This study investigated the validity of various medical service quality factors using the results from a customer satisfaction questionnaire and examined potential causal relationships among the measured indices of medical service quality, treatment effect, patient satisfaction, and intent to revisit. We also assessed which of the five medical service quality factors was most influential in treatment effectiveness and satisfaction.
Items relating to service procedure and physician performance were shown to positively affect treatment effectiveness through hypotheses testing, and physician-related factors had a stronger influence on treatment effectiveness than service procedure factors. Among medical service qualities, facilities and environment, and treatment effectiveness were shown to have positive effects on satisfaction, and upon testing the interaction hypothesis on treatment effectiveness, patient satisfaction, and intent to revisit, all hypothesized pathways from the study model were selected.
In conclusion, through analysis of overall causal relationships between medical service quality and treatment effectiveness, patient satisfaction, and intent to revisit, the pathways of medical service quality → treatment effect → patient satisfaction → intent to revisit, and medical service quality → patient satisfaction → intent to revisit were significant. Physician-related medical service quality factors appeared to have the strongest effect on treatment effectiveness and treatment effectiveness had the greatest impact on patient satisfaction.
Though a previous study by Zeithaml showed that perceived product quality influences product value [28] and Grewal et al. similarly illustrated how service quality positively affects service value [29], there is a distinct paucity of medical service studies assessing service quality with respect to treatment effectiveness. Many studies have been conducted on the importance of personal relationships and the role of service providers and customers in the service industry sector [30], and they generally report that strong personal bonds between the service provider and customer positively influence customer satisfaction and loyalty [31]. Within the medical service frame, the relationship between physician and patient could be seen to correspond with that of the service provider and customer.
Several previous studies agree that the performance of physicians and nurses are factors of highest importance in patient satisfaction [32–34], and Park reported that the physician is the most important factor to inpatients hospitalized at Korean medicine facilities, which is consistent with the findings of the present study [35]. Satisfaction is defined as the level of satisfaction or dissatisfaction with medical service after services have been provided, and denotes that patient satisfaction may act as a mediating variable between service quality and behavior intention [17]. These study results generally concur with previous study results that report on the effect of service quality on satisfaction [36]. In addition, a number of studies have commented on the importance of physical factors such as facilities and environment in service quality [37, 38].
More encounter opportunities are open to patients at Korean medicine hospitals due to the innate nature of Korean medicine compared to conventional medicine, with interventions such as acupuncture, moxibustion, cupping, and Chuna manual therapy all necessitating more time spent in patient interaction and allowing for stronger bonding between provider and patient. These aspects naturally affect building rapport with patients and influence treatment effectiveness.
Establishing a comfortable environment for treatment and equipping the hospital with service-friendly facilities is another important aspect for patient satisfaction [39]. Patients also need to feel that they can trust in their physicians and that their physicians are providing treatment based on sufficient knowledge. This trust enables the patient to feel comfortable and to achieve higher treatment success. In order for patients to feel that the total medical cost or time invested was worthwhile, a certain level of patient satisfaction has to be maintained from registration to treatment, and satisfaction commonly begets a stronger response to treatment. As this Korean medicine facility is a spine-specialty hospital, many patients presented with acute pain and compromised walking or movement, and prompt service and less time to treatment could potentially lead to faster resolution of pain in the patients’ perception.
Though the importance of service quality evaluation should be given higher recognition in medicine, there is some confusion as to which factors constitute medical service. Services mainly pertain to the human body and the amount and degree of involvement on the individual level is extensive [40]. Unlike prior studies covering the relatively straightforward causal pathway from service quality to satisfaction to loyalty, this study evaluated the overall relationship between service quality, treatment effectiveness, patient satisfaction, and intent to revisit. Previous medical service questionnaires developed from general service evaluation methods do not place sufficient weight on treatment effectiveness. In this study, we shifted the focus to treatment effectiveness to assess its impact on the causal relationship between service quality and satisfaction. These results give insight as to how and which factors are involved in determination of medical service quality.
Although many studies have been conducted to evaluate satisfaction in conventional medicine hospitals, those pertaining to Korean medicine are rare [7]. As patient encounter time is much longer in Korean medicine hospitals compared to conventional medicine, it is highly likely that factors regarding treatment effectiveness and satisfaction are different. As most previous studies were limited and stopped at testing the hypotheses in the final model, we attempted to go one step further by examining path coefficients between exogenous latent variables affecting endogenous latent variables and analyzing indirect effects. We also used a large sample size that covered a wide area of geographic importance in Korea, overcoming the limitations of some of the previous studies conducted within a more limited range. This increases the study’s applicability to other Korean medicine hospitals. However, the greatest limitation of this study may be that the hypothesis and results of this study are still reflective of CAM practices in clinical settings within Korea. The fact that the survey was conducted at multiple sites of Jaseng Hospital of Korean medicine limits external validity in generalizing the results to other institutions or countries that use CAM. Countries outside of Korea may not have corresponding spine-specialty hospitals which employ the use of CAM, or healthcare systems that consider quality improvement in similar terms. Still, these findings will hopefully be of use to healthcare policy makers in countries or healthcare systems looking to improve the quality of CAM treatment. Consideration of expanding research to a wider range of medical institutions could be entertained to improve external validity of the model, and the study design should be developed further to secure sample representativeness and improve data accuracy [41]. As pathways may differ by hospital size, scope, and patient group (e.g. inpatient or ambulatory care), comparison of hospitals by structure and patient type could be of further interest [42]. Other limitations include potential interrater difference by survey site and selection bias in convenience sampling. Also, as results are highly subject to change by time in cross-sectional designs, more longitudinal studies are warranted.
Several studies have discussed the implications and methods for heightening application of survey results, and although patient feedback surveys are increasingly seen as a key factor in monitoring and improving the quality of medical services, assessments by patients based on physician-established criteria may not be a reliable basis for measuring the quality of patient care [43]. In addition, considering this incongruity, evaluation of medical service quality based only on patient feedback may not be sufficient foundation on which to instigate change. Still, analysis of customer satisfaction through service quality assessment has been purported to enable better prediction of customer behavior, contain customer reduction rates, and increase customer value [44, 45]. By increasing customer value, service quality improvements additionally increase customer satisfaction, cut financial costs [46, 47], and promote long-term customer relationships [48, 49]. Meanwhile, other studies have attested to how well-designed patient questionnaires can contribute to assessment of both the technical proficiency and interpersonal skills of doctors [50]. Specifics on which constructs scored lower in satisfaction rates are more informative for determining which service quality factors require improved performance as opposed to simply stating satisfaction was low. Therefore, to reach a full circle from survey to actual implementation towards quality improvement, clear factual results that prompt follow-up actions are needed.
The questionnaire used in this study was compiled for research means and to reflect hospital characteristics. Although analysis did not strictly follow the SERVQUAL format, most service quality items from SERVQUAL were included. Satisfaction was analyzed as a single item in the final model after excluding items impeding reliability and validity. Though items interfering with reliability do not necessarily have to be eliminated, they were ultimately excluded to further refine the model and establish higher quality evidence. Future studies should include a sufficient number of category items in preparation for possible exclusion in analyses, and consideration for application of results in service quality measurement and improvement should be given from the survey design stage.