Abstracts

This is an article about the theoretical model for assessing quality in health services proposed by Parasuraman, Zheitaml and Berry, in order to measure the degree of satisfaction of users. This model is based on the analysis of expectations and perceptions of users of health services, by means of five dimensions: tangibility, reliability, responsiveness, assurance and empathy. From the difference between what is expected by the user and the service offered, gaps or shortcomings are derived that may be the main obstacle for users to perceive the provision of such services with quality. It was observed that the use of the psychometric scale called Service Quality (SERVQUAL) in some studies about satisfaction, obtained very favorable results in the institutions in which it was employed. The analysis revealed the need to improve the existing models of evaluation, as well as the importance of measuring user satisfaction in health institutions.

Calidad de la atención de salud; Evaluación de Servicios de Salud; Satisfacción del paciente; Satisfacción de los consumidores

Artículo teórico sobre el modelo de evaluación de la calidad en los servicios de salud, propuesto por Parasuraman, Berry y Zheitaml con el fin de medir el grado de satisfacción de los usuarios. Tal modelo está basado en el análisis de las expectativas y percepciones de los usuarios de los servicios de salud, y mide cinco dimensiones: la confiabilidad, la sensibilidad, la intangibilidad, la garantía y la empatía. De la diferencia entre lo que el usuario espera y el servicio ofrece, derivan las lagunas, o vacíos, que pueden ser el principal obstáculo para que los usuarios perciban la prestación de esos servicios con calidad. Se observó que la utilización de la escala psicométrica, llamada Service Qualiy (SERVQUAL), utilizada en algunos estudios de satisfacción, obtuvo resultados bastante favorables en las instituciones en que fue utilizado. Se evidenció la necesidad de mejorar los modelos de evaluación existentes, así como la importancia de medir la satisfacción de los usuarios en las instituciones de salud.

Qualidade da assistência à saúde; Avaliação de Serviços de Saúde; Satisfação do paciente; Satisfação dos consumidores

Trata-se de um artigo teórico acerca do modelo de avaliação de qualidade em serviços de saúde proposto por Parasuraman, Zheitaml e Berry, a fim de mensurar o grau de satisfação de usuários. Tal modelo baseia-se na análise de expectativas e percepções de usuários de serviços de saúde, por meio de cinco dimensões: tangibilidade, confiabilidade, responsividade, garantia e empatia. Da diferença entre o que é esperado pelo usuário e o serviço oferecido derivam os gaps, ou lacunas, que podem ser o principal obstáculo para que os usuários percebam a prestação desses serviços com qualidade. Observou-se que a utilização da escala psicométrica denominada Service Quality (SERVQUAL) , em alguns estudos sobre satisfação, obteve resultados bastante favoráveis nas instituições em que foi empregado. Evidenciou-se a necessidade de aprimorar os modelos de avaliação existentes, bem como a importância de medir a satisfação dos usuários nas instituições de saúde.

Introduction

Quality models emerged in the late 1970s, as a result of numerous studies proposing
concepts, operationalizations and systematization for quality services. Already the
subjectivity present in the perception of quality is being incorporated through
different approaches and their consequences.

The first essays on the topic of quality in service suggested starting from
comparisons between what users considered that they should be offered by the
provider and what he actually offered(11. Zeithaml V, Parasuraman A. Service quality. Cambridge: Marketing
Science Institute; 1990.). In this direction, quality service can be considered the ratio
of the level of service effectiveness and expectations of the user. Thus, to promote
quality service means to meet the needs and expectations of a user in an effective
manner(11. Zeithaml V, Parasuraman A. Service quality. Cambridge: Marketing
Science Institute; 1990.).

To evaluate a service is more complex than to evaluate a product, because the product
is tangible and its defects can be detected, its functioning assessed and its
durability compared. Conversely, service is first purchased and then it is produced
and consumed simultaneously, and then the possible nonconformities are produced and
experienced, characterizing their inseparability(22. Cruz WBS, Melleiro MM. Assessment levels of the user’s
satisfaction in a private hospital. Rev Esc Enferm USP [Internet]. 2010 [cited
2012 Sept 17];44(1):147-53. Available from:
http://www.scielo.br/pdf/reeusp/v44n1/en_a21v44n1.pdf
http://www.scielo.br/pdf/reeusp/v44n1/en…
).

Services are intangible and heterogeneous, at the same time being judged by the
performance and the experience of those who use them, with the possibility of
interpretation and different judgments, according to the provider and the user in
question. Besides the intangibility, services present three other characteristics
that affect program development: inseparability, variability and
perishability(33. Kloter P, Keller KL. Administração de marketing. São Paulo:
Pearson Prentice Hall; 2006. ).

The intangibility is characterized by the activities which cannot be seen, felt,
heard or proven before they are acquired. The inseparability translates to the
simultaneity in which services are produced and consumed. The professionals
responsible for providing the service are part of it and interaction with users is a
special characteristic of services. The variability concerns to whom, where and when
services are provided. The perishability reinforces that services cannot be stored
in advance, so it is necessary that strategies are established for the balance
between existing demand and provision of services(33. Kloter P, Keller KL. Administração de marketing. São Paulo:
Pearson Prentice Hall; 2006. ).

The objective of this study was to reflect on the assessment model of service quality
of Parasuraman, Zheitaml and Berry, and to demonstrate its applicability in the
evaluation of health services, in order to measure the degree of user
satisfaction.

The evaluation of the model of service quality of Parasuraman, Zheitaml and
Berry

In order to understand how users perceived and assessed the quality of services, a
study was developed in 1985 involving twelve focus groups, three in each of the four
different services investigated – retail banking, credit cards, securities
brokerage, and repairs and maintenance. Based on common perceptions among the
groups, the authors formally defined service quality as the degree and type of
discrepancy between the perceptions and expectations of users, suggesting that they
all, in general, employed similar aspects of service by which quality could be
assessed(44. Parasuraman A, Zheitmal VA, Berry LL. SERVQUAL: a conceptual
model of service quality and its implications for future research. J Mark.
1985;49(1):41-50.).

The results obtained from these focus groups confirmed that users were influenced by
the dimensions of the process and not only by the results of the evaluation of
service quality. In this study, the pattern of responses revealed ten evaluative
criteria by which the user can evaluate, regardless of the service investigated,
namely: tangibility: the physical appearance of the facilities,
equipment, framework for employees and normative materials;
reliability: ability to perform the promised service dependably and
accurately; responsiveness: the ability to help users promptly;
competence: appropriation of the abilities and knowledge required
to perform services; cordiality: politeness, respect, consideration and
friendliness of the employees; credibility: trust, truth and honesty;
safety: absence of danger, risk or doubt; accessibility: proximity
and empathic contact; communication: keeping users informed in
appropriate language; and, comprehension: endeavoring to understand the
user and his needs.

By submitting the results to statistical analysis to determine the interrelationships
between these dimensions, three of them remained intact: tangibility, reliability
and responsiveness. The seven remaining dimensions were included in two others:
assurance and empathy(44. Parasuraman A, Zheitmal VA, Berry LL. SERVQUAL: a conceptual
model of service quality and its implications for future research. J Mark.
1985;49(1):41-50.) . The
analysis of these five dimensions demonstrated that users were using them as
criteria for judging the quality of service. The dimensions are not mutually
exclusive, yet provide an important framework for understanding the expectations of
users, and issues that delineate the service from the point of view of those who
will judge it(11. Zeithaml V, Parasuraman A. Service quality. Cambridge: Marketing
Science Institute; 1990.) .

After this refinement, the following definitions were used:

√Tangibility: concerns the physical facilities, equipment,
personnel and materials that can be perceived by the five human senses;

√Reliability: translated into the ability of the supplier to
execute the service in a safe and efficient manner. It depicts the consistent
performance, free of non-compliance, in which the user can trust. The supplier must
comply with what was promised, without the need for rework.

√Responsiveness: refers to the availability of the provider to
attend voluntarily to users, providing a service in an attentive manner, with
precision and speed of response. It concerns the availability of employees of the
institution to assist users and provide the service promptly;

√Assurance: it is identified as the courtesy, knowledge of
employees and their ability to convey trust;

√Empathy: related to whether the organization cares for the user
and assists him in an individualized manner, referring to the ability to demonstrate
interest and personal attention. Empathy includes accessibility, sensitivity and
effort in understanding the needs of users.

Chart 1 presents a comparison between the
original model and the restructured model of the quality dimensions.

Thumbnail

Chart 1 – Original model compared to the restructured model of
the fi ve dimensions of Parasuraman, Zeithaml & Berry

Investigations have confirmed that reliability is the most important dimension, and
tangibility is less relevant to the quality of service from the perception of the
user(44. Parasuraman A, Zheitmal VA, Berry LL. SERVQUAL: a conceptual
model of service quality and its implications for future research. J Mark.
1985;49(1):41-50.). In view of this,
some dimensions may be more accentuated than others, depending on the type of
service provided.

The result of the analysis as a whole verified that there is a set of key
discrepancies or gaps, consisting of the differences between users’ expectations and
what is actually offered. These gaps can be the main obstacle for users to perceive
the provision of such services as high-quality(55. Parasuraman A, Berry LL, Zheitmal VA. Refinement and
reassessement of the SERVQUAL dimensions. J Retailing.
1991;67(4):420-50.).

When perceptions are higher than expectations, the gaps are narrow and there are high
levels of satisfaction, considering the excellent service and quality. Five
corporate gaps are emphasized that are usually encountered between the expectations
and perceptions of users(55. Parasuraman A, Berry LL, Zheitmal VA. Refinement and
reassessement of the SERVQUAL dimensions. J Retailing.
1991;67(4):420-50.-66. Marshall G, Murdoch I. Service quality in consulting marketing
engineers. Int J Constr Mark. 2001;3(1):41-9. ). These are:

√ Gap 1: refers to consumer expectations and the perception of management
towards them. The service providers do not always understand what requirements
connote excellence of quality for consumers;

√ Gap 2: is the specification of the quality of the services defined by the
translation of perceptions that management has of the expectations of users. This
discrepancy is due to the lack of specification of the offer, adjusted to the wishes
of the consumers;

√ Gap 3: relates to the actual performance of service in the face of previously
established specifications;

√ Gap 4: relates to the service actually provided and external communications
(service specifications announced in the media or other communication channels);

√ Gap 5: This was established as a function of the four previous shortcomings,
namely Gap 5 = f [gap 1, gap 2, gap 3, gap 4].

In summary, one can consider the following definitions for the
gaps:

Gap 1– Not knowing what users want to receive;

Gap 2– Not selecting the right design of the service and established
standards;

Gap 3– Not delivering the standard service;

Gap 4– Not marrying performance with promises;

Gap 5– Established according to the four previous gaps;

Gap 5 = f [gap 1, gap 2, gap 3, gap 4].

Figure 1 illustrates the shortcomings or
gaps in service quality.

Figura 1
– GAP Model of Service Quality

To perform the measurement of user satisfaction it is necessary to focus on the
expectations and perceptions that the user has about the offered services(55. Parasuraman A, Berry LL, Zheitmal VA. Refinement and
reassessement of the SERVQUAL dimensions. J Retailing.
1991;67(4):420-50.). The concept of perceived quality,
used both for services as well as for products, has been understood as superiority
or excellence, while the concept of service quality is more abstract and intangible.
In the absence of objective measures, it may be considered appropriate that the
evaluation is performed by measuring the perception of the service by the
user(77. Zeithaml V, Parasuraman A, Berry LL. Delivering service quality:
balancing customers perceptions and expectations: New York: The Free Press;
1990.).

Service quality:a psychometric scale of the dimension of
quality and its use in health services

A psychometric scale of the dimensions of quality called Service Quality (SERVQUAL)
was the first attempt to operationalize the construct of user satisfaction. The
scale was developed with the assistance of the Marketing Science Institute (MSI),
whose purpose was to provide a tool to derive functional quality, applied to
numerous service providers(88. Parasuraman A, Zheitmal VA, Berry LL. SERVQUAL: a multiple-item
scale for measuring consumer perceptions of service quality. J Retailing.
1998;64(1):12-40.).

The SERVQUAL instrument is composed of 44 questions, divided into two sections, the
first containing 22 affirmations about user expectations regarding the service, and
the second with 22 affirmations related to user perceptions within the specific
categories of service(66. Marshall G, Murdoch I. Service quality in consulting marketing
engineers. Int J Constr Mark. 2001;3(1):41-9. ).

The users must supply two scores for each attribute, one reflecting their
expectations of the level of service that was to be delivered by the institutions
and the other showing their perceptions of the service delivered by a specific unit
within that institution. The scores range from totally disagree to totally agree
(1-7). The differences obtained between expectation and perception scores can be
used to improve the quality of services.

Developed in 1988, after two decades of use, the SERVQUAL scale has
been found to be efficient for measuring perceptions and expectations of the users
about service quality(66. Marshall G, Murdoch I. Service quality in consulting marketing
engineers. Int J Constr Mark. 2001;3(1):41-9. ),
including in health services.

In the health area, several authors have employed the aforementioned scale,
consolidating it as an important tool to get to know the expectations and needs of
users as well as to support decision making in the institutions. In Brazil, several
studies have proposed it for gauging satisfaction levels of users and managers of
health services(22. Cruz WBS, Melleiro MM. Assessment levels of the user’s
satisfaction in a private hospital. Rev Esc Enferm USP [Internet]. 2010 [cited
2012 Sept 17];44(1):147-53. Available from:
http://www.scielo.br/pdf/reeusp/v44n1/en_a21v44n1.pdf
http://www.scielo.br/pdf/reeusp/v44n1/en…
,99. Castellanos PL.Comparação entre a satisfação do usuário com os
serviços oferecidos num hospital geral e a percepção gerencial dessa
satisfação[dissertação]. São Paulo: Escola de Administração de Empresas de São
Paulo, Fundação Getúlio Vargas; 2002.

10. Hercos BVS, Berezovsky A. Qualidade do serviço oftalmológico
prestado aos pacientes ambulatoriais do Sistema Único de Saúde – SUS. Arq Bras
Oftamol. 2006; 69(2):213-9.

11. Arroyo CS.Qualidade de serviços de assistência à saúde: o tempo
de atendimento da consulta médica [tese doutorado]. São Paulo: Faculdade de
Economia, Administração e Contabilidade, Universidade de São Paulo; 2007.

12. Lin DJ, Li YH, Pai JY, Sheu IC, Glen R, Chou MJ, et al. Chronic
kidney-disease screening service quality: questionnaire survey research evidence
from Taichung City. BMC Health Serv Res. 2009;9:239.-1313. Pena MM, Melleiro MM. Degree of satisfaction of users of a
private hospital. Acta Paul Enferm [Internet]. 2012 [cited 2012 Sept
19];25(2):197-203. Available from:
http://www.scielo.br/pdf/ape/v25n2/en_a07v25n2.pdf
http://www.scielo.br/pdf/ape/v25n2/en_a0…
).

The SERVQUAL scale was validated in Brazil, involving both demographic data such as
users’ perception about the care received, and building on the five dimensions, with
all variables grouped into 35 attributes of care(99. Castellanos PL.Comparação entre a satisfação do usuário com os
serviços oferecidos num hospital geral e a percepção gerencial dessa
satisfação[dissertação]. São Paulo: Escola de Administração de Empresas de São
Paulo, Fundação Getúlio Vargas; 2002.). This framework, as previously mentioned, has been
employed in health evaluation research, and was cited in the following studies.

When researching user satisfaction at the University Hospital of USP related to the
attributes of care, and comparing it to the perception that the management team had
of satisfaction, there was a big difference between what the user identified as
quality and what the manager considered to be quality, demonstrating divergences
between the two perceptions. The rate of satisfaction manifested by users was higher
than that perceived by the managers and they, in turn, had a higher expectation than
the actual performance of the operational area. As to the attributes of the care, it
became clear that the user considered the initial care and treatment outcome as the
important attributes for his satisfaction, portrayed predominantly in the dimensions
of empathy and reliability. The study also identified that the quality of services
of the nursing team was a positive difference in the institution(99. Castellanos PL.Comparação entre a satisfação do usuário com os
serviços oferecidos num hospital geral e a percepção gerencial dessa
satisfação[dissertação]. São Paulo: Escola de Administração de Empresas de São
Paulo, Fundação Getúlio Vargas; 2002.).

The quality of an ambulatory ophthalmological service provided to users of the
National Health System in the city of Belo Horizonte (MG) was evaluated using two
structured questionnaires, adapted from the modified SERVQUAL
scale. A slight general dissatisfaction was detected regarding the quality of care,
and safety and reliability were the attributes of greatest importance; the authors
concluded there was a need for planning and implementation of actions to improve
this service(1010. Hercos BVS, Berezovsky A. Qualidade do serviço oftalmológico
prestado aos pacientes ambulatoriais do Sistema Único de Saúde – SUS. Arq Bras
Oftamol. 2006; 69(2):213-9. ).

The quality of health services in the public and private networks in Ribeirão
Preto-SP was analyzed focusing on analysis of the time for the medical consultation.
The study identified fragility in the system of scheduling appointments, especially
in public institutions, and delays in waiting for medical care. Institutions that
presented shorter times of medical consultation also received a lower score on the
quality assessment in relation to others(1111. Arroyo CS.Qualidade de serviços de assistência à saúde: o tempo
de atendimento da consulta médica [tese doutorado]. São Paulo: Faculdade de
Economia, Administração e Contabilidade, Universidade de São Paulo; 2007.
).

The expectations and perceptions of chronic renal patients, in relation to the
dialysis treatment programs, were measured using the SERVQUAL scale, in the city of
Taichung, in Taiwan, and demonstrated that elderly users had a level of perception
of the service that was lower than younger people. With regard to education, users
with higher levels of education demonstrated lower expectations and perceptions in
relationship to the programs. A positive correlation was present between
expectations and perceptions, loyalty and perceptions of the service; however there
was no positive correlation between expectation and loyalty(1212. Lin DJ, Li YH, Pai JY, Sheu IC, Glen R, Chou MJ, et al. Chronic
kidney-disease screening service quality: questionnaire survey research evidence
from Taichung City. BMC Health Serv Res. 2009;9:239.).

Levels of satisfaction in a private hospital the city of São Paulo were analyzed and
the attributes that reached the highest levels of satisfaction corresponded to
education and commitment of medical and nursing staff, the explanations and guidance
about the health problem of the user, respect for privacy and guidance for
continuing care after hospital discharge. Assurance and reliability were the
dimensions that most influenced satisfaction, followed by responsiveness and
empathy. There was also the need to adopt strategies in the nutrition service and in
the initial care of the users(22. Cruz WBS, Melleiro MM. Assessment levels of the user’s
satisfaction in a private hospital. Rev Esc Enferm USP [Internet]. 2010 [cited
2012 Sept 17];44(1):147-53. Available from:
http://www.scielo.br/pdf/reeusp/v44n1/en_a21v44n1.pdf
http://www.scielo.br/pdf/reeusp/v44n1/en…
).

Another study employing the SERVQUAL was conducted at a university hospital in the
interior of the state of São Paulo, with the objectives of verifying the levels of
user satisfaction and knowing the factors involved in their satisfaction . Findings
indicated that the dimensions of reliability and assurance represented the
attributes with the highest degree of satisfaction and that the dimensions of
responsiveness and empathy were the attributes with lower levels of
satisfaction(1313. Pena MM, Melleiro MM. Degree of satisfaction of users of a
private hospital. Acta Paul Enferm [Internet]. 2012 [cited 2012 Sept
19];25(2):197-203. Available from:
http://www.scielo.br/pdf/ape/v25n2/en_a07v25n2.pdf
http://www.scielo.br/pdf/ape/v25n2/en_a0…
).

In the cited studies, an elevated level of user satisfaction was observed in
relationship to the respective health services. The authors mentioned above iterated
the importance of health services counting on assessment tools that enabled managers
to plan improvements, and indicated the need for enhancement of such
instruments.

Despite the recognition that every theoretical model is always partial and
approximate, it is necessary to recognize the relevance of the criticism that
indicates important theoretical and conceptual inconsistencies within the area of
user satisfaction studies. Finally, the establishment of a consensus of experts
should be encouraged, to seek a validation for the concept of user satisfaction and
operationalization for its measurement(1414. Esperidião AM, Trad LAB. Avaliação de satisfação dos usuários:
considerações teórico-conceituais. Cad Saúde Pública.
2006;22(6):1267-76.).

Consequently, on the option of a particular model of evaluation, it is necessary to
remember that, depending on the type of assessment to be developed, one can choose
or adapt one or more approaches in the design process. However, the success of the
evaluation process is conditional on effective planning that meets the specifics of
each organization and the context in which it operates.

Final Considerations

The absence of objective measures to assess the quality of services increases the
degree of complexity in relation to its assessment. There are several models
proposed in the literature to evaluate such an attribute, during and after the
experience of acquisition, ranging in numerical representation, principle
characteristics and conclusions about their applicability.

In this article, the employment of an evaluation model developed in the context of
marketing and applied to the area of health demonstrates the growing concern of
health institutions and professionals themselves regarding user satisfaction.
Furthermore, it reinforces the possibility of using existing models, adapting them
to the the health segment, in order to obtain a model that most closely approximates
the reality of these services.

The monitoring of the quality of services, according to the various existing models,
not only permits the planning of assertive, highly effective strategies of
intervention, but also the monitoring of the responses to these actions,
contributing to scientific and technological advances.