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  • 8/16/2019 Dagger 2007


    This research developed and empirically validated a

    multidimensional hierarchical scale for measuring health

    service quality and investigated the scale’s ability to

     predict important service outcomes, namely, service satis-  faction and behavioral intentions. Data were collected 

     from a qualitative study and three different field studies

    of health care patients in two different health care contexts:

    oncology clinics and a general medical practice. Service

    quality was found to conform to the structure of the hier-

    archical model in all three samples. The research identified 

    nine subdimensions driving four primary dimensions, which

    in turn were found to drive service quality perceptions.

    The primary dimensions were interpersonal quality, tech-

    nical quality, environment quality, and administrative

    quality. The subdimensions were interaction, relationship,

    outcome, expertise, atmosphere, tangibles, timeliness, oper-

    ation, and support. The findings also support the hypothe-

    sis that service quality has a significant impact on service

    satisfaction and behavioral intentions and that service

    quality mediates the relationship between the dimensions

    and intentions.

     Keywords: scale development; service quality; health

    care; satisfaction; intentions

    Health care is one of the fastest growing sectors in

    the service economy (Andaleeb 2001). This growth is due

    in part to an aging population, mounting competitive pres-

    sures (Abramowitz, Coté, and Berry 1987), increasing

    consumerism, and emerging treatments and technolo-

    gies (Ludwig-Beymer et al. 1993; O’Connor, Trinh, and

    Shewchuk 2000). Quality in health care is currently at

    the forefront of professional, political, and managerial

    attention, primarily because it is being seen as a means for

    achieving increased patronage, competitive advantage,

    and long-term profitability (Brown and Swartz 1989;

    Headley and Miller 1993) and ultimately as an approach

    to achieving better health outcomes for consumers (Dagger and Sweeney 2006; Marshall, Hays, and Mazel

    1996; O’Connor, Shewchuk, and Carney 1994). Against

    this background, service quality has become an important

    corporate strategy for health care organizations.

    Journal of Service Research, Volume 10, No. 2, November 2007 123-142 DOI: 10.1177/1094670507309594 © 2007 Sage Publications

    A Hierarchical Model of Health

    Service Quality Scale Development and Investigation of an Integrated Model

    Tracey S. Dagger The University of Queensland 

    Jillian C. SweeneyThe University of Western Australia

    Lester W. Johnson The University of Melbourne

     at Fontys Hogescholen on January 6, 2015 jsr.sagepub.comDownloaded from 

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  • 8/16/2019 Dagger 2007


    The quality of medical care has traditionally been

    measured using objective criteria such as mortality and

    morbidity. Although these indicators are essential to assess-

    ing clinical quality, softer, more subjective assessments

    are often overlooked. In reality, the health care sector has

    been slow to move beyond a supply-side approach to

    quality assessment. However, as the industry structure changes, the role patients play in defining what quality

    means has become a critical competitive consideration

    (Donabedian 1992; Jun, Peterson, and Zsidisin 1998;

    O’Connor, Trinh, and Shewchuk 2000). As a consequence,

    service providers are struggling to implement meaningful

    customer-oriented quality assessment measures (Clemens,

    Ozanne, and Laurensen 2001; Murfin, Schlegelmilch, and

    Diamantopoulos 1995). Because few reliable and valid

    instruments are available, many service providers are imple-

    menting measures that are not aligned to the complexities

    of the health care setting (Draper and Hill 1996).

    The purpose of this article is to describe the develop-

    ment and refinement of a multidimensional, hierarchal

    scale for measuring health service quality that is appro-

    priate to our research contexts, as well as to describe an

    integrated model that includes health consumer outcomes.

    Specifically, our key objectives were (a) to provide a

    conceptualization of the health care service quality con-

    struct that the captures the domain of the construct, (b) to

    systematically develop a scale to measure health service

    quality from the customers’ perspective, (c) to assess the

    psychometric properties of the scale, and (d) to examine

    the effects of this conceptualization of health service

    quality on satisfaction and behavioral intentions.


    Although a considerable amount of research has been

    published in the area of service quality perceptions, much

    of this research has focused on the development of generic

    service quality models (e.g., Brady and Cronin 2001;

    Parasuraman, Zeithaml, and Berry 1985). Relatively few

    studies, in comparison, have focused on the development

    of context-specific service quality models, despite indica-

    tions that service quality evaluations are likely to be

    context dependent (Babakus and Boller 1992; Carman

    1990; Dabholkar, Thorpe, and Rentz 1996). Specifically, research has not directly examined how customers assess

    health service quality. We discuss in the following sections

    key issues relevant to the development of our health service

    quality scale.

    Measuring Service Quality Perceptions

    Service quality perceptions are generally defined as a

    consumer’s judgment of, or impression about, an entity’s

    overall excellence or superiority (Bitner and Hubbert

    1994; Boulding et al. 1993; Cronin and Taylor 1992;

    Parasuraman, Zeithaml, and Berry 1985, 1988). This judg-

    ment is often described in terms of the discrepancy between

    consumers’ expectations of service and actual service

    performance. Grönroos (1984), for example, emphasized

    the use of expectations as a standard of reference against which performance can be judged, and Parasuraman,

    Zeithaml, and Berry (1985) put forward service quality as

    the gap between expected and perceived service. Although

    commonly applied, this approach has been the subject

    of substantial criticism and debate. Babakus and Boller

    (1992), for example, suggested that the measurement of 

    expectations adds limited information beyond what is

    gained from measuring service perceptions alone.

    Similarly, Dabholkar, Shepherd, and Thorpe (2000) found

    that perceptions performed better than difference measures

    when comparing these approaches, and both Cronin and

    Taylor (1992) and Brady and Cronin (2001) focused on

    performance-only measures (i.e., perceptions rather than

    expectations) when modeling service quality perceptions.

    Although the conceptual definition of service quality

    is often specified at an abstract level, most commonly as

    a second-order factor (Grönroos 1984; Parasuraman,

    Zeithaml, and Berry 1988; Rust and Oliver 1994), service

    quality has recently been described as a third-order factor

    (Brady and Cronin 2001; Dabholkar, Thorpe, and Rentz

    1996). This structure suggests that service quality

    comprises several primary dimensions, which in turn share

    a common theme represented by the higher order global

    perceived service quality construct. Moreover, these

    dimensions have subdimensions that combine relatedattributes into subgroups. Perceptions of overall service

    quality are therefore represented as a third-order factor to

    the subdimensions. Modeling service quality in this way

    recognizes that the evaluation of service quality may be

    more complex than previously conceptualized.

    The complexity of service quality evaluations is also

    evident in the many failed attempts to replicate the dimen-

    sional structure of service quality perceptions. The widely

    applied SERVQUAL scale (Parasuraman, Zeithaml, and

    Berry 1985, 1988), for example, has been criticized insofar

    as its five dimensions, namely, reliability, empathy, tangi-

    bles, responsiveness, and assurance, are difficult to replicate

    across diverse service contexts (Buttle 1996). Researchers applying the SERVQUAL scale have, for example, identi-

    fied a range of factors, including 3 factors in an automotive

    servicing context (Bouman and van der Wiele 1992),

    4 factors in the retail clothing sector (Gagliano and Hathcote

    1994), and 3 factors in the context of MBA students’ ser-

    vice quality perceptions (McDougall and Levesque

    1994). Furthermore, Brown, Churchill, and Peter (1993)

    found service quality to be unidimensional when applying

    the five-dimension SERVQUAL scale. The application of 

    124 JOURNAL OF SERVICE RESEARCH / November 2007

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