The impact of total quality service (TQS) on healthcare and patient satisfaction: An empirical study of Turkish private and public hospitals

THE INTERNATIONAL JOURNAL OF HEALTH PLANNING AND MANAGEMENT

Int J Health Plann Mgmt 2014; 29: 292–315.Published online 12 March 2013 in Wiley Online Library(wileyonlinelibrary.com) DOI: 10.1002/hpm.2169

The impact of total quality service (TQS)on healthcare and patient satisfaction: Anempirical study of Turkish private andpublic hospitals

Ismail Bakan, Tuba Buyukbese* and Burcu ErsahanFaculty of Economic and Administrative Sciences, Kahramanmaras Sutcu Imam University,Kahramanmaras, Turkey

SUMMARY

This paper attempts to measure patients’ perceptions of the quality of services in public and pri-vate healthcare centers in Turkey. The main aim was to examine the impact of the dimensions ofpatient-perceived total quality service (TQS) on patients’ satisfaction. The research frameworkand hypotheses are derived from a literature review of service quality and quality in the healthcareindustry. The research data were collected through questionnaires and then statistically analyzedusing descriptive statistics, Pearson product moment correlation and linear regression. The resultssuggest that service quality perceptions positively influence patient satisfaction with overallhospital care (SOHC). The most important factors identified in the regression model regardingpatient SOHC are the quality of the hospital’s social responsibility, administrative processesand overall experience of medical care received. These factors explain 74% of the variancein SOHC. The findings of the study can be used to improve TQS in both private and publichospitals. Copyright © 2013 John Wiley & Sons, Ltd.

KEY WORDS: patient-perceived healthcare quality; patient satisfaction

INTRODUCTION

According to the World Health Organization, the goals for healthcare systems are goodhealth, responsiveness to the expectations of the population and fair financial contribu-tion. As a provider of healthcare, hospitals must ensure qualified, efficient, acceptableand equal service for their consumers. Patients are the most important consumers of hos-pital services. In a competitive environment, patient perception of healthcare servicequality is the essential factor when choosing a hospital. Because of increasing living stan-dards and higher expectations, healthcare services must provide continually higher stan-dards of medical care for their consumers. Hospitals want to attract not only local patientsbut also people from abroad. In this context, Turkey has become a choice destination for

*Correspondence to: T. Buyukbese, Faculty of Economic and Administrative Sciences, KahramanmarasSutcu Imam University, Avsar Campus, 46100, Kahramanmaras, Turkey.E-mail: [email protected]

Copyright © 2013 John Wiley & Sons, Ltd.

293TQS IN HEALTHCARE AND PATIENT SATISFACTION

medical tourists coming from European countries such as England, The Netherlands,Russia, Ukraine, Germany, Romania and Bulgaria as well as Middle Eastern and Arabcountries. According to a recent study conducted by the Turkish Statistical Institute,165000 visitors came to the country for healthcare in 2010, contributing an income ofapproximately $US360m. One of the biggest markets for Turkey’s medical tourism isthe UK. In a 2007 study, Britain rated Turkey as one of the top three medicaltourism destinations along with India and Hungary; the most commonly mentionedprocedures were hip replacement, knee replacement, laser eye surgery and cataractremoval (Vequist and Gursoy, 2009).

The right to healthcare provision is guaranteed by constitutional law in Turkey. TheMinistry of Health of Turkey (established in 1920) is the main healthcare service pro-vider. After 1998, major events and policy changes had a substantial impact on incomeand health expenditures leading to a series of reforms to restructure the health and socialsecurity systems (Sulku and Caner, 2011). For instance, in 2003, Turkey started theHealth Transformation Programme (HTP) created to align its healthcare system withthat of the European Union and OECD countries. This extensive program aims to orga-nize, finance and deliver health services in an effective, efficient and equal manner.HTP adheres to the “Health for All in the 21st Century” policy of the World Health Or-ganization, an Accession Partnership Document declared by the European Union andother international bodies. The main goal of this program is to provide “accessible,high-quality and sustainable health service for all” (Akdag, 2010).

Before July 2003, patients purchased private care services through out-of-pocketpayments. Since then, patients who received social security under such organizationsas Government Employee Retirement and Blue-Collar Public Sector Employee havestarted to receive healthcare services from private hospitals (Caha, 2007). Comparedwith other OECD countries, private healthcare increased in Turkey. The number ofprivate hospitals continues to grow rapidly, from 271 in 2002 to 489 in 2010. Thenumber of public hospitals increased from 774 to 843 over the same period. In total,there were 1439 hospitals (public, private, university and other) in Turkey in 2010(Mollahaliloglu et al., 2010). The number of total hospital visits increased from124 313 659 in 2002 to 302 984 218 in 2010 (Mollahaliloglu et al., 2010).

With the establishment of the HTP, social security organizations were unified un-der the governance of the Social Security Institute. Moreover, financial institutionswere distinguished from service providers. One important contribution of the reformwas the introduction of family medicine. Universal health insurance coverage hasbeen extended to the entire society. Investments in personnel and informationtechnology systems have been made, and stakeholders have worked together toimplement the reforms (Akdag, 2010). The OECD General Secretariat identifiedTurkey as a successful example of countries making reforms in the healthcare sector.The 2011 OECD health system review of Turkey stated:

“Turkey is closing the performance gap with other OECD countries and, on anumber of measures including overall costs, performs well relative to othercomparable upper middle-income countries. Indeed, there may be much that othercountries can learn from the recent health reforms in Turkey, especially in the useof performance-related pay to raise staff productivity.”

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These events and policy changes have affected patient satisfaction. According to alife satisfaction survey conducted by TurkStat, the rate of satisfaction with healthcareservices was 39.5% in 2003 and rose to 65.1% in 2009 (Akdag, 2010). Providing thebest quality care is important issue for hospitals to survive in a competitive environ-ment. Many researchers have studied how to improve the quality of healthcareservice and patient satisfaction. Crowe et al. (2002) identified 37 studies on method-ological issues and 138 studies investigating determinants of satisfaction. They con-cluded that there is no overall agreement in the literature on the definition of patientsatisfaction with healthcare.The present study examines the impact of patient-perceived total quality service

(TQS) on patient satisfaction in Turkish hospitals. First, quality, service qualityand service quality in healthcare are examined theoretically. Then seven dimensionsof TQS in healthcare are described: infrastructure (IN), personnel quality (PQ), pro-cess of clinical care (PCC), administrative procedures (AP), safety indicators (SI),overall experience of medical care received (OE) and social responsibility (SR).Next, the methodology, findings and analyses of the study are presented.

Definition of quality

In today’s complex and global competitive business environments, quality is one ofthe most important sources of competitive advantage for organizations seeking toserve and attract primary customers (Senthilkumar and Arulraj, 2011). Many organi-zations now recognize the importance of systematic processes to manage quality inorder to gain and maintain a competitive position (Eraqi, 2006). Quality is the keydeterminant for market share, investment return and cost reduction (Anderson andZeithaml, 1984).In the literature, there is no universal definition of quality, which has been defined

in many ways. Some define quality as “fitness for use,” whereas others view it as“meeting the customer’s needs,” “satisfying the customer” or “performance to stan-dards” (Reid and Sanders, 2010: 138; Fuller, 2000: 315). The American NationalStandards Institute and American Society Quality defined quality as “the totality offeatures and characterizes of a care or service that bears on its ability to satisfy givenneeds” (Patel, 2009: 1). Peters (1999: 7) described the quality movement as follows:

• fitness for purpose: understanding what people want from a service or product anddelivering it to match those needs;

• conformance to specification: drawing detailed specifications on the basis of thearticulated customer needs and delivering carefully to them;

• process control: understanding and managing the variables in the manufacturing/service delivery process, which can lead to deviation from specification; and

• quality audit/document control: keeping detailed records of the process allowingdeviations to be traced and rectified.

In the healthcare sector, quality is the art of doing the right thing, at the right time,in the right way, for the right person and having the best possible results (Zineldin,2006). The importance of services and their relation to health, quality assuranceand quality promotion have been receiving more attention from taxpayers, who


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have increasing expectations of hospitals and other healthcare providers (Nekoei-Moghadam and Amiresmaili, 2011).

Service quality

Providing high-quality services and evaluating service quality are important issuesfor contemporary managers (Jensen and Markland, 1996; Parasuraman et al.,1994). Service quality is the difference between predicted, or expected, service(customer expectations) and perceived service (customer perceptions; Parasuramanet al., 1985). Lim and Tang (2000) described expectations as the wants of consumersand what they feel a service provider should offer; perceptions refer to consumers’evaluations of the service provider (Rashid and Jusoff, 2009). Listening to the voiceof the customer is critical for understanding expectations and perceptions and is thestarting point for planning and/or adapting services (Aghlmand et al., 2010).

Service quality is the outcome of an interactive process between the service pro-vider and the service receiver. It has been described as a form of attitude, whichis related, but not equivalent to, satisfaction that results from the comparison ofexpectations with performance (Parasuraman et al., 1988). The interactive featuresof service quality are thus crucial to the ultimate outcome (Owusu-Frimpong et al.,2010: 206). If performance meets or exceeds expectations, then the perceived servicequality is satisfactory (Holder and Berndt, 2011).

Service quality in healthcare

The quality of healthcare services has become an essential issue in marketing health-care services, which has gained greater significance in the current competitivehealthcare environment. The optimal degree of health outcomes through deliveryof effective, efficient and cost–benefit professional health services to people andcommunities can be defined as the quality of healthcare (Tafreshi et al., 2007).Examining customer satisfaction with quality of care is vital, because unless thepatient is satisfied with the care delivered at a reasonable cost and the risk ofadverse effects are minimized, healthcare organizations could go out of business(Chattopadhyay and Szydlowski, 1999; Atinga et al., 2011: 549).

Researchers have proposed various instruments to determine service quality.Some of these instruments were developed for the healthcare sector, such as thecustomer quality index cataract questionnaire, the Picker Patient ExperienceQuestionnaire (Jenkinson et al., 2002), the Newcastle satisfaction with nursing scale(Alasad and Ahmad, 2003), the SERVPERF instrument (Mukherjee and Nath, 2005)and the SERVQUAL instrument (Parasuraman et al., 1988). SERVQUAL is consid-ered to be one of the most understood and adaptable instruments for measuring ser-vice quality (Buttle, 1996). Some find it to be suitable for use in the healthcare sectorfollowing some modifications (Mostafa, 2005; Ramsaran-Fowdar, 2007; Holder andBerndt, 2011), whereas others consider this scale inadequate for examining patientsatisfaction (Asubonteng et al., 1996; Buttle, 1996; Teas, 1994; Cronin and Taylor,1992; Fick and Ritchie, 1991; Andaleeb, 1998; O’Connor and Shewchuk, 2003).

On the basis of an extensive review of the literature on healthcare service quality,this study adopts the instrument of Duggirala et al. (2008a, 2008b) to measure


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critical dimensions of patient-perceived healthcare quality. These dimensions arenow explained in the following section.

Patient satisfaction with hospital care and patient-perceived dimensions of TQS inhealthcare

Satisfaction is a function of perceived performance and expectations. The patientis the main beneficiary of good healthcare service. Patient satisfaction is definedon the basis of the view of the patient as a consumer. According to Donabedian(1980), consumer satisfaction is of fundamental importance as a measure ofquality of care, because it gives information on the provider’s success at meetingthe values and expectations of the client who is the ultimate authority. Therefore,the measurement of healthcare satisfaction is an important tool for research, ad-ministration and planning in healthcare. Additionally, patient satisfaction isessential for ensuring continuity of care, better patient compliance with treatmentand favorable clinical outcomes (Fan et al., 2005). Quality care aims to satisfythe consumers’ requirements; it is therefore necessary to know their needs andexpectations in order to be able to meet them. Although the level of service qual-ity can be quite low (or high), the main issue is how consumers perceive qualityof service and the efficiency of healthcare (Petersen, 1988). Consumer perceptionis the main indicator of quality healthcare service (O’Connor et al., 1994; Croninand Taylor, 1992).Most researchers agree that there is a relationship between consumer perception of

service quality and their satisfaction (Cronin and Taylor, 1994; McAlexander et al.,1994). High service quality does not guarantee high satisfaction or positive behavior.Li et al. (2011) reported that sound physical environments or sufficient equipment,for example, can match customers’ expectations but cannot offset dissatisfactionwith long waiting times. Patients may be satisfied with core services (e.g., doctors’diagnoses), but the poor quality of supplemental services (e.g., inconvenience andslow processing speed at the payment counter or pharmacy) can give patients abad impression. The relationship between service quality and satisfaction is nonlin-ear, and so moderating effects need to be considered (Li et al., 2011).Increased competition and fear of litigation make patient satisfaction with hos-

pital care more important than ever. Perceived quality of hospital care should bemeasured by patients’ biological health outcomes, their functional health status,their perceived health benefit and judgments of satisfaction with the care received(Larson et al., 1996). In this study, patients’ overall satisfaction with hospital careis measured by five dimensions: overall satisfaction with the hospital process (HP)including admission, stay, treatment and discharge; overall satisfaction with med-ical care and treatment (MT) provided by doctors and nurses; overall satisfactionwith the care provided by support staff and administrative staff (SA); overall sat-isfaction with the amount of hospital expenses (EXP) in comparison with themedical care received; and overall comfort of stay with respect to hospital envi-ronment (HE) and housekeeping. The effects of patient-perceived service qualityon patient satisfaction with overall hospital care (SOHC) is the main subject ofthis research.


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Zeithaml (2000) defined perceived quality as the consumer’s evaluative judgmentregarding the superiority of service performance. Martinez Fuentes (1999) definedmedical service quality perception as

“a multidimensional concept reflecting a judgement as to whether the serviceperformed for a patient was the most appropriate to produce the best result thatcould be reasonably expected by the patient, and whether those services weredelivered with due attention to the doctor/patient relationship”.

According to Groönroos (1982), perceived total quality will depend on twovariables: what the customer expects from the service and the manner in which thisservice is performed in its technical and functional aspects. The healthcare literaturerefers to the former as process’ attributes and the latter as outcome attributes (Zifko-Baliga and Krampf, 1997; De Ruyter and Wetzels, 1998). In the literature, differentdimensions of patient-perceived healthcare service are identified, such as IN, PQ,experience, knowledge and competence of hospital personnel, empathy, AP and SI,corporate image, SR, and trustworthiness of the hospital (Padma et al., 2009: 175;Edvardsson et al., 1994). Duggirala et al. (2008a, 2008b) reviewed the critical dimen-sions of patient-perceived healthcare quality dimensions and developed an instrumentmeasuring the patient’s viewpoint on healthcare quality. The following are the dimen-sions of patient-perceived TQS in healthcare by Duggirala et al.:

(1) IN(2) PQ

Copy

(i) Doctor’s care(ii) Nursing care(iii) Paramedical and support staff quality(iv) Quality of communication

(3) PCC(4) AP(5) SI(6) Overall, experience of medical care received (OE)(7) SR

Table 1 shows the various dimensions of service quality and related studies. Thesehealthcare service quality dimensions are explained in the following sections.

Infrastructure. The environment of the healthcare facility largely influences patientsatisfaction with quality of care. Patients derive their first impression of the health-care facility through its physical appearance; this reinforces the need to keep thehospital tidy at all times. A clean, safe and pleasing environment can significantlyimprove the patient’s mood, satisfaction and perceived quality of the healthcareexperience. Fottler, Ford and Heaton (2002) identified three reasons for maintaininga hygienic environment (Atinga et al., 2011: 553):

• It creates an excellent opportunity to meet or exceed patient expectations.• It improves the mood and boosts the morale of both patients and providers.• It adds value to other functions of the hospital.

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Table 1. Critical dimensions of service quality in healthcare

Dimension Typology of dimension Important related literature

Infrastructure Tangibles; facilities; physicalenvironment; accommodationaspect; clinic infrastructure;facilities management; facility;distance; affordability; nursinghome facilities

Parasuraman et al. (1985);Sureshchandar et al. (2002);Olorunniwo et al. (2006);Reidenbach and Smallwood (1990)and Otani and Kurz (2004); Tomesand Ng (1995); Rao et al. (2006);JCI (2007); Duggirala et al. (2008a,2008b); Andaleeb (1998); Pakdiland Harwood (2005); Haran et al.(1993); Kleinsorge and Koenig(1991)

Personnelquality

Empathy; assurance;responsiveness; courtesy; humanelement of service delivery;interpersonal care; nursing;doctors’ qualification;communication; competence anddemeanor; positive physician–patient interaction; nursing care;demeanor of the staff in variousservice settings

Parasuraman et al. (1985); Sohailand Shaik (2004); Issac et al.(2003); Andaleeb (1998) and Hasinet al. (2001); Otani and Kurz(2004); Rao et al. (2006); Das andHammer (2007); Baalbaki et al.(2008); Duggirala et al. (2008a,2008b); Andaleeb (1998); Marr andGreengarten (1995); Oswald et al.(1998); Ross et al. (1993); Haran et al.(1993); Andaleeb and Simmonds(1998); Grewal and Sharma (1991)

Process ofclinical care

Primary quality; technical quality;treatment process and its outcome;reliability; understanding of illness;diagnosis, dental services; free-standing medical imaging facilities;emergency room services; managedcare programs; outpatientpsychotherapy practices

Groönroos (1982); Baldwin andSohal (2003); Rohini andMahadevappa (2006); Rose et al.(2004); Duggirala et al. (2008a,2008b); Haran et al. (1993);Gopalakrishnan and Mummaleni(1993); Peyrot et al. (1993);Mowen et al. (1993); Whipple andEdick (1993); Dolinsky and Caputo(1990); Gelb et al. (1991)

Administrativeprocedures

Process of service delivery; non-human element of service delivery;punctuality; waiting time; duration

Sureshchandar et al. (2002);Boshoff and Gray (2004) andDuggirala et al. (2008a, 2008b);Pakdil and Harwood (2005); Haranet al. (1993)

Safetyindicators

Safety indicators; drug Poon and Low (2005); Duggirala et al.(2008a, 2008b); Haran et al.(1993)

Socialresponsibility

Social responsibility; stakeholderfocus; integrity; high interaction

Chiu and Lin (2004);Sureshchandar et al. (2002) andDuggirala et al. (2008a, 2008b);Johnston (1997); Angur et al.(1999)

Overallexperience ofmedical carereceived

Technical competence of themedical practitioner; medicalcourses; patients’ familymembers/friends

Carson et al. (1998); John (1996);Duggirala et al. (2008a, 2008b);Strasser et al. (1995)

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The physical environment can influence behaviors in several ways. Thus, identi-fying desirable customer behaviors and the strategic goals that the organizationhopes to advance through its physical facility is central in the purposeful design ofthe servicescape. Customer responses to dimensions of their physical surroundingsinfluence their behaviors (Bitner, 1992).

The appearance of physical facilities, equipment, personnel and communicationmaterials are tangible assets. Tangible aspects of event quality can include physicalenvironment variables such as ambience/atmosphere, non-visual aspects (e.g., temper-ature, natural light and fresh air, scent, noise, music, peaceful, tranquil andmaintenanceservices), space (e.g., location, layout, equipment, furnishings, cleaning and parkinglot), signage (e.g., style, decor and size), facility reliability, process flow, capacitybalance, control of flow process flexibility, timeliness, speed ranges of services offeredand communication (Moon et al., 2011; Bitner, 1992; Brady and Cronin, 2001; Chahaland Sharma, 2004; Chahal and Kumari, 2011; Zineldin, 2006; Olorunniwo et al., 2006;Crotts et al., 2005; Seth et al., 2005).

Personnel quality. Personnel quality refers to the quality of all personnel involved indelivering service, such as doctors, nurses, paramedical and support staff. PQ consistsof all interactions between service personnel and patients including moments of truth,critical incidents and service recovery (Padma et al., 2009). Personnel are expected tobe timely, communicative, courteous, warm, friendly, responsive, reliable, sincere,competent, professional, accessible, flexible, helpful and honest (Seth et al., 2005;Padma et al., 2009; Duggirala et al., 2008a, 2008b; Chahal and Kumari, 2011).

Doctor care. A basic expectation among patients is the assurance that they will beattended by skilled and competent staff who will clearly answer their questions orconcerns regarding their health status, testing procedures and results, or treatmentprocedures (Andaleeb, 2001). Patients must be satisfied with core services such asdoctors’ diagnoses (Li et al., 2011). Healthcare providers must be more responsiveto patients’ needs while working within a clearly established framework for deter-mining clinical performance (Duggirala et al., 2008a, 2008b).

Cohen (1996) observed that the main sources of patient dissatisfaction with qual-ity of care are lack of opportunity to ask questions, unexplained choices, inadequatetime with doctors and poor doctor attitude (Atinga et al., 2011).

Nursing care. Nursing service is one of the most important components of hospitalservices. Researchers have found a significant relationship between nursing andpatient outcomes (Duggirala et al., 2008a, 2008b). In a study by Abramowitzet al. (1987), the most important determinants of patient satisfaction with qualityof care were explanations offered by nurses (Atinga et al., 2011). Tafreshi et al.(2007) described high-quality nursing care as “meeting all needs of the patients orpatients you are looking after” (p. 321). A smart, smiling nurse or a pleasant care set-ting can compensate for a negative outcome or unskillful doctor struggling to diag-nose the patient’s disease (Eleuch, 2011). Insufficient time caused by lack of humanor physical resources was perceived as the main reason for inability to consistentlyprovide quality nursing care (Tafreshi et al., 2007).


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Paramedical and support staff. Patient perception of the quality of care, attention, em-pathy, communication ability and skill of the paramedical and support staff in a healthorganization are also important. Studies have underscored the importance of the serviceencounter in determining overall satisfaction (Duggirala et al., 2008a, 2008b).

Quality of communication. Communication is of vital importance when accessingtreatment, as it gives patients the opportunity to engage in dialogue. When patientshave easy access to information on their conditions, treatment or hospital, theirsatisfaction increases. Counseling, advice and guidance from providers improvepatient–provider communication. Explanations of patient condition, side effectsand medical tests are important aspects of patient–provider communication (Atingaet al., 2011). Williams and Calnan (1991) find that patient satisfaction with care isstrongly correlated with adequate communication (Atinga et al., 2011). The commu-nication quality between patient and personnel is important for the patient’s overallperception of quality of care (Duggirala et al., 2008a, 2008b).When choosing a provider for the first time, patients often obtain information from

friends and family. Negative word-of-mouth about healthcare services can bedetrimental to business (Owusu-Frimpong et al., 2010: 208). Poor communicationbetween patients, doctors and nurses in an organization appear to be strong barriersto establishing deep and long-lasting relationships with healthcare organizations(Eleuch, 2011).

Process of clinical care. The PCC covers the experience of the patient with clinicaltreatment processes and outcomes of care in the hospital. According to Padma et al.(2010), this dimension is primary service or technical quality of hospital service.This is more important for patients than other aspects; that is, even if the personnelare friendly in a hospital, the patient may not perceive the service to be of highquality if the doctor lacks the necessary competence and skill (Padma et al., 2010).

Administrative procedures. The processes of admission, stay and discharge ofpatients are examined in the dimension of administrative processes (AP). Theseprocesses are critical indicators of patient satisfaction with overall medical care.Many studies have found that patients are dissatisfied with the long waiting timesfor diagnosis, treatment and so on and with the delay at different stages of the hos-pital stay (Pakdil and Harwood, 2005; Duggirala et al., 2008a, 2008b; Padma et al.,2010). The ease of obtaining appointments, access to ambulance services and thesimplicity of admission and discharge are essential for ensuring problem-free treat-ment. Efficient administration helps patients to appreciate better service (Padmaet al., 2010). Hospital administration services must organize AP to make thepatient’s stay a pleasant experience.

Safety indicators. Healthcare institutions must attend to ensuring that their person-nel and patients feel safe and secure; without reliable safety, there can be no quality(Birnbaum and Van Buren, 2010). Safety is a basic necessity for individuals. Safetyand security standards are established by law and should be considered as qualitystandards (Eraqi, 2006). Admission, diagnosis, medical and nursing care, support


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service, health education, follow-up and discharge are all typical HPs. Qualityimprovement plays an important role in bringing about a holistic and systemic ap-proach to achieving the overall safety of core processes and support systems(Alhatmi, 2011). The provision of ramps and elevators, checking for drugs causingallergic reaction in patients and special facilities for older and physically challengedpeople must be considered by the hospital (Padma et al., 2009). A hospital must pro-vide safe service for its patients.

Overall experience of medical care received. The evaluation of healthcare service isessential to the assessment and quality improvement of medical services. Thepatient’s experience with the hospital as a whole, the likelihood of the patient recom-mending the hospital to a family member or friend, the care expected and received atthe hospital and quality of care in the hospital with respect to other comparablehospitals are all measured as contributing to the overall experience of medical carereceived (Duggirala et al., 2008a, 2008b). High levels of consumer-perceived qualityare positively related to patient satisfaction, employee satisfaction, intention to use aservice again, compliance with advice and treatment regimes, choice of provider orplan, decreased turnover and malpractice lawsuits, better health outcomes, higherfinancial performance, lower employee turnover, strengthened competitive position,enhanced placebo effect and better risk management (DeMan et al., 2002; Press,2002; Polluste et al., 2000).

Social responsibility. To achieve social welfare and improve the quality of life of thecommunity, it has been argued that the business world must increase healthy economicgrowth and take environmental issues into account (Hidayati, 2011). Healthcareorganizations are required to provide high clinical quality, high functional quality(i.e., patient satisfaction) and cost-effective patient care in a hyper-competitive envi-ronment by utilizing the scarce resources they are allocated (Fottler and Blair, 2002).Hospitals must provide good and fair service for their patients. Rohini and Mahadevappa(2010) proposed that hospitals must take into account all patient characteristics (social,financial and so on). Hospitals seek to inspire, support and promote a culture that ispeople-centered, committed to quality, accountable and corporate. In addition, hospi-tals must set realistic prices for people who cannot afford services. Other socialresponsibilities of hospitals include providing workplace safety, meeting workers’basic needs, reducing energy consumption by minimizing waste and recycling materi-als, and organizing education and research activities (Rohini andMahadevappa, 2010).The level of SR refers to the whole contribution of the hospital to society in terms of fairmedical treatment, reasonable medical care cost, free or low-cost medical services forthose in need, ethical principles, and maintaining patient privacy and confidentiality(Duggirala et al., 2008a, 2008b) (see Figure 1).

Previous studies in Turkey

A number of research studies on patient satisfaction have been carried out in public,university and private hospitals in Turkey (Tengilimoglu et al., 1999). These studiesshow that the quality of the public healthcare sector is quite low and inadequate.


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INFRASTRUCTURE (IN)

PERSONEL QUALITY (PQ)

-Doctor Care-Nursing Care-Paramedical and Support Stuff

-Quality ofCommunication

PROCESS OF CLINICAL CARE

(PCC)- Treatment Process- Outcome of Clinical Care

ADMINISTRATIVE PROCEDURES (AP)- Admission Procedures- Administrative Processer-Exit/Discharge

SAFETY INDICATORS (SI)

OVERALL EXPERIENCE OF MEDICAL CARE RECEIVED (OE)

SOCIAL RESPONSIBILITY

(SR)

SATISFACTION WITH OVERALL HOSPITAL CARE

-HOSPITAL PROCESS (HP) -MEDICAL CARE AND

TREATMENT (MT)-STAFF AND ADMINISTRATIVE

STAFF (SA) -HOSPITAL EXPENSES (EXP) -HOSPITAL ENVIRONMENT (HE)

Figure 1. Patient-perceived dimensions of TQS in healthcare

302 I. BAKAN ET AL.

Patients are dissatisfied with the level of service provided in public hospitals (Karaet al., 2003; Dursun and Cerci, 2004). Yagci and Duman (2006) found that publichospitals had the lowest values in service quality dimensions of overall satisfactionfollowed by university and private hospitals. The main reasons are factors such asovercrowding and the lack of adequate work force and equipment. Private hospitalsoffer an alternative to increase the satisfaction of patients in Turkey (Caha, 2007).


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According to Camgoz-Akdag and Zineldin (2010), the most important factoraffecting patients’ perception of cumulative satisfaction in Turkey is the quality ofthe hospital IN and interaction.

The study of public hospitals by Top et al. (2010) revealed the significant predic-tors of patient satisfaction as general quality of the hospital, levels of teamwork, gen-eral cleaning and orderliness of the hospital. Varinli and Cakir (2004), Zerenler andOgut (2007) and Demirel et al. (2009) found that recommendations by others wereone of the most important factors (Yesilada and Direktor, 2010).

Importance and aim of the study

Healthcare satisfaction is an important service quality indicator and a quality compo-nent in developing countries (Camgoz-Akdag and Zineldin, 2010). Having a stronghealthcare system in place will enable healthcare providers to deliver better qualityand value to patients (Radhika et al., 2007). Patients’ evaluation of healthcare qualityis important for making critical decisions about healthcare services (Gilbert et al.,1992) and for determining and improving weaker aspects of healthcare deliverysystems (Camgoz-Akdag and Zineldin, 2010). The quality of care and patientsatisfaction will improve with continuous monitoring of patients’ perceptions andimprovements on the basis of patient feedback (Taner and Antony, 2006).

Patients have numerous hospital choices. If they are not satisfied with one, they canreadily choose another provider. Thus, there is strong competition among hospitals. Asan example of successful reform in the healthcare sector, Turkey is selected as a casestudy. The research aims to determine the impact of the dimensions of TQS on patientsatisfaction in public and private hospitals in Turkey. After an extensive review of the lit-erature on service quality, critical dimensions of patient-perceived healthcare quality havebeen identified. The instrument developed by Duggirala et al. (2008a, 2008b) is used inthis study to measure the patient’s view of healthcare quality. The following hypothesesare proposed:

Hypothesis 1

The patient-perceived dimensions of TQS in healthcare explain a significant amountof variation in overall satisfaction with HP.

Hypothesis 2

The patient-perceived dimensions of TQS in healthcare explain a significant amountof variation in overall satisfaction with MT.

Hypothesis 3

The patient-perceived dimensions of TQS in healthcare explain a significant amountof variation in overall satisfaction with SA.

Hypothesis 4

The patient-perceived dimensions of TQS in healthcare explain a significant amountof variation in overall satisfaction with EXP.


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Hypothesis 5

The patient-perceived dimensions of TQS in healthcare explain a significant amountof variation in overall satisfaction with the HE.

Hypothesis 6

The patient-perceived dimensions of TQS in healthcare explain a significant amountof variation in overall satisfaction.

RESEARCH METHODOLOGY

To assess the proposed hypotheses and test the research model, we employed thesurvey method for data collection and Statistical Package for Social Sciences (SPSS;IBM, Armonk, NY) for the statistical analyses.For this study, hospital accessibility and time available for collecting sample data

were taken into consideration before determining the sample size. We collected datafrom in-patients who underwent treatment in the hospitals of Kahramanmaras,Turkey. Patients were interviewed in the hospitals just before discharge followingtreatment as well as after discharge. A total of around 200 respondents (100 eachin public and private hospitals) were obtained. The actual sample size in the studyis 200 patients. Because of issues of patient confidentiality and limited access tohospital administration, the study made use of a convenience sampling method togather responses from each hospital. The hospitals were selected on the basis of theiraccessibility and consent to patients participating in the survey.

Instruments (questionnaire). The research questionnaire was adapted from previousresearch by Duggirala et al. (2008a, 2008b). Our questionnaire contains a total of 99items, which were identified to be the most relevant attributes for hospitals. Thequestionnaire was translated into Turkish to provide better understanding, increasethe response rate and improve the quality of the data. Kahramanmaras was chosenas the region in which to collect the research data.The questionnaire consisted of two parts. The first part included demographic

questions. The second part consisted of Likert-scale questions that included attitudestatements asking respondents to state their level of agreement on a five-point scale(1 = strongly disagree, 2 = disagree, 3 = neither agree nor disagree, 4 = agree and5 = strongly agree). This format has been recommended for healthcare surveys(Elbeck, 1987; Steiber, 1989). Multiple items were used to assess reliability. Consis-tent with the literature, the scale items selected for the dependent variable were directmeasures of patients’ overall satisfaction with the services received from hospitals.

Analysis. The data were analyzed for the entire sample. Data analyses were per-formed with the SPSS by using techniques that included descriptive statistics, reliabil-ity, correlation analysis and linear regression analysis. Reliability refers to theinstrument’s ability to provide consistent results over recurrent use (Gatewood andField, 1990). Cronbach’s alpha coefficient has been widely used as a measure for


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reliability. All dimensions exceeded the acceptable threshold value of 0.70 suggestedby Hair et al. (1995). Furthermore, the relationship between dimensions of patient-perceived TQS in healthcare was analyzed by Pearson’s product moment correla-tion; almost all variables were correlated, and a statistically significant relationshipwas found between variables (Table 4).

Survey and reliability analysis. A total of 350 questionnaires were sent to the largestprivate and public hospitals in the city of Kahramanmaras. One survey briefexplained that the respondent should answer for a system of three hospitals. In orderto adjust for this misleading instruction, variables were combined for those hospitals.The net response rate of 57.1% (200 of 350) can be considered exceptional andprovides evidence of the extent to which hospitals are concerned with qualityservice. Reliability of the items measuring quality service practices was tested byinternal consistency. The impact of each item was evaluated on the basis of the reli-ability of the combined items designed to measure each quality service dimension.The reliability analysis for the scale generated a Cronbach alpha score of 0.87, whichis satisfactory (acceptable) (Nunnally, 1978) (see Table 2).

Demographic characteristics of survey respondents. The female to male ratio ofrespondents was 48.9% and 51.1%, respectively. There were 26.2% participantsyounger than 26 years, 25.8% between 26 and 30 years, 33.6% between 31 and45 years, and 14.4% older than 45 years. Regarding highest education level, 24%indicated primary school, 16.8% secondary school, 29.6% high school, 10.2%college and 10.7% faculty. When asked to specify their job status, 31.8% indicatedhousewife, 14.1% officer, 4% retired, 27.3% worker, 5.6% unemployed, 11.1%student and 6.1% other. Regarding frequency of hospital visits, 30.5% said rarely,38.6% occasionally and 6.1% often. Finally, 6.9% of participants indicated ahousehold income of less than 400 Turkish lira (TL), 24.9% of 400 to 800 TL,and 2.6% over 2001 TL (see Table 3).

Relation of service quality perceived by patients and satisfaction with overallhospital care. Correlations of the main variables, including factors generated, arepresented in Table 4. High inter-variable correlations are observed. All eight factorshave the expected 0.01 level of significant correlation with one another, as an

Table 2. Scaling of reliability test

Constructs Measurement items Cronbach’s alpha

Infrastructure I14–I24 0.91Personnel quality PQ25–PQ48 0.95Process of clinical care PCC49–PCC57 0.88Administrative procedures AP58–AP79 0.95Safety indicator SI80–SI82 0.72Overall experience of medical care received OE83–OE88 0.84Social responsibility SR-89–SR94 0.86Satisfaction with overall hospital care SOHC95–SOHC-99 0.87


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Table 3. Participants’ demographic characteristics

Frequency(f) Percentage

Frequency(f) Percentage

Gender Age (years)Female 92 48.9 Less than 26 51 26.2Male 96 51.1 26–30 50 25.8

Educational status 31–35 32 16.5Illiterate 13 6.6 36–40 23 11.9Primary school 47 24.0 41–45 10 5.2Secondary school 33 16.8 46–50 9 4.6High school 58 29.6 More than 51 19 9.8College 20 10.2 Job statusFaculty 21 10.7 Housewife 63 31.8Master’s degree 4 2.0 Officer 28 14.1

Monthly income Retired 8 4.0No regular income 63 33.3 Worker 54 27.3400 TL and less 13 6.9 Unemployed 11 5.6401–800 TL 47 24.9 Student 22 11.1801–1200 TL 29 15.3 Others 12 6.11201–1600 TL 20 10.6 Frequency of

visiting hospital1601–2000 TL 12 6.3 Rarely 60 30.52001 and more 5 2.6 Occasionally 76 38.6

Sometimes 44 22.3Often 12 6.1Always 5 2.5

306 I. BAKAN ET AL.

orthogonal rotation in principal component analysis creates this relationship(Hatcher, 1994). The correlations of the seven TQS dimensions with satisfactionoverall hospital care are also shown. All correlations were statistically significant.This study confirms that SOHC is positively correlated with AP (Table 4).

Regression analysis. The theoretical model was tested using regression analysis,developing a composite measure for the dependent and independent variables by tak-ing an average of different items on a scale. This involves the assumption that all

Table 4. Bivariate correlation among dimensions of patient-perceived total quality service inhealthcare (n= 200)

Factor Satisfaction with overall hospital care

Infrastructure 0.63*Personnel quality 0.71*Process of clinical care 0.72*Administrative procedures 0.82*Safety indicator 0.72*Overall experience of medical care received 0.81*Social responsibility 0.80*

Note:*Significant at the 0.01 level (two tailed).


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items contribute equally to the construct. For a confirmatory study of this nature, es-pecially considering that the scales were previously untested in the country of study,these results are important.

The dependent variable is measured by asking respondents to rate their SOHCand the patient-perceived total quality of services rendered in the hospitals, using afive-point scale (1 = strongly disagree to 5 = strongly agree). In this direction, thedependent variable is metric (Braunsberger and Gates, 2002). The directions of therelationships were hypothesized, and a linear regression analysis was used to analyzethe hypotheses (Hair et al., 1995; Braunsberger and Gates, 2002).

The regression model was significant with an overall F value of 19 865 (p< 0.01)and explained 41.8% of the variation in the dependent variable as indicated by theadjusted R2 value. All six independent variables are not significant in explainingsatisfaction with HP except for overall experience of medical care received (Table 5).The overall experience of medical care received dimension had the greatest impacton overall satisfaction involving HP as indicated by the standardized beta (b) valueof 0.34. Thus, hypothesis H1 is supported.

Linear regression analysis reveals that the model significantly predicted a sizableproportion of variance in overall satisfaction with MT, producing an overall F valueof 28.082 (p< 0.01). The R2 for the model is 0.52, and the adjusted R2 is 0.50. Table 6displays the standard error, standardized regression coefficients and t statistics foreach variable.

Table 5. Regression results (dependent variable: hospital process)

Independent variables Standard error b t Sig

(Constant) 0.332 1.000 0.319Infrastructure 0.126 �0.034 �0.384 0.701Personnel quality 0.180 0.107 0.843 0.401Processes of clinical care 0.170 0.035 0.287 0.775Administrative processes 0.197 0.138 0.996 0.321Safety indicators 0.116 0.038 0.381 0.704Overall experience of medical care received 0.160 0.336 2.760 0.006Social responsibility 0.136 0.094 0.877 0.382

R2 = 0.440, Adjust. R2 = 0.418, F= 19.865, Sig = 0.000.

Table 6. Regression results (dependent variable: medical care and treatment)


(Constant) 0.315 0.079 0.937Infrastructure 0.120 �0.011 �0.139 0.890Personnel quality 0.170 0.196 1.703 0.090Processes of clinical care 0.158 �0.169 �1.545 0.124Administrative processes 0.187 0.109 0.863 0.389Safety indicators 0.106 0.187 2.083 0.039Overall experience of medical care received 0.153 0.157 1.387 0.167Social responsibility 0.130 0.316 3.195 0.002

R2 = 0.522, Adjust. R2 = 0.503, F= 28.082, Sig = 0.000.


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308 I. BAKAN ET AL.

Patients indicated positive overall satisfaction with MT when they were moresatisfied with SR (b= 0.31, p< 0.01), PQ (b= 0.19, p< 0.10) and SI (b= 0.18,p< 0.05). However, IN, processes of clinical care, AP and overall experience ofmedical care received were not found to be significant predictors of overall satisfac-tion with MT. The results for the regression model (based on Table 6) indicatethat the three dimensions differed significantly from each other, except for IN(t=�0.139, p> 0.1), AP (t= 0.863, p> 0.1) and overall experience of medical carereceived (t= 1.387, p> 0.1). There is a marginal relationship among processes ofclinical care (t=�1.545, p> 0.01). Thus, the second hypothesis H2 is supported.Another regression test was conducted to determine the effect of the dimensions of

TQS on SA. The regression results show that SR and overall experience of medical carereceived contribute significantly, with an overall F value of 31.115 (p< 0.01), and pre-dict 53.3% of the variance in overall satisfaction with SA. According to the regressioncoefficients, overall experience of medical care received (b=0.27, p< 0.01) and SR(b=0.25, p< 0.05) have significant effects on overall satisfaction with SA. Therefore,these dimensions predict a significant change in SA. The results also show that there isa significant relationship between SR (t=2.704, p=0.008), overall experience ofmedical care received (t=2.482, p=0.014) and SA. Thus, hypothesis H3 is supported.Table 8 presents all regression results regarding the effect of the dimensions of

TQS on satisfaction with the amount of EXP. The linear regression model is signif-icant with an overall F value of 23.015 (p< 0.01) and explained 46% of the variationin the dependent variable as indicated by the adjusted R2 value. All four independentvariables are not significant in explaining overall satisfaction with EXP except forSR, AP and SI (Table 8). AP (b= 0.33, p< 0.05), SR (b= 0.29, p< 0.01) and SI(b= 0.16, p< 0.10) have a significant positive relationship with overall satisfactionwith EXP. Thus, hypothesis H4 is supported.On the item level, there are significant differences between the perceptions of

patients (Table 8), except for items related to IN (t= 0.342, p= 0.733), overall expe-rience of medical care received (t=�0.373, p = 0.710), processes of clinical care(t= 0.491, p = 0.624) and PQ (t=�0.766, p = 0.445).The effect of the dimensions of TQS on the overall comfort of stay with respect to

HE was determined using linear regression analysis (Table 9). The results show thatpatient-perceived dimensions contribute significantly with an overall F of value22.612 (p< 0.01) and predict 45% of the variation in the level of overall comfort ofstay with respect to HE. Therefore, these dimensions predict a significant changein HE. The results also show that there is a significant relationship betweenIN (b= 0.285, p< 0.01), administrative process (b= 0.263, p< 0.05) and PQ(b=�0.227, p< 0.01) with respect to HE. The result shows no significant relationshipbetween the processes of clinical care (p=0.295), SI (p=0.696), overall experience ofmedical care received (p= 0.304), SR (p=0.108) and level of overall comfort of staywith respect to HE. Of all seven dimensions, IN has the strongest value (b= 0.285),followed by AP (b=0.263) and PQ (b=�0.227). Thus, hypothesis H5 is supported.The previous regression models (Tables 5–9) were developed to investigate the

effects of TQS on separate dimensions of SOHC. A new regression model was de-veloped (Table 10) to investigate the effect of patient-perceived dimensions ofTQS on satisfaction SOHC. The estimated regression model is statistically


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Table 7. Regression results (dependent variable: staff and administrative staff)


(Constant) 0.286 0.092 0.927Infrastructure 0.110 �0.052 �0.652 0.515Personnel quality 0.154 0.096 0.852 0.395Processes of clinical care 0.145 0.134 1.248 0.214Administrative processes 0.171 0.191 1.545 0.124Safety indicators 0.097 �0.118 �1.348 0.179Overall experience of medical care received 0.139 0.270 2.482 0.014Social responsibility 0.118 0.259 2.704 0.008

R2 = 0.550, Adjust. R2 = 0.533, F= 31.115, Sig = 0.000.

Table 8. Regression results (dependent variable: hospital expenses)


(Constant) 0.321 0.823 0.411Infrastructure 0.122 0.029 0.342 0.733Personnel quality 0.174 �0.094 �0.766 0.445Processes of clinical care 0.160 0.057 0.491 0.624Administrative processes 0.190 0.330 2.471 0.014Safety indicators 0.108 0.167 1.761 0.080Overall experience of medical care received 0.158 �0.045 �0.373 0.710Social responsibility 0.134 0.298 2.813 0.005

R2 = 0.550, Adjust. R2 = 0.533, F= 31.115, Sig = 0.000.

Table 9. Regression results (dependent variable: hospital environment)


(Constant) 0.355 �1.356 0.177Infrastructure 0.137 0.285 3.281 0.001Personnel quality 0.193 �0.227 �1.862 0.064Processes of clinical care 0.179 0.122 1.051 0.295Administrative processes 0.208 0.263 2.000 0.047Safety indicators 0.120 0.037 0.392 0.696Overall experience of medical care received 0.171 0.121 1.032 0.304Social responsibility 0.143 0.164 1.613 0.108

R2 = 0.468, Adjust. R2 = 0.447, F= 22.612, Sig = 0.000.


significant as indicated by the overall F value of 78.448 (p< 0.01). Additionally,74% of the variance for the dependent variable is explained as indicated by the ad-justed R2 value.

Four out of seven dimensions of TQS were not significant in explaining SOHC(Table 10). SR (b= 0.27, p< 0.01) and AP (b= 0.27, p< 0.01) have the greatest im-pact on SOHC. Overall experience of medical care received (b= 0.22, p< 0.01) wassignificant but less important in explaining SOHC.


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Table 10. Regression results (dependent variable: satisfaction with overall hospital care)


(Constant) 0.176 0.293 0.770Infrastructure 0.067 0.068 1.169 0.244Personnel quality 0.095 0.008 0.097 0.923Processes of clinical care 0.088 0.034 0.427 0.670Administrative processes 0.103 0.272 3.041 0.003Safety indicators 0.059 0.080 1.245 0.215Overall experience of medical care received 0.085 0.221 2.769 0.006Social responsibility 0.070 0.274 3.947 0.000

R2 = 0.750, Adjust. R2 = 0.740, F = 78.448, Sig = 0.000.

310 I. BAKAN ET AL.

In the linear regression model, the direct link between SR and SOHC is significant(t= 3.947, p< 0.01). The other two quality service dimensions, overall experience ofmedical care received and AP as a whole, also have direct positive effects on SOHC.Thus, hypothesis H6 is supported. However, there is no significant relationshipbetween PQ (t= 0.097, p= 0.923), processes of clinical care (t= 0.427, p = 0.670),IN (t= 1.169, p = 0.244), SI (t= 1.245, p = 0.215) and SOHC.

CONCLUSIONS

Customers have very high expectations, especially when it comes to medicaltreatment. Patients expect to receive satisfactory healthcare services from hospitals.Satisfactory healthcare service involves a range of factors reflecting patients’ expec-tations, values and experiences (Baker and Streatfield, 1995). The dimensions of TQSin a healthcare facility play pivotal roles in determining patient satisfaction with thequality of care, and because illness reduces the physical ability of the patient, thisfurther obliges service providers to offer the best support. Duggirala et al. (2008a,2008b) identified dimensions of patient-perceived TQS in the healthcare sector.These dimensions present relevant guidelines for hospital managers to help themunderstand what patients take into consideration when evaluating the qualitydelivered by service providers. The various dimensions of quality service used in thisstudy can help to improve hospital service quality as perceived by patients.In this study, the dimensions of TQS byDuggirala et al. (2008a, 2008b) were used to

determine the impact of the dimensions of patient-perceived TQS on patientsatisfaction within the hospitals in Turkey. We have examined how IN, PQ, PCC,AP, SI, overall experience of medical care received (OE) and SR predict patientsatisfaction with quality of hospital services. The effects of the dimensions of TQS inhealthcare on patient satisfaction were analyzed in two phases. First, the effect ofTQS on individual factors of patient satisfaction—namely HP, MT, SA, EXP andHE—were analyzed. Then the effect of TQS on patient SOHC was analyzed. Theresults indicate that the dimensions of TQS explain a significant amount of the variancein patient satisfaction with the HP (41.8%), MT (50.3%), medical and administrativestaff (53.3%), EXP (45.6%) and the HE (44.7%). Among other findings are as follows:


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• Overall experience of medical care received had a significant effect on patients’satisfaction with HPs.

• Personal quality, SI and SR significantly affect patients’ satisfaction with MT.• Overall experience of medical care received and SR significantly affect patients’satisfaction with hospital staff.

• AP, SI and SR were the highest predictors of patients’ satisfaction with EXP.• IN, personal quality and administrative process significantly affect the patients’satisfaction with HE.

The major finding of this study is that the dimensions of TQS significantly affectpatients’ SOHC (explaining 74.0% of the variance). In this study, SR emerged as thehighest predictor and core dimension of patients’ satisfaction, followed by AP andoverall experience of medical care received.

We conclude that the findings from this survey are relevant and generalizable toTurkish healthcare services. We recommend that the healthcare sector acknowledgesthat, distinct from the medical treatment received, patients value SR and AP. In otherwords, administration procedures and SR of hospitals are principal and significantpredictors of patient satisfaction. Therefore, patients’ perceptions of administrativeprocess, SR, and overall experience of medical care received are likely to improvetheir SOHC. As the healthcare industry becomes even more competitive, hospitaladministrators should recognize that patients attach importance to the soft aspectsof the healthcare service such as SI, SR and AP.

The majority of healthcare administrators face pressure to manage costs andprovide better clinical treatment. However, the findings of this study show thathealthcare administrators should also be aware of the importance of safety, SR andAP to improve patients’ SOHC. Thus, the link between TQS culture and patient sat-isfaction is becoming clear in the healthcare sector. One of the most important prin-ciples is to ensure that medical treatment provided by the staff meets patients’ socialexpectations. To increase patients’ satisfaction with hospital care, the processes ofadmission, stay and discharge should be improved. Efficient administration makespatients more satisfied. Hospital administrators should also provide safe healthcareservice, from admission to support service for patients. As SR, healthcare organiza-tions must provide high clinical quality, cost-effective patient care, and good and fairservice as well as implement measures to reduce energy consumption and organizeactivities in the fields of health education and research.

ACKNOWLEDGEMENTS

The authors have no competing interests.

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The impact of total quality service (TQS) on healthcare and patient satisfaction: An empirical study of Turkish private and public hospitals