................................................................................................... vi

List of Figures ............................................................................................................. vii

CHAPTER 1 INTRODUCTION ................................................................................... 1

1.1 Research Background.................................................................................... 1

1.2 Research Motivations .................................................................................... 1

1.3 Research Purposes ........................................................................................ 5

1.4 Research Procedures ..................................................................................... 5

CHAPTER 2 LITERATURE REVIEW ........................................................................ 8

2.1 The concepts and characteristics of service.................................................... 8

2.2 Service quality ............................................................................................ 10

2.3 Customer satisfaction .................................................................................. 11

2.4 The relationship between service quality and customer satisfaction ............. 11

2.5 Research models of service quality and customer satisfaction...................... 11

2.5.1 The service quality five gap model ..................................................... 12

2.5.2 SERVQUAL model ........................................................................... 14

2.5.3 European Customer Satisfaction Index model .................................... 14

2.6 Some recent researches on customer satisfaction in the field of health care . 16

CHAPTER 3 RESEARCH METHODOLOGY ........................................................... 18

3.1 Research model ........................................................................................... 18

3.2 Research Hypotheses .................................................................................. 19

3.3 Measurement of observed variables ............................................................. 19

3.4 Research Design ......................................................................................... 21

3.4.1 Discussion for scale adjustment.......................................................... 21

3.4.2 Scale selection ................................................................................... 22

3.4.3 Research sample selection .................................................................. 23

iv

3.5 Method of data analysis............................................................................... 25

3.5.1 Descriptive Statistics .......................................................................... 25

3.5.2 Testing the reliability of scales ........................................................... 25

3.5.3 Explore factor analysis ....................................................................... 25

3.5.4 Building the regression function ......................................................... 26

3.5.5 Testing the research hypotheses ......................................................... 26

CHAPTER 4 RESEARCH RESULTS ........................................................................ 28

4.1 Descriptive statistics ................................................................................... 28

4.1.1 Sample classification by age of patients ............................................. 28

4.1.2 Sample classification by the education level of patient’s parents (the

carers) ......................................................................................................... 29

4.1.3 Sample structure by job of parents ..................................................... 30

4.1.4 Sample classification by the income of patient’s parents .................... 31

4.2 The research results from questionnaire....................................................... 32

4.3 Testing the reliability of research scales for factors ..................................... 33

4.4 Explore factor analysis ................................................................................ 34

4.4.1 Explore factor analysis with independent variables ............................ 35

4.4.2 Explore factor analysis with the dependent variable ........................... 36

4.5 Correlation analysis..................................................................................... 37

4.6 Regression analysis ..................................................................................... 38

4.6.1 The results from regression analysis by Enter ..................................... 39

4.6.2 Testing the research hypotheses ......................................................... 40

4.7 The differences between groups of patients according to classification signals

42

4.7.1 Testing the differences between groups of different age ..................... 42

4.7.2 Testing the differences between different groups according to the

education level of patient’s parents .............................................................. 43

4.7.3 Testing the differences between groups of different job ...................... 44

4.7.4 Testing the differences between groups of different income ............... 45

4.8 Discussion about the research results........................................................... 46

v

CHAPTER 5 CONCLUSIONS AND RECOMMENDATIONS .................................. 49

5.1 Conclusions ................................................................................................ 49

5.2 Recommendations ....................................................................................... 51

5.3 Contributions and the importance of the study ............................................. 53

5.3.1 Contributions of the study .................................................................. 53

5.3.2 Importance of the study ...................................................................... 54

5.4 Limitations of the study............................................................................... 54

5.5 Directions for further studies ....................................................................... 55

REFERENCES ........................................................................................................... 56

QUESTIONNAIRE .................................................................................................... 60

vi

List of Tables

Table 1. Summary of some recent related studies on the satisfaction of patients with the

health care services ............................................................................................. 16

Table 2. The observed variables .................................................................................. 20

Table 3:Table Sample distribution by age and k-formula results .................................. 24

Table 4. Summary of results from questionnaire ......................................................... 32

Table 5. Results from testing the reliability of scales for factors .................................. 33

Table 6. KMO and Bartlett's Test with independent variables...................................... 35

Table 7. Total Variance Explained with independent variables .................................... 35

Table 8. Rotated Component Matrix with independent variables ................................. 35

Table 9. KMO and Bartlett's Test with the dependent variable .................................... 36

Table 10. Total Variance Explained with the dependent variable ................................. 37

Table 11. Component Matrix with the dependent variable ........................................... 37

Table 12. Pearson correlation coefficient..................................................................... 38

Table 13. Summary of estimated model by Enter ........................................................ 39

Table 14. ANOVA by Enter ........................................................................................ 39

Table 15. Coefficients of the estimated model by Enter ............................................... 39

Table 16. Summary of average value of groups by age ................................................ 42

Table 17. Results from variance analysis by age.......................................................... 42

Table 18. Summary of average values by education level ............................................ 43

Table 19. The results from variance analysis by education level .................................. 43

Table 20. Summary of average values by job .............................................................. 44

Table 21. The results from variance analysis by job .................................................... 45

Table 22. Summary of average values by income ........................................................ 45

Table 23. The results from variance analysis by income .............................................. 46

Table 24. The statistical values of factors .................................................................... 47

vii

List of Figures

Figure 1. The research procedures 6

Figure 2. The Service Quality Five Gap Model 13

Figure 3. The European Customer Satisfaction Index – ECSI 15

Figure 4. The research model 19

Figure 5. The rate of child patients by age 29

Figure 6. Sample structure by the education level of patient’s parents 30

Figure 7. Sample structure by the parent’s job 31

Figure 8. Sample structure by the income of patient’s parents 31

Figure 9. The graph of average points of satisfaction level by age 43

Figure 10. The graph of average points by education level 44

Figure 11. The graph of average values of groups by different jobs 45

Figure 12. The graph of average values by income 46

Figure 13. The relationship between factors in the model 48

1

CHAPTER 1 INTRODUCTION

This chapter will present the research background, research motivations, research

purposes and research procedure as follows:

1.1 Research Background

Service quality has been studied for a very long time, typically in the research

field of Japanese quality service (e.g.: Deming, 1964, Ishikawa, 1974. Taguchi, 1972,

Kano, 1984), in the field of product quality management (e.g.: Crosby, 1979, Stewart,

1935, quoted from Nguyen Dinh Phan, 2006), in the field of service quality by

Parasuraman et al. in America (1985, 1988, 1991), by Gronroos in Europe (1984), by

Kano in Japan (1984), etc. Nowadays, the researches on service quality and customer

satisfaction also have been done by various researchers in many different fields such as:

the field of retail selling services (Naik et al., 2010; Durvasula and Lysonski, 2010); the

field of insurance services (Bala et al., 2011; Siami & Gorji, 2012; Tahmouri, 2012);

health care service (Babakus and Mangold, 1992; Mostafa, 2005; Ahuja et al., 2011;

Chakraborty and Majumdar, 2011; Ahmad and Samreen, 2011; Barser and Joshi, 2011;

Zarei et al, 2012; Soita, 2012), etc. The studies on service quality have become an

important topic because they have relationship with the “cost” (Crosby, 1979), “benefit”

(Buzzell and Gale, 1987; Rust and Zahorik, 1993), “customer satisfaction” (Bollton and

Drew, 1991; Boulding et al., 1993), the buy-back-possibility of customers (Reichelheld

and Sasser, 1990) (quoted from Buttle, 1996). These detections play an important role

for managers and service providers in improving their products and services in order to

better meet customer’s needs.

2

In the field of health care services in Vietnam, the methods of traditional

medicine currently have applied and used by various places such as state hospitals,

private hospitals and many other doctors. Along with the success of the family planning

program, the birth rate reduced from 2.3% / year down to 1.2%/ year in the 1990s, and

the rate of poverty and malnutrition in children also reduced in the 2000s (Report of

Ministry of Health, 2006). The development of the economy requires the higher quality

of services, especially in the health sector and health care services for children. The

reason for this special carings with children is that the current income of household

increases, and the number of childs in a family is also much fewer than before. For this

reason, it is needed for providers who provide services for children to improve their

service quality in order to meet higher and higher needs of the parents. The medical and

health care services are not an exception.

Hai Duong Children's Hospital

Hai Duong Children’s Hospital is a grade II hospital under Hai Duong

Department of Health. Every year, the hospital performs the tasks as follows:

To get, examine and treat diseases belongingthe hospital's speciality for resident or

non-resident child patients in the province and neighboring provinces;

To do health examination and forensic medicine examination in the field of

paediatrics for the Provincial Medical Evaluation Board or when competent authorities

request information;

3

Is a practical unit to train medical staffs and train pediatric medicine at the school

levels as prescribed; Organize to ongoing train for the medical staffs in the hospital and

other sub-units to improve their speciality skills;

To organize the implementation of research titles and application of science and

technology in the field of pediatrics for the examination, treatment and protection of

people's health care;

To build plans and directions as well as to guide the pediatrics for sub-units and also

for private medical practitioners related to pediatrics in the province in order to develop

and improve the pediatrics in the division of the Department of Health;

To co-ordinate with health care unit do to some medical avtitives such as the

implementation of primary health care programs and the pediatrics program in the

community as assigned by the Department of Health;

To combine with other health care unit to perform regularly the works of disease

prevention and treatment as assigned by the Department of Health;

Currently the researches on customer satisfaction with services have been done in

Vietnam in many different fields (e.g.: Nguyen Thi Phuong Tram, 2008; Nguyen Trung

Kien, 2005, Pham Duc Ky, 2007, etc.), however, there have been few studies on

customer satisfaction with the quality of hospital’s services and just only focused on

adults (e.g.: Bui Thi Thu Huong, 2009; Pham Nhat Yen, 2008). Thus, the research on

children’s hospital is necessary and through it we will have real views on the state of the

4

service providers and assessments on the differences between service quality for the

group of child patients and services for other groups.

1.2 Research Motivations

Why researching on customer satisfaction with service quality? Like other types

of services, health services also require the service providers (hospitals) to meet higher-

and-higher needs and requirements of customers. It is proven that the quality of services

has impact on the cost (Crosby, 1979), benefit (Buzzell and Gale, 1987; Rust and

Zahorik, 1993), customer satisfaction (Bollton and Drew, 1991; Boulding et al., 1993),

and the possibility of buy-back of customers (Reichelheld and Sasser, 1990) (quoted

from Buttle, 1995). Therefore, researching on customer satisfaction with service quality

is needed for every business to better improve their service supplying ability and create

competitive advantage or their brand positioning (Ries and Trout, 2001). Nowadays

when life standards of employees are better improved and with the implementation of

the policy of family planning by Government, the birth rate becomes lower and then

requirements health services for young children are increasingly interested. In addition,

besides State hospitals, the private hospitals are being opened to make competition with

services of other public hospitals. Therefore, it is needed to do systematical researches

to find solutions for satisfying customer needs.

Why selecting Hai Duong Children’s hospital? Hai Duong Children’s Hospital is

a level-2 hospital in Hai Duong Department of Health. Until now, there have not been

any studies on assessment of service quality in the hospitals. Some surveys have also

been done but just only stopped at evaluating in statistic description, not in-deep-

researching on the nature of relationships between factors affecting patient’s satisfaction

on the services of the hospitals. Thus, a systematical study on this field is needed to

done in order to detect factors and answer the questions that the research posed.

Why using SERVQUAL model? The SERVQUAL is a popular model in

measuring service quality in many different research fields, including the field of health

care services (e.g.: Babakus and Mangold, 1992; Mostafa., 2005; Ahuja et al., 2011;

5

Chakraborty and Majumdar, 2011; Ahmad. and Samreen., 2011; Barser and Joshi, 2011;

Zarei. et al., 2012) and is proven as an appropriate and reliable scale. Thus, the

application of SERVQUAL to assess and measure the quality of services and customer

satisfaction with services of Hai Duong Children’s Hospital is appropriate and

reasonable.

1.3 Research Purposes

This study posed some main purposes as follows:

The first, to evaluate the status of service quality provided by Hai Duong

Children’s hospital based on main aspects of SERVQUAL model and general

assessments of customer on the quality of the services.

The second, to detect and explore meaningful and meaningless factors that

influence the satisfaction of patients with services of the hospital.

The third, assess differences among demographic factors that affect the level of

patient’s satisfaction.

1.4 Research Procedures

The research procedures are described as follows:

6

Figure 1. The research procedures

Step 1: Define the research issues. At this step, the author defined issues posed

in the parts of research motivation, research purposes and research procedures in the

thesis based on experiences and instructions of advisors and co-advisors. The results of

this step were that the author outlined main contents of the two first chapters: chapter 1

and chapter 2.

Step 2: Research and design the research model: After defining the research

issues, research motivations, purposes and procedures at the step 1, the author

considered theories of service quality and other research models on customer

satisfaction from previous researches. It was needed to select an appropriate and reliable

research model as the basic theoretical research model of the thesis. In details in this

thesis, the author selected SERVQUAL as the basic model because it reliability was

proven through many different researches (see more in chapter 2).

Step 3: Develop survey questions for the data collection. After building the

theoretical research model, the author developed survey questions. The questions

inherited from questionnaires of previous researched and were adjusted to suit specific

Research issues

Research and design the model

Develop survey questions for the data collection

Distribute questionnaire and collect answers

Collect, analyze and process data

Complete the thesis

Write chapter 1, 2

Write chapter 3 Write chapter 4

Complete chapter 1.2.3

Write chapter 5

7

research conditions of the research field of children’s health care. To adjust aspects in

the theoretical model, the author made a group discussion.

Step 4: Investigate and collect data. After final questionnaire were completed, the

author distributed them to customers and got actual data. The method used here was

distributing paper questionnaire directly to the patient’s relatives who were taking care

of them in the hospital. The questionnaire after being interviewed and answered would

be collected, tested and cleaned in order to use in the next step of data processing.

Along with the data collection, the author edited and wrote chapter 1, 2 and 3 according

to the instruction of teachers.

Step 5: Collect and analyze data. Data after being cleaned and coded would be

collected and analyzed with the various statistical analysis methods. Applied PASW

(SPSS) 18.0 with the statistical analysis steps such as: descriptive statistics, testing the

reliability of the scale, factor analysis, regression analysis and testing the research

hypotheses.

Step 6: Complete the thesis. At this last step, the author evaluated the contribution

of the thesis in the domain of learning and reality, suggestions from research results,

limitations of the thesis and directions for future researches in the same field.

8

CHAPTER 2 LITERATURE REVIEW

This chapter will present general theories of service, service quality, customer

satisfaction, the relationship between service quality and customer satisfaction with

services, related research models and some other recent researches on customer

satisfaction. The contents in details are as follows:

2.1 The concepts and characteristics of service

Service is a special kind of economic goods, intangible and different from other

tangible goods. Different researchers have different viewpoints of service, and in this

study the author will introduce some popular concepts of service as follows:

According to Zeithaml and Britner (2000), a service is an act or performance

offered by one party to another to create value for customers to use service and satisfy

needs and expectations of customers.

According to Lovelock (2001, quoted from Oliveira, 2010), service is an

economic activity that creates values and brings benefit to customers in a specific time

and place as a result of a desired change or on behalf of the service recipient (user).

According to Kotler & Armstrong (2004), service is an activity or benefits that

business can offer to customers to build, strengthen and expand the long-term

partnerships with them.

Accordting to Mairelles (2006, quoted from Oliveira, 2010), a service has

intangible characteristics and is evaluated in combination with other functions such as

the production process and tangible products.

In this study, health care service can be understood as the whole processes and

solutions that bring utilities, advantages for patients in order to meet their needs of

health care.

In conclusions, we can understand that services are activities which are created to

bring benefits to satisfy customer’s needs of a specific activity. Researchers can have

different concepts of service but in general, they al agree in the characteristics of

service. In the book “Quality management in the organization” of Nguyen Dinh Phan et

al. (2006), service has some following characteristics:

9

(1) Intangibility: The products of service are “intangible” products, that they

cannot be touched, gripped, handled, looked at, smelled, tasted or heard.

Quality of service is only shown in the interactive process between customers and

employees of the company. Because of this characteristic, customers are difficult

to know in advance the quality of service which they intend to buy. In the other

words, service quality depends much on subjective perceptiveness of customers,

and it is difficult to measure it accurately with the specific technical criteria.

(2) Heterogeneity: Service quality has no heterogeneity between the times

of service performance and depends on individual perceptiveness on service. With

the same providing process, each customer has different perceptiveness of the

service quality at different specific time. Also with the same service, each

individual has one particular feeling about it. Service is assessed from bad to

excellent level because it also depends on customer’s expectation. This

characteristic makes the standardization of services more difficult than other

tangible goods.

(3) Inseparability: The inseparability of service is reflected in the difficulty of

distinguishing the service creation process and service usage. They are

two separate processes. A service cannot be separated into two separate processes:

(1) service creation process and (2) service usage process. They are simultaneous.

The creation and usage of a service simultaneously occur. This is the big

differences with other tangible goods: Tangible goods are produced and put in

storage or distributed to customers. They are two separate processes and can be

clearly separated. In contrast, service is a process of creating, using at the same

time, customers and service providers involved throughout the service creation

process.

(4) Non-ownership: Service has production process and using process which

occur in the same period of time, so it cannot store. In other words, the consumers

do not secure ownership of the service and not set up warehouses to store goods.

10

(5) Simultaneity: The simultaneity of services expresses that services are

rendered and consumed during the same period of time. We cannot separate these

two processes.

2.2 Service quality

Service quality is different levels between the expectations of customers of

services and their awareness of service outcome (Parasuraman, 1988). Service quality

does not formed by many different factors, but is a concept which has many different

aspects. Parasuraman et al. (1985) gave out ten determinants of service quality

including: (1) reliability; (2) responsiveness; (3) assurance; (4) access, (5) courtesy, (6)

communication, (7) credibility, (8) security; (9) understanding customer; and (10)

tangibles. Based on these ten determinants, later researches have receded to five main

determinants of service quality (e.g. Parasuraman et al., 1988, 1991) including:

(1) Reliability: expresses the ability to perform the promised service dependably

and accurately.

(2) Responsiveness: expresses the willingness and/ or readiness of employees to

help customers and to provide prompt service, timeliness of service.

(3) Assurance: expresses the knowledge and courtesy of employees and their

ability to convey trust and confidence

(4) Empathy: expresses the provision of caring, individualized attention to

customers.

(5) Tangibles: expresses physical evidence of the service: appearance of physical

facilities, tools and equipments used to provide the service, appearance of

personnel and communication materials.

Some researches in the field of mobile telecommunications (Kim et al., 2004,

Pham Duc Ky, 2008) showed that the quality of services in mobile telecommunications

includes following aspects: (1) Call quality, (2) value-added services, (3) price structure,

(4) convenience, and (5) customer support.

In conclusions, we can see that service quality is a concept including many

aspects, and also a general indicator of the different factors. In different service fields,

the quality of services is measured by different factors (standards).

11

2.3 Customer satisfaction

Customer satisfaction is the emotional state of products and services that

customers used to use (Spreng et al., 1996). Bachelet (1995) defined customer

satisfaction as an emotional reaction of customers in response to their experiences of a

product or service. Customer satisfaction is the level of a person's state of feeling

derived from the comparison of the results obtained from the consumption of products /

services with his expectations (Kotler, 1996).

In general, researchers considered customer satisfaction as comfortable feelings

when customer’s expectations of services and products are met. General satisfaction

with services is also considered as a separate variable in the relationship with other

determinants of service quality (e.g.: Andaleeb and Simmonds (1998); Kassim and

Bojei (2002), Atilgan et al. (2003), Gilbert and Wong (2003), Chow and Luk (2005),

Lee and Lin (2005), Durvasula and Lysonski (2010), Bala et al. (2011), etc).

2.4 The relationship between service quality and customer satisfaction

Many researches showed that service quality and customer satisfaction have close

relationship with each other, in which service quality is the cause and customer

satisfaction if the effect (e.g.: Spereng, 1996, Andaleeb and Simmonds (1998), Atilgan

et al. (2003), Chow and Luk (2005), Bala et al. (2011), Amad and Samreen (2011),

Meybodi (2012), Tahmouri (2012), etc). The relationship between service quality and

customer satisfaction is a same-direction relationship, service quality has positive

impact on peceiveness of customers.

According to Zeithaml and Bitner (2000), “service quality” and “customer

satisfaction” are two different concepts. If service quality just specifically focuses on

the determinants of service, in contrast, customer satisfaction is a generic concept.

According to Cronin and Taylor (1992), and Spereng (1996), between service quality

and customer satisfaction there is a relationship.

2.5 Research models of service quality and customer satisfaction

In the research field of service quality and customer satisfaction, many studies

have been done in recent time. There are some popular and famous models such as The

service quality five gap model (Parasuraman et al., 1985), the model of quality

12

functional / technical quality (Gronroos, 1984), the product attributes model of Kano

(1984), SERVQUAL (Parasuraman et al, 1988), Models of customer satisfaction index

(CSI) of nations (Fornell, 2000, Martesen el al., 2000, Le Van Huy, 2007). Therefore,

this study will introduce some common research models which were applied in many

researches.

2.5.1 The service quality five gap model

The service quality five gap models have been introduced by Parasuraman

et al. since 1995 in the magazine Journal of Marketing. According to Parasuraman

et al, expectations are considered as customers hope and belief that are based on

outside information, individual needs, and their experiences.

Gap 1 is the distance between what customers expect and what service providers

think they expect.

Gap 2 occurs when service provider has difficulty in changing their perception of

customer expectations of customer expectations into the feature of service quality.

It means, in many cases, service providers may be aware of customer expectations

but they cannot always transfer these expectations to the specific criteria of

quality and transfer them right as customers expected.

Gap 3 occurs when the staffs of the company do not transfer services to customer

right according to the determined criteria. Because service providing process is an

inter-relationship between service provider and customers, this gap depends much

on the quality of the staffs that directly provide the service to customers. In many

cases, attitudes and professional skills of the staffs do not satisfy their customers

or make them feel nuisance, so services cannot be transferred to customer right

according to the determined criteria.

Gap 4 is the gap between the delivery of the customer experience and what is

communicated to customers. Advertisements make customer expectations change

in the direction of much more satisfaction on services, so if real quality of services

is not as ads, perceived quality of services will be lower..

Gap 5 is the gap between a customer's perception of the experience and the

customer's expectation of the service. After using the service, customers will draw

13

comparisons between the qualities of service that they actually receive and

perceive with the quality they expected before using it. To ensure the quality of

the service, the values that customers received during using process must be good

or much better than they expected. Thus, service quality is depreciated or

appreciated, that depends on actual feelings of customers compared with what

they expected about the service.

Experience

CO

NSU

MER

Personal Needs

Gap 5

Perceived Service

MA

KET

ER

Expected Service

Gap 2

Word of mouth communications

Communications to customers

Service Delivery

Gap 4

Change the company’s feeling into quality standard

Gap 3

Gap

1

Management perceptions of consumer expectations

14

Source: A.Parasuraman, Valarie A.Zeithaml and Leonard L. Berry (1985), a

conceptual model of service quality and its implications for future research, Journal of

Marketing, 49, 44

2.5.2 SERVQUAL model

In 1988, Parasuraman et al. introduced SERVQUAL model which was

applied in the field of retail selling. Service includes five following determinants:

Reliability: The ability to perform the promised service dependably and

accurately

Responsiveness: The willingness and readiness of the staffs to help

customers and to provide prompt service, timeliness of service.

Assurance: The knowledge and courtesy of employees and their ability to

convey trust and confidence.

Empathy: The provision of caring, individualized attention to customers.

Tangibles: Physical evidence of the service: appearance of physical

facilities, tools and equipments used to provide the service, appearance of

personnel and communication materials.

SERVQUAL scale has quickly become the most popular model to measure

service quality in many different fields such as: retail sales (Parasuraman et al,

1988, Bala et al, 2011; Duvasula and Lysonski, 2010), telecommunications

(Seth,Momaya and Gupta, 2008; Khan, 2010; Loke et al, 2011; Zekiri, 2011),

education sector (Stodnick and Rogers, 2008; Hasan et al, 2008; Hanaysha et al,

2011; Oliveira, 2009; Miller and Brooks, 2010) or health care services (Mostafa,

2005; Amad and Samreen, 2011). Thus in this study, the author will use five

factors in SERVQUAL model to assess how they affect the satisfaction of patients

in the hospital.

2.5.3 European Customer Satisfaction Index model

Perceived

values Customer satisfaction

(SI)

Perceved quality-Prod

Perceved quality–Serv

Loyalty

Image

Expectations

15

Figure 3. The European Customer Satisfaction Index – ECSI

Source: Martensen. A., Gronholdt, L. and Kristensen, K. (2000), The drivers of

customer satisfaction and loyalty. Cross-industry findings from Denmark, Total Quality

Management, 11, 8544-8553

The ECSI model explains that perceived value is directly affected by: (1)

organization image, (2) desire, (3) perceived product quality, and (4) perceived

service quality. Satisfaction is directly affected by four following determinants:

(1) image, (2) perceived value, (3) perceived product quality, and (4) perceived

service quality. In other hand, customer satisfaction directly influences customer

loyalty.

In which:

Image: Image expresses the relationship between brand and customer

associations on the attributes of the brand. The image of companies, organizations

is reflected through their reputation, prestige, and customer loyalty with the

company’s brand (trademark). It is a signal for customers to the trust of the

business as well as services of the business. The image of businesses and

organizations positively or negatively affects perceived value of customer on the

service and customer satisfaction.

Expectations: expresses customer hope and beliefs of services that they will

get when seeing and getting in touch with the service provider through their

image. Customer expectations have impact on perceived value on service quality.

If responsiveness level of the business is equal or more than what customers

expected, perceived value will be higher, and in contrast, perceived value will be

lower.

Perceived quality: There are two kinds of perceived quality including (1)

perceived product quality and (2) perceived service quality. Perceived product

quality is recent consumer-based assessments of product of customers and

perceived service quality is assessments of related services such as during and

16

after sales service, terms of supply and delivery, etc. Perceived quality is customer

evaluations compared with their expectations about services before using them. It

has direct influence on customer satisfaction. The better customer’s perceptions of

service quality are, the higher satisfaction level is and vice versa.

Perceived value: is defined as the benefit customers believe they receive

relative to the costs associated with its consumption. It is also the comparison of

financial and non-financial cost that customers must pay to use the service.

Perceived value is not necessarily equated with low prices because services with a

perceived high value may in practice carry high or low prices.

Customer satisfaction: is defined as responses of customers to being met

their expectations when using the service. Customer satisfaction is thus a function

of relative level of expectation and perceived performance.

Loyalty: expresses that customers voluntarily continue using the service of

the business when the business meets customer needs and has good

responsiveness for customers as they expected when using the service of the

company.

2.6 Some recent researches on customer satisfaction in the field of health care

In the research field of health care services, many studies have been done and

model popularly used has been SERVQUAL. Some studies added other new factors into

the research model. Below is the summary of some recent researches on the satisfaction

of patients with the quality of services.

Table 1. Summary of some recent related studies on the satisfaction of patients

with the health care services

No. Author Article Research model

1 Emin Babakus .E and Mangold.F(1992),

Adapting the SERVQUAL scale to hospital services: An empirical investigation, Heath service research, 26(6), 767 - 786

1. Reliability 2. Responsiveness 3. Assurance 4. Empathy 5. Tangibles

2 Mostafa. M.M (2005)

An empirical study of patients expectations and satisfactions in

1. Human performance quality

17

Egyptian hospitals, International journal of health care quality assurance, 18 (7), 516 - 532

2. Human Reliability 3. Facility quality

3 Ahuja.M et al. (2011),

Study of service quality management with SERVQUAL model: An empirical study of GOVT/NGO`S eye hospitals in Haryana, Indian journal of commerce and management studies, 2(2) 310 - 318

1. Reliability 2. Responsiveness 3. Assurance 4. Empathy 5. Tangibles

4 Chakraborty.R and Majumdar. A (2011),

Measuring consumer satisfaction in heath care sector: The applicability of SERVQUAL, International refereed research journal, 2(4), 149 -160

1. Reliability 2. Responsiveness 3. Assurance 4. Empathy 5. Tangibles

5 Ahmad.R and Samreen. H (2011),

Assessing the service quality of some selected hospitals in Karachi based the SERVQUAL model, Pakistan review, Juny, 266 - 314

1. Tangibles and Profesionalism 2. Reliability and Responsiveness 3. Assurance and Empathy 4. Feedback and Guidance 5. Affordability

6 Brahmbohatt, Barser and Joshi (2011),

Adapting the SERVQUAL scale to hospital service: An empirical investigation of patients` perception of service quality, International Journal of Multidisciplinary Research, 1(8), 27 -42

1. Physical Aspects. 2. Encounter (Responsiveness, Empathy) 3.Process 4.Policy

7 Zarei et al. (2012),

Service quality of private hospitals: The Iranian patients` perspective, BMC Health service Research, 1 -7

1. Reliability and Responsiveness 2. Assurance 3. Empathy 4. Tangibles

8 Soita .P.W (2012)

Measuring perceived service quality using SERVQUAL: A case Uganda Health and Fitness sector, International Journal of Business and Social Science, 3(5), 261 -277

1. Reliability 2. Responsiveness 3. Assurance 4. Empathy 5. Tangibles

18

CHAPTER 3 RESEARCH METHODOLOGY

This chapter will present the contents of research methodology such as research

model, research hypotheses, research design and other methods of data analysis. The

contents in details are as follows:

3.1 Research model

This study selected SERVQUAL as the theoretical research model combined with

the hypothesis of the relationship between service quality and customer satisfaction

(Spereng et al., 1996) which was tested in many different research fields such as: retail

selling (e.g: Naik et al., 2010; Durvasula and Lysonski, 2010); insurance sector (Bala et

al., 2011; S.Siami and Gorji, 2012; Tahmouri, 2012); telecommunications (Kassim and

Bojei, 2002; Seth, Momaya and Gupta, 2008, Ahmed et al., 2011; Zekiri, 2011; Islam,

2012); restaurant services (Chow and Luk, 2005; Andaleeb and Conway, 2006;

Markovic et al., 2010), and also the field of health care services (Mostafa, 2005; Ahuja

et al., 2011; Chakraborty and Majumdar, 2011; Ahmad and Samreen, 2011; Barser and

Joshi, 2011; Zarei et al., 2012; Soita, 2012). Therefore, the author proposed the research

model with following factors:

(1) Reliability

(2) Responsiveness

(3) Assurance

(4) Empathy

(5) Tangibles

19

Figure 4. The research model

3.2 Research Hypotheses

H1: The factor reliability of the hospital positively affects general satisfaction of

patients.

H2: The factor assurance of the hospital positively affects general satisfaction of

patients.

H3: The factor empathy positively affects general satisfaction of patients.

H4: The factor responsiveness positively affects general satisfaction of patients.

H5: The factor “tangibles” of the hospital positively affects general satisfaction of

patients.

Besides above hypotheses, the author also considered the differences between

different groups of patients through the analysis of variance (ANOVA).

3.3 Measurement of observed variables

Observed variables (survey questions) used in the study inherited from previous

researches. The questionnaire includes 26 observed items which were standardized by

Parasuraman et al. (1988) and referenced from questionnaire of the research of Mostafa

(2005) in Egypt, the research of Amad and Samreen (2011) in Pakistan in the field of

Reliability

Assurance

Tangibles

Responsiveness

Empathy Customer satisfaction

H2

H3

H4

H5

H1

20

health care services. In addition, the author also used a group discussion with the

patient’s relatives who are taking care of the patients in order to adjust the measurement

aspects of factors. The contents in details are as follows:

Table 2 the observed variables

No. Code Contents of question I Reliability

01 REL1 You trust the results of diagnosis and treatments of the hospital. 02 REL2 You see that the hospital staffs tried not to make mistakes when

implementing treatments for patients. 03 REL3 You see that the quality of health care services is as good as the notice

of the hospital. 04 REL4 You find the medical examinations of the hospital are precisely done. 05 REL5 You find if the staffs of the hospital promise to do something in a fix

time, they will do it. II Assurance 06 ASS1 You see that the doctors and nurses are never too busy to meet the

needs of the patients (for example: medical procedures, asking the place to test, etc.).

07 ASS2 You are informed by medical staffs about the done-time of the services will be carried out (for example: time to response the test results, etc.).

08 ASS3 You see that the doctors and nurses always show their courtesy and willingness to help the patients.

09 ASS4 You find that the services of the hospital are always provided fully and promptly.

III Empathy 10 EMP1 You find that the doctors devotedly care for each patient. 11 EMP2 You feel that the doctors and nurses always understand the worry and

special needs of the patients. 12 EMP3 You find that the patients are treated and cared enthusiastically and

thoughtfully. 13 EMP4 You find the time of medical examination is convenient for the

patients. IV Responsiveness 14 RES1 You think that the behaviors of the physicians create the trust to

patients. 15 RES2 You feel safe when diagnosing and treating diseases in the hospital.

21

16 RES3 You think that the hospital has good doctors and nurses. 17 RES4 You think that the medical staffs have sufficient knowledge to answer

all questions of patients. V Tangibles 18 TAN1 You find that the hospital is always clean. 29 TAN2 You see that the uniforms of the medical staffs are always neat and

courteous. 20 TAN3 You think the facilities of the hospital are attractive. 21 TAN4 You think that the facilities (tools, equipments…) of the hospital are

modern and sufficiently provided. VI General satisfaction with medical examination services 22 SAT1 You feel satisfied with the facilities of the hospital.

23 SAT2 You feel satisfied with the assurance of the hospital. 24 SAT3 You will use the medical examination services of the hospital for your

children when needed. 25 SAT4 You will introduce the hospital to others. 26 SAT5 In general, you feel satisfied with the services of the hospital.

3.4 Research Design

3.4.1 Discussion for scale adjustment

To build the survey questions, the author inherited the questionnaire from

the research of Parasuraman et al. (1988) and the questionnaire of Mostafa (2005)

in Egypt, questionnaire of Amad and Samreen (2011) in Pakistan. These questions

were translated from English into Vietnamese and distributed for the patients’

relatives to collect opinions through a group discussion (because of the features of

a children’s hospital, we cannot directly ask the patients, but the relatives of the

patients who are taking care of them) and then adjusted the questions in order to

get the final questionnaire for the research.

The discussion results showed that all opinions agreed with aspects (items)

posed in the trial questionnaire. It is just needed to adjust questions in semantics

and words to be more understanding for interviewees. Some groups of opinions

are as follows:

22

For the factor “tangibles”, the patient’s relatives pay attention to issues such

as: the application of modern equipments, the clean environment of the hospital,

the uniforms of the medical staffs must be neat; the facilities of the hospital must

be attractive. They are factors they supposed to have impact on their feelings

when making the medical examinations for your children in the hospital.

For the factor “reliability”, the patient’s relatives care the precision of the

medical examination methods, the careful style of work of the staffs, the quality of

services compared with ads information of the hospital. They are factors affecting

their feelings of the service quality.

For the factor “responsiveness”, the patient’s relatives pay attention to the

knowledge of the doctors and nurses when instructing and answering their

questions, the attitudes of doctors, and their feelings of the safety of medical

treatment methods. In their opinion, these factors need to be ensured and create

the safe feelings for the patients.

For the factor “assurance”, the patient’s relatives pay attention to the

timeliness of services, the caring of the medical staffs, the willingness to help

patients, etc. They are factors that are meaningful and important for them when

evaluating the service quality of the hospital.

For the factor “empathy”, the patient’s relatives care the enthusiasm and

thoughtfulness of the doctors, the convenient time, or the understanding of the

doctors with special needs of each patient.

In conclusions, we can see that most of opinions agree with posed items for

each factor. At once, the author adjusted questions in semantics. To get the final

questionnaire, the trial questionnaires would be adjusted once again through

collecting opinions of the patient’s relatives.

3.4.2 Scale selection

This study is a quantitative research, so scales must be hierarchical scales or

ratio scales, not identification ones. Hierarchical scales can be used here are

Stapel or Likert; however Likert scale is selected because it has advantage of

23

using a sequence of positive numbers. In details in this study, the five point Likert

scale is selected as the scales for survey items in the questionnaire.

3.4.3 Research sample selection

Sampling method

In this study, the author used the stratified sampling. After defining an

appropriate sample size, the samples would be distributed to each group of

patients depending on their age. The reason for stratifying samples on the age

group is that for the child patients there are similarities of the level of illness and

the diseases suffered by certain age groups. In details in this study, the patients

were divided into five small groups including the group at the age under 1, from 1

to 2, from 2 to 3, from 3 to 5 and the group at the age above 5. The structure of

samples was divided by the corresponding percentage of patients for each age

group.

The sample size of the study is determined by the principle of minimum

sample size to get the necessary reliability of the study. There are many different

opinions of a minimum sample size. Maccallum et al. (1999) summed up opinions

of previous researchers about the principle of minimum sample size with Factor

Analysis. According to Kline (1979) the minimum number of samples is 100,

Guiford (1954) supposed 200, Comrey and Lee (1992) gave the sample size for

the respective views with same opinions: 100 = bad, 200 = pretty, 300 = good,

500 = very good, 1000 or more = excellent. In this research, sampling was based

on the rule of Comrey and Lee (1992), the sample size was defined = 200 is a

good sample size.

Research objectives: Because the patients of the children’s hospital are child

patients, so the author did not make survey with them but with their relatives

(persons who directly take care of them in the hospital). These research objectives

are reasonable because for child patients, their parents are those who decide which

hospital to test. Moreover, child patients cannot understand much and answer all

questions.

24

Method of data collection: First of all, the author listed a name list of

patients who are diagnosing and treating diseases in the hospital, then divided

them into small groups of different age to get the overall number of each group.

Next, based on the number of samples for each group, the author listed patients to

investigate. In this step, the author divides child patients into following groups:

Group 1 included patients less than 1 year old, group 2 includes patient from 1 to

2 years old, group 3 includes patients from 2 to 3 years old, group 4 includes

patients from 3 to 5 years old, and group 5 includes patients more than 5 years

old. The reason for dividing those groups is that biological characteristics of the

patient's diseases base on recommendations from the Department of Health. And

the list of patients depends on the distribution of sample size for each age group.

The ratio of distribution of the questionnaire was divided by the proportion of

patients hospitalized at the time of the survey. At that time, there are 487 patients

diagnosing at the hospital, the author distributes 220 questionnaires to these five

groups base on the age of patients as above table. The selection of patients for

each group was based the k-jump formula as follows: k = m/n, in which m the

number of patient determined in an age group, n – the total of patients in this

group, k will be rounded to the smaller number (for example: k = 2.7 will be

rounded to 2). After that, from the list of each patient group, the author selected in

turn k, 2k, 3k,…, mk. This method will ensure the randomness of collected

samples. The results of distribution of samples by age group and k-formula to

select survey patients are as follows:

Table 3: Table Sample distribution by age and k-formula results

Patient group Quantity(n)

Estimated ratio of

distribution

Actual number of patients(m)

Estimated k Actual k

< 1 year 122 55.1129 55 2.21818 2 1 - 2 years 119 53.7577 55 2.16364 2 2 - 3 years 81 36.5914 35 2.31429 2 3 - 5 years 79 35.6879 35 2.25714 2 > 5 years o 86 38.8501 40 2.15 2

25

Total 487 220

After sample classified, questionnaires will be distributed to different groups to

make interviews with main interviewees. The obtained results will be summed up and

cleaned (wrong questionnaires removed) and then analyzed. The author classifies

sample by different age groups because of different features about the biology and

pathology of child patients. According to the Ministry of Health's recommendations on

child health care, children who usually have the same pathological will be divided into

following five groups: less than 1 year old, from 1 to 2 years old, from 2 to 3 years old,

from 3 to 5 years old, and above 5 years old.

3.5 Method of data analysis

The actual data were cleaned and analyzed SPSS 20.0 for Window through

statistical steps as follows:

3.5.1 Descriptive Statistics

The collected samples would be analyzed by descriptive statistics:

classifying the samples according to the classification criteria, calculating the

average point, maximum value, and standard deviation of the answers in collected

questionnaire.

3.5.2 Testing the reliability of scales

To test the reliability of scales used in the research, the author used

Cronbach`s Alpha coefficient and the total correlation coefficient. The observed

variables which did not ensure the reliability would be removed from the scale

and do not appear in the explore factor analysis (EFA). The standards were:

Cronbach`s Alpha must be at least 0.6 (Hair et al., 2006), the total correlation

coefficient less than 0.3 would be a “spam” variable and removed from the scale

(Nunally and Burstein, 1994).

3.5.3 Explore factor analysis

After factors were tested by Cronbach`s Alpha, they would be analyzed by

EFA method. Factor analysis would help the author detect implicit factors from a

26

set of smaller observed variables. Some standards applied in analyzing the EFA in

the study are as follows:

- Testing the suitability of factor analysis with data set through the value of

Kaiser-Meyer-Olkin (KMO). IF KMO is greater than 0,5, factor analysis with this

factor is appropriate (Garson, 2002), in contrast, if KMO is less than 0,5, the

application of factor analysis with that factor is not appropriate with the data set.

- The number of factor: The number of factors is determined based on the

eigenvalue index which represents the variation explained by each factor.

According to Kaiser’s standards, the factors with an eigenvalue index less than 1

will be removed from the research model (Garson, 2002).

- Variance explained criteria: The total variance explained criteria must be

greater than 50 % (Hair et al., 1998).

- The convergence value: To meet the convergence value of the scale, the

single correlation coefficient between variables and the factor loading must be

greater than or equal to 0.5 within a factor (Garbing and Anderson, 1988).

- Principal components method with Varimax rotation to ensure the number

of factors is smallest (Hoang Trong and chu Nguyen Ngoc, 2008).

3.5.4 Building the regression function

After the scales of factors were tested, the author would build the linear

regression function by the method of Ordinary least squares (OLS) with the

support of Enter method. According to Nguyen Dinh Tho (2011), Enter is more

appropriate for the testing researches.

3.5.5 Testing the research hypotheses

The research hypotheses would be tested through the research data from

regression function. The testing standards used the t statistics and the p-value

(sig.). With the reliability coefficient = 95%, the p-value would be directly

compared with 0.05 to conclude the acceptance or rejection of research

hypotheses. For testing the difference between subtotals, the study used t-test and

ANOVA to test each hypothesis, and the testing standards based on the value of

the corresponding p-value for each specific testing step. To test the suitability of

27

data and model, the author used F statistics, t statistics, and the adjusted R-square.

In addition, to assess the importance of factors, the author checked the Beta

coefficient in the regression function, which was built by research data.

28

CHAPTER 4 RESEARCH RESULTS

This chapter will present main results from data set which was collected by

statistical methods such as: descriptive statistics, scale verification, explore factor

analysis, correlation analysis, regression analysis, and testing research hypotheses. The

software analysis tool used here is SPSS 20.0. The contents in details are as follows:

4.1 Descriptive statistics

The expected sample size of the study is 200. To get this size, the author

distributed 220 samples, and got back 211 answered questionnaires. From these 211

ones, the author started cleaning them and then collected 204 valid ones which would be

analyzed in the next step. The results according to different sample groups are as

follows:

Patient group

Questionnaire number

Collected questionnaire

Questionnaire removed

Valid questionnaire

< 1 year old 55 52 2 50 1 - 2 years old 55 54 0 54 2 - 3 years old 35 34 1 33 3 - 5 years old 35 32 2 30 > 5 years old 40 39 2 37 Total 220 211 7 204

4.1.1 Sample classification by age of patients

In 204 valid answered questionnaires, the results showed that there were

two groups which had the biggest number of patients including the group of

patients at the age under 1 (50 patients) and the group at the age from 1 to 2 (54

patients) (corresponding with 25% and 26%), the left three groups including the

group at the age from 2 to 3, from 3 to 5, and above 5 had lower proportion and

were approximately equal to each other (corresponding with 33, 30 and 37

patients) (16%, 15% and 18%) (Figure 5). This result also reflected the tendency

29

of health of the child patients, the groups of newborn babies and children under 2

years old were the groups which were endangered of getting a disease more easily

than other groups. .

Figure 5. The rate of child patients by age

4.1.2 Sample classification by the education level of patient’s parents (the

career)

In 204 patient’s relatives (mostly the patient’s parents) there are over 50%

persons who are at college-level (105 persons, 52%), next is the group at

university-level with 39 persons (19%), the group at high school-level includes 33

persons (16%), the group at intermediate-level has 18 persons (9%), and the last

group has 9 persons (4%). This proves that the education level of the patient’s

parents currently is at quite high level.

30

Figure 6. Sample structure by the education level of patient’s parents

4.1.3 Sample structure by job of parents

In these 204 valid questionnaires, there are 105 ones belonging to the group

of persons who work in the office (52%), next is the group of workers with 57

persons (28%), the group of farmers includes 27 persons (13 %), and the last

group has 15 persons (7%). This proves that majority of persons who diagnose

and treat diseases in the hospital are mostly from urban areas and have parents

working in the office or working as workers. The number of children whose

parents are farmers has a low proportion. The reason comes from the restrictions

on economic conditions so that the children in rural areas are often treated their

diseases at home or in local medical stations.

31

Figure 7 Sample structure by the parent’s job

4.1.4 Sample classification by the income of patient’s parents

In 204 valid questionnaires, there are 135 persons who have income from 5

to 10 mil./month (66%), 55 persons have income less than 5 mil./month (27%), 12

persons have income from 10 to 15mil./month (6%), and only 2 persons have

income more than 15 mil./month (1%). This also reflects the fact that the parents

of child patients are still quite young, they are the new working group and have

not so high income in the society.

Figure 8. Sample structure by the income of patient’s parents

32

4.2 The research results from questionnaire

The results from questionnaire showed that the answers were from level 2

(minimum) to level 5 in the five point Likert scale, the standard deviation was quite

small (less than 1), and the average point was more than 3. This proved that the

perception level of patient’s relatives with the norms in the questionnaire was quite

alike (the standard deviation is small) and also at good level.

Table 4. Summary of results from questionnaire

Item N Minimum Maximum Mean Std. Deviation REL1 204 2.00 5.00 4.2402 .57549 REL2 204 2.00 5.00 4.1127 .64482 REL3 204 2.00 5.00 3.8922 .70055 REL4 204 2.00 5.00 3.5098 .77199 REL5 204 2.00 5.00 3.7500 .78862 ASS1 204 2.00 5.00 3.9902 .56140 ASS2 204 2.00 5.00 3.9314 .57467 ASS3 204 2.00 5.00 3.9216 .56475 ASS4 204 3.00 5.00 3.8382 .58580 EMP1 204 2.00 5.00 3.9069 .64031 EMP2 204 2.00 5.00 3.5441 .70398 EMP3 204 2.00 5.00 3.5539 .73077 EMP4 204 2.00 5.00 3.5735 .69444 RES1 204 2.00 5.00 3.3284 .76563 RES2 204 2.00 5.00 3.4706 .77784 RES3 204 2.00 5.00 3.3775 .78764 RES4 204 2.00 5.00 3.2353 .78378 TAN1 204 2.00 5.00 3.8725 .59838 TAN2 204 2.00 5.00 3.5588 .68154 TAN3 204 2.00 5.00 3.8873 .57195 TAN4 204 2.00 5.00 3.7598 .71998 SAT1 204 2.00 5.00 3.7990 .58200 SAT2 204 2.00 5.00 3.7598 .63257 SAT3 204 2.00 5.00 3.7598 .61680 SAT4 204 2.00 5.00 3.5245 .73235 SAT5 204 2.00 5.00 3.7598 .65552

33

4.3 Testing the reliability of research scales for factors

Each factor in the research model is formed by many other observed items

(questions). To test the reliability of scales for each factor, we use Cronbach`s Alpha

coefficient. To test if the item in the factor really belongs to this factor or not, we test

the correlation of this item with other items. This will be tested by the total correlation

coefficient. The standards here include: Cronbach`s Alpha coefficient must be at least

0.6 (Hair et al., 2006), the total correlation coefficient must be at least 0.3 (Nunnally,

1994), factors have Cronbach`s Alpha less than 0.6 will be considered as inappropriate

factors or in other words, they will not be formed in the research environment. Observed

items (questions) if have the total correlation coefficient less than 0.3 will be considered

as “spam” variables and then be removed from the factor. The results from testing the

reliability of scales for factors are as follows:

Table 5. Results from testing the reliability of scales for factors

Observed item

Scale Mean if Item Deleted

Scale Variance if Item Deleted

Corrected Item-Total Correlation

Cronbach's Alpha if Item Deleted

I. The factor “Reliability”: α = 0.702, N = 5 REL1 15.2647 4.235 .437 .664 REL2 15.3922 3.786 .557 .615 REL3 15.6127 3.569 .582 .599 REL4 15.9951 3.887 .367 .695 REL5 15.7549 3.782 .390 .687 II. The factor “Assurance” α = 0.660, N = 3 (removed item ASS1) ASS1 11.6912 1.771 .128 .660 ASS2 11.7500 1.312 .483 .382 ASS3 11.7598 1.356 .458 .406 ASS4 11.8431 1.424 .365 .484 III. The factor “empathy”: α = 0.770, N = 4 EMP1 10.6716 3.394 .316 .832 EMP2 11.0343 2.772 .547 .728 EMP3 11.0245 2.339 .750 .610 EMP4 11.0049 2.517 .704 .642 IV. The factor “Responsiveness”: α = 0.824, N = 4 RES1 10.0833 3.929 .605 .798

34

RES2 9.9412 3.878 .610 .796 RES3 10.0343 3.649 .692 .758 RES4 10.1765 3.673 .687 .760 V. The factor “Tangibles”: α = 0.759, N = 4 TAN1 11.2059 2.411 .596 .685 TAN2 11.5196 2.320 .526 .722 TAN3 11.1912 2.402 .647 .663 TAN4 11.3186 2.287 .491 .746 VI. The dependent variable “general satisfaction”: α = 0.886, N =5 SAT1 14.8039 5.252 .587 .890 SAT2 14.8431 4.557 .815 .840 SAT3 14.8431 4.813 .726 .861 SAT4 15.0784 4.467 .696 .871 SAT5 14.8431 4.468 .815 .839

The results from testing the reliability of scales from data set showed that the

scales for factors are appropriate with Cronbach`s Alpha coefficient greater than 0.6 and

the total correlation coefficient greater than 0.3 (excluding the item ASS1). So, the

factors in the research model are reliable and appropriate (see table 5).

4.4 Explore factor analysis

Explore factor analysis will help the author collect a set of fewer implicit variables

(factors) from the data set of observed variables. Appropriate standards for explore

factor analysis are: KMO coefficient must be at least 0.5, Bartlett-test has p-value less

than .05, factor loading coefficient must be at least 0.5, the variance extracted must

equal to at least 50%. Because the method of factor analysis does not consider the

distinguishing relationship between the dependent variable with independent variables

(Hoang Trong and Chu Nguyen Mong Ngoc, 2008) but the reciprocal relationship

between all factors, so we will do factor analysis particularly with the dependent

variable and the independent variables. Factor extraction method is Principal

Component with Varimax. The results from factor analysis in details are as follows:

35

4.4.1 Explore factor analysis with independent variables

From the data set, data will be analyzed with the support of SPSS software,

after removing factors which have factor loading coefficient less than 0.5, and

then we get final results as follows:

Table 6. KMO and Bartlett's Test with independent variables

Kaiser-Meyer-Olkin Measure of Sampling Adequacy. .775

Bartlett's Test of Sphericity Approx. Chi-Square 1374.793 Df 153 Sig. .000

Table 7. Total Variance Explained with independent variables

Component Initial Eigenvalues Rotation Sums of Squared Loadings

Total % of Variance Cumulative % Total % of Variance Cumulative % 1 4.944 27.469 27.469 2.732 15.180 15.180 2 2.229 12.384 39.853 2.490 13.835 29.015 3 1.960 10.888 50.740 2.252 12.509 41.523 4 1.444 8.020 58.760 2.150 11.947 53.470 5 1.030 5.724 64.484 1.983 11.014 64.484 6 .925 5.139 69.624 7 .762 4.234 73.858 8 .628 3.489 77.348 9 .607 3.370 80.718 10 .558 3.102 83.819 11 .517 2.871 86.691 12 .501 2.786 89.477 13 .471 2.615 92.092 14 .366 2.035 94.127 15 .340 1.887 96.014 16 .320 1.775 97.789 17 .229 1.273 99.062 18 .169 .938 100.000

Table 8. Rotated Component Matrix with independent variables

Component 1 2 3 4 5

36

RES3 .857 RES4 .826 RES2 .693 RES1 .657 TAN3 .804 TAN1 .794 TAN2 .727 TAN4 .689 EMP4 .794 EMP3 .784 EMP2 .753 ASS3 .787 ASS2 .772 ASS4 .632 EMP1 .586 REL2 .824 REL1 .780 REL3 .722 Extraction Method: Principal Component Analysis. Rotation Method: Varimax with Kaiser Normalization. a. Rotation converged in 6 iterations.

The analysis results show that KMO = 0.775 > 0.5, Batlett-test has p-value

= 0.000 < 0.05 (table 5), the variance extracted is 64.484% > 50% (table 7), factor

loading coefficients are greater than 0.5, and observed variables form five factors

(table 8). Therefore, the standards when doing factor analysis are appropriate with

the data set.

4.4.2 Explore factor analysis with the dependent variable

The results from EFA show that KMO = 0.761 > 0.5, Bartlett-test has p-

value = 0.000 < 0.05 (table 9), the variance extracted is 69.181% > 50% (table

10), and observed items form only one factor (table 11). Thus, using EFA with the

dependent variable is appropriate and the scale for factor “general satisfaction” is

a unidirectional scale.

Table 9. KMO and Bartlett's Test with the dependent variable

Kaiser-Meyer-Olkin Measure of Sampling Adequacy. .761

37

Bartlett's Test of Sphericity Approx. Chi-Square 872.871 Df 10 Sig. .000

Table 10. Total Variance Explained with the dependent variable

Component Initial Eigenvalues Extraction Sums of Squared Loadings

Total % of Variance Cumulative % Total % of Variance Cumulative % 1 3.459 69.181 69.181 3.459 69.181 69.181 2 .643 12.870 82.050 3 .569 11.389 93.440 4 .293 5.869 99.308 5 .035 .692 100.000 Extraction Method: Principal Component Analysis.

Table 11. Component Matrix with the dependent variable

Component 1

SAT5 .902 SAT2 .900 SAT3 .822 SAT4 .805 SAT1 .714 Extraction Method: Principal Component Analysis. a. 1 component extracted. So, after doing factor analysis with the set of observed items, there are no

factors being changed. The research model and hypotheses still be kept like in the

original model.

4.5 Correlation analysis

To test the relationship between the dependent variable “general satisfaction” and

factors in the research model, we use single correlation coefficient (Pearson correlation

coefficient). If the correlation coefficient is differ from 0 and p-value of two-sided test

less than 0.05, factors in the model have relationship with each other. A positive

correlation coefficient reflects a positive relationship, and in contrast, a negative

correlation coefficient reflects a negative relationship, and the bigger the correlation

38

coefficient between factors is, the closer the relationship between them is. The results

from data set are as follows:

Table 12. Pearson correlation coefficient

RES TAN EMP ASS REL SAT Pearson Correlation 1 .180** .540** .318** .138* .619** Sig. (2-tailed) .010 .000 .000 .050 .000 N 204 204 204 204 204 204 Pearson Correlation .180** 1 .204** .203** .137 .334** Sig. (2-tailed) .010 .003 .004 .051 .000 N 204 204 204 204 204 204 Pearson Correlation .540** .204** 1 .368** .336** .492** Sig. (2-tailed) .000 .003 .000 .000 .000 N 204 204 204 204 204 204 Pearson Correlation .318** .203** .368** 1 .313** .405** Sig. (2-tailed) .000 .004 .000 .000 .000 N 204 204 204 204 204 204 Pearson Correlation .138* .137 .336** .313** 1 .263** Sig. (2-tailed) .050 .051 .000 .000 .000 N 204 204 204 204 204 204 Pearson Correlation .619** .334** .492** .405** .263** 1 Sig. (2-tailed) .000 .000 .000 .000 .000 N 204 204 204 204 204 204 **. Correlation is significant at the 0.01 level (2-tailed). *. Correlation is significant at the 0.05 level (2-tailed).

Note: RES is responsiveness; TAN is tangibles, EMP is empathy; ASS is

assurance; REL is reliability, and SAT is general satisfaction.

The research results show that factors in the model have relationship with the

dependent variable “general satisfaction”, in which the factor has biggest correlation is

RES (0.619, p < 0.05) and the factor has smallest correlation is REL (0.263, p < 0.05).

Between factors there is also relationship with each other, the two-sided test also shows

p-value < 0.05 (table 12). This suggests that it is needed to test the multicollinearity in

the multi regression function.

4.6 Regression analysis

39

Regression analysis will show the relationships between factors however, we

cannot know exactly which relationship they have to test the research hypotheses. Thus,

we need to use the regression analysis to test this. The analysis method used here is the

ordinary least squares (OLS), and the method of adding variables into regression is

Enter (adding all variables at a time). Because this is a testing research, so Enter method

will be more appropriate than Stepwise (Nguyen Dinh Tho, 2011).

4.6.1 The results from regression analysis by Enter

The estimated results from data set are as follows:

Table 13. Summary of estimated model by Enter

Model R R Square Adjusted R Square

Std. Error of the Estimate

Durbin-Watson

1 .700a .490 .477 .38685 1.964 a. Predictors: (Constant), REL, TAN, RES, ASS, EMP b. Dependent Variable: SAT

Table 14. ANOVA by Enter

Model Sum of Squares

Df Mean Square

F Sig.

1 Regression 28.482 5 5.696 38.063 .000b Residual 29.632 198 .150 Total 58.114 203

a. Dependent Variable: SAT b. Predictors: (Constant), REL, TAN, RES, ASS, EMP

Table 15. Coefficients of the estimated model by Enter

Model Unstandardized Coefficients

Standardized Coefficients

T Sig. Collinearity Statistics

B Std. Error Beta Tolerance VIF

1

(Constant) .181 .328 .552 .582 RES .391 .052 .461 7.506 .000 .683 1.463 TAN .200 .057 .184 3.505 .001 .933 1.072 EMP .106 .056 .122 1.886 .041 .616 1.622 ASS .186 .071 .149 2.617 .010 .790 1.266 REL .090 .058 .087 1.559 .121 .836 1.196

40

a. Dependent Variable: SAT

The regression function is determined as follows:

SAT = 0.181 + 0.391RES + 0.200TAN + 0.106EMP + 0.186 ASS + 0.090REL

F statistics of variance analysis has p-value = 0.000 (table), it means that the

estimated results are appropriate. Adjusted R –square = 0.477 shows that the

model explains 47.7% of the variability of the dependent variable “general

satisfaction”. .

4.6.2 Testing the research hypotheses

Testing the hypothesis H1

Hypothesis H1: The factor “reliability” of the hospital positively affects

general satisfaction of patients. It means Beta coefficient of the variable REL must

be positive. From the results of regression analysis, Beta coefficient = 0.090 > 0,

however p- value = 0.121 > 0.05 (table 15), so with the reliability coefficient =

95% we have not enough basics to conclude that Beta coefficient of REL positive.

In other words, we reject the hypothesis H1. The result shows that in this research

condition with hospital services for child patients, the factor “reliability” is not a

factor that has clear impact on patient’s satisfaction. This is explained that for

child patients in Vietnam, patient’s family often has tendency to choose the most

reliable hospital. Therefore, the feature” reliability is considered as a “must-be”

feature of the hospital, if there is lack of this feature, the relatives of patients will

feel dissatisfied or will not use the services of hospital (Kano, 1984)

Tesitng the hypothesis H2

Hypothesis H2: The factor “assurance” of the hospital positively affects

general satisfaction of patients. It means Beta coefficient of the variable ASS must

be positive. From the results of regression analysis, Beta coefficient = 0.186 > 0,

and p-value = 0.010 < 0.05 (table 15), so with the reliability coefficient = 95% we

have enough basics to conclude that Beta coefficient of ASS positive. In other

words, we accept the hypothesis H2. This result shows that if the hospital

improves the factor “assurance” and makes patient’s satisfaction level increase 1

41

unit (in 5-point Likert scale), the satisfaction level of patients will increase by

0.186.

Testing the hypothesis H3

Hypothesis H3: The factor “empathy” positively affects general satisfaction

of patients. It means Beta coefficient of the variable EMP must be positive. From

the results of regression analysis, Beta coefficient of the variable EMP = 0.106 >

0, and p –value = 0.041 < 0.05 (table 15), so with the reliability coefficient = 95%

we have enough basics to conclude that Beta coefficient of EMP positive. In other

words, we accept the hypothesis H3. This result shows that factor “empathy”

positively affects to satisfaction patients. If the hospital improves the factor

“empatthy” and makes patient’s satisfaction perceived level increase 1 unit (in 5-

point Likert scale), the satisfaction level of patients will increase by 0.106 unit

Testing the hypothesis H4

Hypothesis H4: The factor “responsiveness” positively affects general

satisfaction of patients. It means Beta coefficient of the variable RES must be

positive. From the results of regression analysis, Beta coefficient of the variable

RES = 0.391> 0, and p –value = 0.000 < 0.05 (table 15), so with the reliability

coefficient = 95% we have enough basics to conclude that Beta coefficient of RES

positive. In other words, we accept the hypothesis H4. This result shows that if the

hospital improves the factor “responsiveness” and makes patient’s satisfaction

level increase 1 unit , the satisfaction level of patients will increase by 0.391 unit.

Testing the hypothesis H5

Hypothesis H5: The factor “tangibles” of the hospital positively affects

general satisfaction of patients. It means Beta coefficient of the variable TAN

must be positive. From the results of regression analysis, Beta coefficient of the

variable TAN = 0.200 > 0, and p –value = 0.001< 0.05 (table 15), so with the

reliability coefficient = 95% we have enough basics to conclude that Beta

coefficient of TAN positive. In other words, we accept the hypothesis H5. This

results shows that factor “tangibles” positively influences to satisfaction patients.

42

If the hospital improves the factor “tangibles” and makes patient’s satisfaction

level increase 1 unit , the satisfaction level of patients will increase by 0.200 unit.

4.7 The differences between groups of patients according to classification signals

To test the differences between groups of patients according to classification

signals, we use the method of Analysis Of Variance (ANOVA) and get following

results:

4.7.1 Testing the differences between groups of different age

The results from ANOVA between groups of patient of different age show

that

Table 16. Summary of average value of groups by age

N Mean Std. Deviation Std. Error 95% Confidence Interval for

Mean Lower Bound Upper Bound

< 1 year 50 3.7120 .50976 .07209 3.5671 3.8569 1 to 2 years 54 3.6296 .47010 .06397 3.5013 3.7579 2 to 3 years 33 3.6848 .63054 .10976 3.4613 3.9084 3 to 5 years 30 3.7333 .49919 .09114 3.5469 3.9197 > 5 years 37 3.8865 .58222 .09572 3.6924 4.0806 Total 204 3.7206 .53505 .03746 3.6467 3.7945

Table 17. Results from variance analysis by age

Sum of Squares Df Mean Square F Sig. Between Groups 1.516 4 .379 1.332 .259 Within Groups 56.598 199 .284

Total 58.114 203

43

AGE GROUP

Figure 10. The graph of average points of satisfaction level by age

The analysis results show p-value of F test between groups = 0.259 > 0.05

(table 16), thus there are no differences between groups of different age. The

deviation of average value between these two groups is insignificant (see table 15

and figure 10).

4.7.2 Testing the differences between different groups according to the

education level of patient’s parents

The results from ANOVA based on the education level of patient’s parents

are as follows:

Table 18. Summary of average values by education level

N Mean Std.

Deviation Std. Error

95% Confidence Interval for Mean

Lower Bound Upper Bound High school 9 3.5333 .96437 .32146 2.7921 4.2746 Intermediate 18 3.4778 .43999 .10371 3.2590 3.6966 College 105 3.7352 .49185 .04800 3.6401 3.8304 University 39 3.7641 .60675 .09716 3.5674 3.9608 Other 33 3.8061 .45134 .07857 3.6460 3.9661 Total 204 3.7206 .53505 .03746 3.6467 3.7945

Table 19. The results from variance analysis by education level

44

Sum of Squares Df Mean Square F Sig. Between Groups 1.714 4 .429 1.512 .200 Within Groups 56.399 199 .283 Total 58.114 203

High school Vocational School colledge university other

Education Figure 11. The graph of average points by education level

The analysis results show that F test between groups has p – value = 0.200 >

0.05 (table 18), So, we can suppose that there are no differences between sample

groups of different education level. This is also reflected in a very small deviation

of the average value of each group (see table 17 and figure 11).

4.7.3 Testing the differences between groups of different job

The results from ANOVA based on job of the patient’s parents are:

Table 19. Summary of average values by job

N Mean Std.

Deviation Std. Error

95% Confidence Interval for Mean

Lower Bound Upper Bound Farmer 27 3.7852 .66778 .12851 3.5210 4.0493 Worker 57 3.6386 .52296 .06927 3.4998 3.7774 Officer 105 3.7467 .52350 .05109 3.6454 3.8480 Other 15 3.7333 .39036 .10079 3.5172 3.9495 Total 204 3.7206 .53505 .03746 3.6467 3.7945

45

Table 20. The results from variance analysis by job

Sum of Squares df Mean Square F Sig. Between Groups .570 3 .190 .660 .578 Within Groups 57.544 200 .288 Total 58.114 203

Famer worker officer other

Job Figure 12. The graph of average values of groups by different jobs

From the analysis results, F test between groups has p – value = 0.578 >

0.05 (table 20), so we can suppose that there are no differences between groups of

different job. This is also reflected in a very small deviation of the average value

of each group (see table 19 and figure 12).

4.7.4 Testing the differences between groups of different income

The research results from ANOVA with different groups based on the

income of patient’s parents are as follows:

Table 21. Summary of average values by income

N Mean Std. Deviation

Std. Error 95% Confidence Interval for Mean

Lower Bound Upper Bound < 5 mil 55 3.6800 .56778 .07656 3.5265 3.8335 5 - 10 mil 135 3.7481 .53530 .04607 3.6570 3.8393 10 - 15 mil 12 3.5500 .38258 .11044 3.3069 3.7931 > 15 mil 2 4.0000 .00000 .00000 4.0000 4.0000 Total 204 3.7206 .53505 .03746 3.6467 3.7945

46

Table 22. The results from variance analysis by income

Sum of Squares df Mean Square F Sig. Between Groups .698 3 .233 .811 .489 Within Groups 57.415 200 .287 Total 58.114 203

<5m 5-10m 10-15m >15m

Income

Figure 13. The graph of average values by income

From the analysis results, F test between groups has p –value = 0.489 > 0.05

(table 22), so we can conclude that there are no differences on the satisfaction

level between groups of different income. This is also reflected in a very small

deviation of the average value of each group (see table 21 and figure 13)

4.8 Discussion about the research results

The research results show that there are four factors affecting general satisfaction

of patients including: (1) responsiveness, (2) tangibles, (3) empathy, and (4) assurance.

The investigation results at Hai Duong Children’s Hospital also show different

assessment level for each factor, in which the best point belongs to the factor

“assurance” (the average point = 3.8995), the worst point belongs to the factor

“responsiveness” (3.3529). The equal level of answers between variables is also

different from each other: the factor “assurance” has lowest fluctuation level, (σ =

0.42874) and the factor “responsiveness” has highest fluctuation level (σ = 0.63007)

(table 23).

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Table 23. The statistical values of factors

N Minimum Maximum Mean Std. Deviation Responsiveness 204 2.00 5.00 3.3529 .63007 Tangibles 204 2.00 5.00 3.7696 .49216 Empathy 204 2.00 5.00 3.5572 .61410 Assurance 204 2.50 5.00 3.8995 .42874 General satisfaction 204 2.00 5.00 3.7206 .53505

With these results, we can see that the assessment level on factors affecting the

quality of services is above mean level, and it can increase through policies of

improving service quality.

The research results also show that the importance of each factor on general

satisfaction of the patients is different. This is reflected in Beta coefficients of each

variable in the regression function. From the regression function: SAT = 0.181 +

0.391RES + 0.200TAN + 0.106EMP + 0.186 ASS, we can easily see that the factor

“responsiveness” has biggest impact (Beta = 0,391), next is the factor “tangibles” (Beta

= 0,200), the factor “assurance” (Beta = 0.186), and the last is the factor “empathy”

(Beta = 0,106) (in this function, the variable REL was removed because it had no

statistical meaning).

According to the assessment results, the variable REL “reliability” has no

influence on the satisfaction of patients with the services of the hospital. This can be

explained because the services of the hospital require the very high reliability, and it

affects the health even the life of patients. Thus, the feature “reliability” of the service is

consider as an obligatory feature for the patients (patient’s relatives), and plays an

important role in the patient’s decision in choosing hospital to examine and treat. It can

be considered as a must-be feature in Kano model (1984), it means without this feature,

customers will feel dissatisfied but with it, customers do not also feel more satisfied.

The research results also show that there are no clear differences on general

satisfaction of the patient’s relatives according to the classification signals (age, job,

education level, income). This proves that the requirements of the quality of services for

child patients do not depend on these variables (factors). This is because Vietnamese

48

families always have the tradition of emphasis on children, regardless of that family

comes from what walk of life in the society. Children are always considered as the most

valuable "asset" of the family.

The research results also show Adjusted R –square =0.477, it means we can add

other factors into the research model in order to improve the explanation ability on the

variability of the dependent variable “general satisfaction”. Some other factors such as

the hospital fees, support activities after examination, etc. can be added into the model

to measure their impact intensity on the satisfaction of patients with services.

Statistically significant Statistically insignificant

*: The significance level 5% (0.05)

Figure 14. The relationship between factors in the model

Reliability

Assurance

Tangibles

Responsiveness

Empathy Customer satisfaction

0.186*

0.106*

0.391*

0.200*

49

CHAPTER 5 CONCLUSIONS AND RECOMMENDATIONS

This chapter will present main conclusions from the research results,

recommendations, contributions and the importance of the study as well as limitations

and directions for further researches in the same field. The contents in details are as

follows:

5.1 Conclusions

The study has reached the targets posed in the part of research purposes

including: (1) detect and explore factors affecting the satisfaction of patients with the

services of the hospital, (2) measure the real satisfaction level on the service quality of

the hospital based on main factors and general satisfaction, (3) the impact intensity of

factors of service quality on general satisfaction of customers.

The research results show that in five original factors in SERVQUAL there are

only four factors affecting general satisfaction of patients including: (1) assurance, (2)

empathy, (3) responsiveness, and (4) tangibles. The factor “reliability” has no impact on

general satisfaction. The patients consider this factor as a must-be feature for services of

the hospital. These results also have similarity with the results from the research of

Mostafa (2005) in Egypt. The research of Mostafa showed three in five main factors of

SERVQUAL affecting the satisfaction of customers. They are (1) human performance

quality, (2) human reliability, and facility quality. The differences between results from

Mostafa’s study and the results from this study are that the factor “reliability” in the

research of Mostafa is considered as a very important factor that influences the

satisfaction of patients on the disease diagnosis and treatment services. In this study,

this factor in contrast has no impact on the satisfaction of the patients. The reasons may

come from the differences on the culture and the research objects. In this study, the

research objects are child patients so that the requirements of the reliability of services

can be higher. These results are also different from the research results from the study of

Amad and Samreen (2011) in Pakistan. The study of Amad and Samreen showed that

50

there are 5 factors in SERVQUAL affecting the satisfaction of the patients, besides

other factors such as: Professionality, Feedback and Guidance, Affordability.

With regard to the question of real assessment on factors of service quality and

customer satisfaction on services of Hai Duong Children’s Hospital, the average

assessment point is above the mean point (above 3 in the five point Likert scale) for

every factor. Customer response level is quite focused (the deviation level of answers is

quite small). These results compared with results from other researches in Vietnam

show that the satisfaction level of the patients with disease diagnosis and treatment

services of Hai Duong Children’s Hospital is higher, but not so much. For example, the

research of Bui Thi Thu Huong in Tien Du General Hospital in Bac Ninh province has

the average point = 3.43 but in study = 3.72, corresponding to factors of service quality:

Responsiveness (3.35 compared with 3.5), Assurance (3.89 compared with 3.25),

Empathy (3.55 compared with 3.39), Tangibles (3.76 compared with 3.53). So, we can

see that the satisfaction level of patients on the services of the hospital in this study is

higher than in the research of Bui Thi Thu Huong (2009) (excluding the factor

“responsiveness”). However the differential level is not high and the research of Bui Thi

Thu Huong was done three years ago when the economic conditions of the medical

branch of Vietnam are not as good as today.

For the impact intensity of factors on general satisfaction of the patients, the

factor “responsiveness” is the most important (β = 0.391), next is the factor “tangibles”

(β = 0.200), the factor “assurance” (β = 0.186), and the last is the factor “empathy” (β =

0.106). These research results are also similar with the results from the study of Amad

and Samreen (2011) which show that the factor “responsiveness and reliability” has the

biggest impact (β = 0.343), next is the factor “tangibles and professionality” (β = 0.222),

and the factor “assurance and empathy” has smallest impact (β = 0.189). This proves

that the assessment levels on the impact intensity of factors affecting the satisfaction of

patients with medical services of hospital in Vietnam (Hai Duong) in Pakistan fairly

resemble each other though the culture between these two countries is different

(Pakistan has Muslim tradition, Vietnam has Confucian and Buddhist tradition).

Moreover a very big similarity between these two societies is that both Pakistan and

51

Vietnam are developing countries, per capita income is low (1300usd/person for

Vietnam and 1378usd/person for Pakistan). (Source: the World Bank Data).

In addition, the research results also show no differences between demographic

factors on the satisfaction of patients with the disease diagnosis and treatment services

of the hospital. Besides this, there are still some other factors which may be added into

the research model to better improve the variability of the dependent variable “general

satisfaction”.

5.2 Recommendations

The research results show that to improve the quality of disease diagnosis and

treatment services of the hospital and customer satisfaction, it is needed to focus on

factors which have biggest impact first and then factors with lower assessment point as

a priority. From these results, the author recommends some following solutions for

increasing service quality and customer satisfaction:

(1) Solutions for improving the responsiveness. According to the assessment of

patient’s relatives, this is the most important factor that influences their satisfaction with

the service. The results also show that the assessment point for this factor is lowest (the

average point = 3.35), so to improve the satisfaction on this factor, the hospital needs to

do some solutions as follows:

+ Create truth for patients and their relatives by polite and right behaviors. To do

this, it is needed to adjust and standardize healthcare processes towards simplicity.

Build a culture of service and uniform code of conduct in the hospital. Create an

information channel (notifications, via email, feedback letter) in order that the hospital

leaders can know exactly the feelings and expectations of the patients, solve the

difficulties of the patients and therefore create trust from them.

+ Recruit good and professional doctors to the hospital. Have frequent

professional training programs for the staffs of the hospital. Owning good doctors will

bring trust and loyalty to the patients with the disease diagnosis and treatment services,

so the hospital needs to have policies for attracting professional doctors and nurses or

having collaboration with physicians from the major hospitals in examining and treating

the patients. At the same time, it is necessary for implementing of expertise capacity as

52

well as accessing to modern methods for existing staffs through training programs and

short and long-term training. The importance of the recruitment and expertise training is

to bring this information to the patients through propagation and dissemination of

medical knowledge and the achievements of the doctors working in the hospital.

+ Training the knowledge and answering skills for the nurses and staffs of the

hospital. Because the questions of patients often come to these persons first, so it is

needed for them to have professional and right knowledge to create trust on the disease

diagnosis and treatment services of the hospital.

(2) Solution for improving the factor “tangibles”. The factor “tangibles” is the

second important factor in the p\opinion of the patients. To improve this factor, the

hospital needs to do some following solutions:

+ The hospital need to be clean always. Hygiene requirement is a mandatory

requirement for the hospital. There is not only the place for treating diseases but also the

source of the risk of infection if it is not cleaned well, especially for child patients. To

ensure the hygienic conditions, the hospital needs to comply with the provisions of

health, regular do inspection and monitoring activities of the labor part to timely correct

when sanitation problems occur.

+ Require the staffs of the hospital to wear neat and polite uniforms.

+ Purchase and use modern medical equipments. During the operation, the

hospital facilities should be maintained and checked periodically to ensure no problems

and work well. The use of modern equipments of the hospital when diagnosing and

treating diseases will create huge trust from patients

+ Organize the using the facilities of the hospital scientifically, economically and

simply.

(3) Solutions for improving the factor “assurance”. This is also an important

factor affecting the satisfaction of the patients. To improve this factor, the hospital

should note some aspects as follows:

+ Need to notify accurately the time of diagnosing and treating diseases as well as

time for getting examination results for the patients. The creation of the accuracy in the

time of notification will create huge trust from patients, reduce the waiting time without

53

knowing when the service will be served, that may create discomfort to the patients and

their family.

+ Team of nurses and doctors in the hospital must always be ready to help the

patients. The requirements of services always need to be met fully and timely.

+ The hospital staffs must take care each patient carefully, show their sharing for

the difficulties of the patients when they are hospitalized.

(4) Solutions for improving the factor “empathy”. This is also an important

factor in the opinions of the patients. From the research results, the author recommends

some following suggestions:

+ Building the serving cultures for doctors, nurses and staffs of the hospital. They

need to understand the concerns and special needs of patients for appropriate

counseling. The serving attitudes must always be appreciated. And it will be better if the

hospital has incentive policies for special mirrors of caring patients. The creation of

honor awards will create the proud from the hospital staffs. They are expressed

themselves to others to satisfy their own perfection demand (Maslow, 1943).

+ Arrange suitable time of disease diagnosis and treatment for many different

objects. It is needed to have policies for receiving clinical diseases in any time to

facilitate the patients and their relatives.

Besides those solutions, the hospital also needs to concentrate on the factor

“reliability” of the hospital. Although the research results show that this factor has no

impact on the satisfaction of the patients with the services of the hospital, it is still a

must-be feature of the service, because if the hospital does not meet this requirement,

the customers (patients) will feel dissatisfied with the services.

5.3 Contributions and the importance of the study

5.3.1 Contributions of the study

SERVQUAL model has become a popular model to measure service

quality and test the relationship between service quality and customer satisfaction.

The main purpose of the study is to explore and test this relationship. The research

results show that there are relations between aspects of service quality in

54

SERVQUAL and customer satisfaction, at the same time proves that the factor

“reliability” has no impact on the satisfaction of the patients.

Main contributions of this study are:

Firstly is to test the reliability of SERVQUAL model in measuring service

quality and customer satisfaction in the health sector in a developing country like

Vietnam, especially the health care services for child patients.

Secondly, this study points out differences in awareness of Vietnamese

patients (customers) compared with other studies. In this study, the factor

“reliability” is considered as a must-be feature for health care services.

Thirdly, the study also provides useful reference documents for other studies

in the health sector.

5.3.2 Importance of the study

In the domain of learning, this study once again proved that SERVQUAL is

a good model for measuring the quality of the service and customer satisfaction.

Moreover, the detections of the study show that in a special field like healthcare

services, there are some factor in the original model that have no impact on the

satisfaction of customers (factor “reliability”). The study also suggests other

factors into the model to better explain the variability of the dependent variable

“general satisfaction”.

In the domain of reality, the research results helped the hospital leaders

know the status of the quality of the hospital’s services and the satisfaction level

of patients. This study also answered questions posed in the first part: Which

factors affect the satisfaction of patients with the services of the hospital? How is

the impact intensity of these factors? In addition, the study suggested some

solutions for improving the quality of the services and customer satisfaction with

the hospital.

5.4 Limitations of the study

Like other researches, the study also has some certain limitations as follows:

55

Firstly, the study just focused on one hospital and the research objects were only

inpatients, so there was no basic to compare the satisfaction level between hospitals

with each other and the differences between the group of inpatients and group of

outpatients. .

Secondly, the sample size of the study was still quite small and the sampling

method was non-probability, therefore it might lead to uncontrolled errors affecting the

results of the study.

Thirdly, because the research objects were the patient’s relatives, so it might be

lacked of the real perceptions and feelings of the patients with the quality of the

services.

Fourthly, the study was just done in a time point and not be tested again, so it

might not also evaluate the changing tendency of patient’s feelings about the quality of

the hospital’s services.

5.5 Directions for further studies

From above limitations, the author proposes some direction for future researches

as follows:

The first, it is need to expand the research scope to a group of different hospitals

to compare the public hospitals and private hospitals as well as the hospitals in different

areas.

The second, it is necessary for further studies to enlarge the sample size. They

can determine the sample size through probability theory and multiple sampling

(determine the minimum sample standard deviation of the first sample size) to increase

the accuracy of the statistical process.

The third, future studies can do repeated researches to detect the changing

tendencies in the long term and short term and explore “basic” factors affecting the

satisfaction of the patients with the hospital’s services.

The fourth, further researches should consider to add other new factors into the

research model to better improve the explanation ability of the existing model.

56

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QUESTIONNAIRE

Hello!

I am Thanh. a Master student at Shu-Te University, Taiwan. At this time, I am

doing Master’s thesis research under the title "A relationship study between healthcare

quality and patient’s key caretaker satisfaction for Hai Duong children’s hospital in

Vietnam."

Under the direction of Dr. Jau-Shyong Wang and Dr. Sheng-Jung Li in the

Faculty of the School of Business Administration, Shu-te University and Dr. Pham Vu

Thang, To complete this thesis, I would like to invite you, the patient’s relatives in Hai

Duong Children’s Hospital to answer questions in this questionnaire. All your private

information will be kept strictly confidential and will not be attributed to the individual

or organization. All responses will be stored in a secure environment. The results of this

research would be used for academic purposes only. This thesis is a non-profit research,

so if you need to know about research results, please contact me via email address….

1. The contents of questions

Please rate the extent to which you agree with each statement below. Circle the

number that best indicates for each statement (the higher agreement level you choose,

the more you agree with). In which:

(1) Strongly disagree

(2) Disagree

(3) Neutral

(4) Agree

(5) Strongly agree

No. Code The contents of question Agreement level

1 2 3 4 5 I Reliability 1 REL1 You trust the results of diagnosis and treatments of the

hospital.. 1 2 3 4 5 2 REL2 You see that the hospital staffs tried not to make

mistakes when implementing treatments for patients. 1 2 3 4 5

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3 REL3 You see that the quality of health care services is as good as the notice of the hospital. 1 2 3 4 5

4 REL4 You find the medical examinations of the hospital are precisely done. 1 2 3 4 5

5 REL5 You find if the staffs of the hospital promise to do something in a fix time, they will do it. 1 2 3 4 5

II Assurance 6 ASS1 You see that the doctors and nurses are never too busy

to meet the needs of the patients (for example: medical procedures, asking the place to test, etc.). 1 2 3 4 5

7 ASS2 You are informed by medical staffs about the done-time of the services will be carried out (for example: time to response the test results, etc.). 1 2 3 4 5

8 ASS3 You see that the doctors and nurses always show their courtesy and willingness to help the patients. 1 2 3 4 5

9 ASS4 You find that the services of the hospital are always provided fully and promptly. 1 2 3 4 5

III Empathy 10 EMP1 You find that the doctors devotedly care for each

patient. 1 2 3 4 5 11 EMP2 You feel that the doctors and nurses always understand

the worries and special needs of the patients. 1 2 3 4 5 12 EMP3 You find that the patients are treated and cared

enthusiastically and thoughtfully. 1 2 3 4 5 13 EMP4 You find the time of medical examination is convenient

for the patients. 1 2 3 4 5 IV Responsiveness 14 RES1 You think that the behaviors of the physicians create

the trust to patients. 1 2 3 4 5 15 RES2 You feel safe when diagnosing and treating diseases in

the hospital. 1 2 3 4 5 16 RES3 You think that the hospital has good doctors and

nurses. 1 2 3 4 5 17 RES4 You think that the medical staffs have sufficient

knowledge to answer all questions of patients. 1 2 3 4 5 V Tangibles

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18 TAN1 You find that the hospital is always clean. 1 2 3 4 5 19 TAN2 You see that the uniforms of the medical staffs are

always neat and courteous. 1 2 3 4 5 20 TAN3 You think the facilities of the hospital are attractive.

1 2 3 4 5 21 TAN4 You think that the facilities (tools, equipments…) of

the hospital are modern and sufficiently provided. 1 2 3 4 5 VI General satisfaction with disease diagnosis and treatment

services 22 SAT1 You feel satisfied with the facilities of the hospital 1 2 3 4 5 23 SAT2 You feel satisfied with the assurance of the hospital. 1 2 3 4 5 24 SAT3 You will use the medical examination services of the

hospital for your children when needed. 1 2 3 4 5 25 SAT4 You will introduce the hospital to others. 1 2 3 4 5 26 SAT5 In general, you feel satisfied with the services of the

hospital. 1 2 3 4 5 2. Personal information

Please share with us your personal information by answering following questions:

- The age of your relative (patient):

1. < 1; 2. From 1 to 2; 3. From 2 to 3; 4. From 3 to 5; 5. > 5

- Your education level:

1. High school; 2. Intermediate; 3. College; 4. University and above; 5. Other

- Your job:

1. Farmer; 2. Worker; 3. Officer; 4. other

- Your montSATy income (both husband and wife) (vnd):

1. < 5 mil.; 2. From 5 -10 mil.; 3. From 10 -15 mil.; 4.> 15 mil.

Thank you for your cooperation!