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Examining the Impact of Service Quality on Patients’ Satisfaction: A Study of Selected Private Hospitals in Amman City

The health care industry has recently experienced unprecedented challenges because of intensified competition. In order to create competitive advantage, health care providers stresses on the efficacy and effectiveness of health service outcomes by taking i nto account patients’ concerns and interests. Service quality and patient satisfaction remain critical issues for health care providers. Patient satisfaction leads to favorable results, such as higher rates of patient retention, positive word of mouth and higher profits for health care providers. It also influences the rate of patient compliance with physician advice and requests. Thus, patient satisfaction assessment has become an integral part of health care organizations’ strategic processes. This study attempts to identify the service quality factors that influence patient satisfaction in selected private hospitals with the help of field survey conducted in the year 2019. Non-probability judgment sampling method was used to obtain information regarding patients’ perceptions towards service quality dimensions. Multiple linear regression was used to identify the service quality factors that influence patients’ satisfaction. The results highlighted significant impact of service quality dimensions on patient s’ satisfaction in selected hospitals in Amman city


Introduction
Service quality has been perhaps the most explored topic in services marketing. The concept of service quality has aroused considerable interest and debate in the literature because of the difficulties in both defining it and measuring it (Andaleeb, 2001). Quality does not have exact meaning. Quality is particularly difficult to describe, explain, calculate and consequently manage in services. It means different things to different people as a producer's perception of quality might be different from a customer. Quality is resolute by inexact individual factors such as perceptions, expectations and experiences of customers (Khan, 2016). Service quality can be defined as the extent to which a service meets customers' needs or expectations. Service quality is the delivery of excellent or superior service relative to customer expectation (Parasuraman, Zeitham and Berry, 1988).
Service quality is an assessment of how well a delivered service conforms to the client's expectations. Service business operators often assess the service quality provided to their customers in order to improve their service, to quickly identify problems, and to better assess client satisfaction. Continuous attempts have been made by all service organizations to deliver quality service to their customers and therefore they use considerable time in measuring service quality. Service organizations like other manufacturing organizations are also focusing to deliver the services that meet customer needs in order to make their customer happy. Therefore, understanding, measuring and improving quality is an alarming challenge for all organizations since they compete to great degree on the basis of service. The provision of high service quality enables a company to be competitive and, contributes to their productivity and profitability. It increases cash flow and shareholder value, gives businesses a competitive advantage, enhances customer satisfaction, and enhances customer loyalty.

Service Quality in Health Care
Health care services have a distinct position among other services due to highly involving and risky nature of services and the general lack of adequate knowledge possessed by consumers (Sharmila & Krishnan, 2013). The concern of people regarding their health has increased to a greater extent. The changing lifestyle of people has affected their health in a critical way. Stressful work environment, commitments, high expectations, etc. have resulted in health disorder (Rahman and Kutubi, 2013). Health care industry additionally turned into an extremely aggressive and rapidly developing industry around the globe. The greatest test looked by health care services markets is how to characterize and measure the service quality. It makes measuring customer satisfaction and service quality in health care industry more complex (Sangwan, 2012). Patient perception of service quality is a key determinant of a health care organization's success due to its primary role in achieving patient satisfaction and hospital profitability. The provision of high service quality enables a hospital to be competitive and gets a competitive advantage, enhances patients' satisfaction, and enhances patients' loyalty (Badri, Attia, and Ustadi, 2009). Patient satisfaction leads to favorable results, such as higher rates of patient retention, positive word of mouth and higher profits for health care providers. It also influences the rate of patient compliance with physician advice and requests (Kumar, 2014). Thus, patient satisfaction assessment has become an integral part of health care organizations' strategic processes. The present research used twenty four statements (under four major heads) which were developed after a comprehensive literature review to measure the service quality attributes. A detailed discussion of all these variables is in the methodology part. Shabbir, Kaufmann, and Shehzad (2010) examined the impact of service quality provided in Pakistani hospitals (Public and Private) on patient satisfaction with the help of a field survey conducted in Islamabad. The sample size of the study was 245 patients. Correlation and regression analysis were used to find out the impact of service quality, word of mouth and trust on patient's satisfaction. It was revealed that Pakistani patient's perceived public hospitals to be superior in the quality of their service. The findings highlighted that services quality, trust was positively and significantly correlated with patient satisfaction but word of mouth was not significantly correlated with patient satisfaction. Besides, trust had the second greatest impact on patient satisfaction and word of mouth has the least impact on patient satisfaction. Moreover, it was found that the patient satisfaction was higher among postgraduates and lower income respondents. Irfan, Ijaz, and Farooq (2012) investigated the quality of services delivered to patients by public hospitals in Pakistan. A questionnaire was developed based on modified 'SERVQUAL' on the sample of 369 patients who were availing services from the public hospitals in Lahore. Data was analyzed by structural equation modeling technique (SEM) and results highlighted that public hospitals were not making visible efforts to deliver quality of services to their patients and are not making any visible efforts to meet patient's needs and wants. Ramez (2012) examined patients' perception towards service quality provided in the hospitals of Bahrain on a sample of 235 patients. The author used SERVPERF scale instead of SERVQUAL scale. The results highlighted that SERVPERF dimensions explains 45.9% of the variation in the overall service quality. Positive and significant relationships were found between overall service quality (OSQ), patients' satisfaction (SAT), and their behavior intention (BI). Khalid, Ahmed, and Ahmad, (2013) conducted a study on a sample of 400 drawn from the University of Gujarat by using structured questionnaires. The relationships were then assessed by using Structural Equation Modeling (SEM).The result revealed that the social factors and personal factors have very important contribution in consumer decision-making. This study also concludes that as WoM is a very influential tool therefore, the healthcare practitioners should use it to enhance and promote their personal image. Akbulut (2016) make a comparative study of the factors affecting service quality on the Patient Satisfaction from patient's perspectives in Jordan. The sample consisted of 200 respondents divided between King Hussein Medical Centre Hospital and Al-Bashir Hospital. The results revealed that statistically significant differences at (α ≤ 0.05) level in patient's satisfaction towards service quality across gender, age, and educational level in the two hospitals. The study recommended that the two hospitals have to set up criteria for their quality provided for patients, and provide sufficient number of qualifies medical staff to deal with the increased number of patients.

Research Gap
The review of literature highlights that numerous studies have been carried out on service quality and patients' satisfaction. But, there exists a clear empirical gap with respect of the influences of service quality on patients' satisfaction in Jordan. This empirical gap becomes a problem to all private hospitals to know whether or not their services are successful among the patients and the changes that should be incorporated in their services. Indeed, there is a need to evaluate what extend the improvements in the services by hospitals should be made.

Objectives of the Study
1. To explicate the concept of service quality. 2. To examine the impact of service quality dimensions on patient's satisfaction.

Hypotheses of the Study
H01: There is no significant impact of service quality on patient's satisfaction.
Ha1: There is a significant impact of service quality on patient's satisfaction.

Research Methodology
This study identified and obtained information on the patient (outpatient) satisfaction with the service quality dimensions of five private hospitals in the capital city of Jordan.

Population and Sampling Method
The population of the study includes all patients admitted in selected hospitals of Jordan. Nonprobability judgment sampling plan was implemented in the study because some judgment on the part of the researcher was necessary in order to select the right respondents.

Data Collection Method
The study used both primary and secondary data. Secondary information was gathered from different sources such as books, magazines, journals, newspapers and online databases via internet etc. Moreover, a self-administered questionnaire was used for collecting primary data. It is considered as a superior mode for minimizing bias and improving response rates. The questionnaire consists of six variables wherein five variables were independent and one variable i.e. patient's satisfaction was dependent. Figure 1 highlights the framework of the present research. To measure the service quality attributes, the study used twenty four items. Treatment quality, behavioral aspects and financial aspects were measured by four statements and structural aspects by five statements. However, Patient satisfaction was measured through four items. The effects of independent variables on the dependable variable were assessed by the 5-point Likert attitude scale. The questionnaire was pretested two times.

Distribution of Questionnaires and Duration of field survey
A total of 500 questionnaires after judgement sampling were distributed to the patients admitted in five different hospitals, who met the sampling requirements. A total of 375 questionnaires were returned wherein 364 questionnaires were considered valid for data analysis. Table 1 shows the questionnaires distributed, rejected, and accepted. The data collection period was four months from September,2019 to December,2019. Source: Table 1 Analysis of Data Data collected from primary as well as secondary sources was analysed and interpreted and on the basis of which conclusions were drawn. For analyzing the data, multiple linear regression analysis was been used and hypotheses were tested at confidence level of 95%. This technique was widely used in prior empirical studies namely Irfan, Ijaz, and Farooq (2012)

Reliability Analysis
Cronbach alpha which is the most used test of reliability was applied to examine the reliability of the data. Cronbach alpha of all study variables is ranging from 0.7 to 0.9 and hence the data is reliable. Table 7 in Appendix highlights the reliability of all statements of the study.  Multiple linear regression has been applied to examine the impact of service quality dimensions on patients' satisfaction. Table 4 highlights the values of Pearson correlation, R square, adjusted R square, standard error, and Durbin Watson. The value of adjusted R square is 0.686 which means 68.6 percent variation in patients' satisfaction is explained by service quality dimensions and rest of the variation (1-R 2 ) is an unexplained variation in patients' satisfaction due to variables that has not been considered in this model.  Table 5 shows the results of ANOVA. It shows the model significance. The overall model is significant because the p value is 0.000 (P<0.05). Hence, the model construct is validated.  Table 6 shows the results of regression coefficients, t value, significant value, and collinearity statistics. An unstandardized beta coefficient gives a measure of contribution of each variable to the model. A larger value indicates that a unit change in the predictor variable has a larger impact on the criterion variable. Firstly, the value of unstandardized beta coefficient on X1 is 0.525 which is an indication of positive impact of Treatment quality on patients' satisfaction. It shows that one unit change in it will bring 0.525 unit change in patients' satisfaction. The significant value corresponding to it is 0.000 which is less than 0.05. It shows that there is a significant impact of treatment quality on patients' satisfaction. Secondly, the values of unstandardized beta coefficients on X2, X3, and X4, are positive and statistically significant at 95% confidence level (P<0.05). Therefore, the null hypothesis is rejected and it can be said that there is a significant impact of service quality dimensions on patients' satisfaction in selected hospitals in Amman city.

Conclusion
Health care services have a distinct position among other services due to highly risky nature of services. The concern of people regarding their health has increased to a greater extent due to changing lifestyle of people stressful work environment; commitments, high expectations. Health care is rapidly developing industry around the globe. The greatest test looked by health care services markets is how to characterize and measure the service quality. It makes measuring customer satisfaction and service quality in health care industry more complex. Taking this into cognizance, this research has been conducted to examine the impact of service quality dimensions on patient's satisfaction in five private hospitals in the capital city of Jordan. A self-administered questionnaire was used for collecting primary data. The questionnaire consists of twenty four statements under six variables wherein five variables were independent and one variable i.e. patient's satisfaction was dependent. A total of 500 questionnaires were distributed to the patients admitted in five different hospitals, who met the sampling requirements. A total of 375 questionnaires were returned wherein 364 questionnaires were considered valid for data analysis. The data collection period was four months from September, 2019 to December,2019. For analyzing the data, multiple linear regression analysis was used and hypotheses were tested at confidence level of 95%. Cronbach alpha was applied before testing hypotheses to examine the data reliability and data was proved reliable. Thereafter, regression was run in SPSS at confidence level of 95%. The results highlighted that the value of adjusted R square was 0.686 which means 68.6 percent variation in patients' satisfaction was explained by service quality dimensions and rest of the variation (1-R 2 ) was an unexplained variation. Furthermore, the regression coefficients on all variables under study treatment quality, behavioral aspects, structural aspects, and financial aspect were positive and statistically significant at 95%confidence level. Therefore, the null hypothesis is rejected and it can be said that there is a significant impact of service quality dimensions on patients' satisfaction in selected hospitals in Amman city.

Limitations of this Study and Directions for Future Research
The present study includes only limited dimensions of service quality like Treatment quality, behavioral aspects, structural aspects, and financial aspects. It is conducted on sample size of 364 patients taken from Amman city of Jordan. Therefore, the results cannot be generalized to other cities of Jordan. Hence, in future a research might be conducted by taking more cities and more private hospitals in Jordan. A comparative study between public and private hospitals of Jordan might be conducted to examine the differences in patients' satisfaction towards service quality. It is quantitative research that only testifies the relationships between selected variables.