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Multi-criteria decision making methods based weighted SERVQUAL scales to

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Article in Total Quality Management & Business Excellence · December 2012

DOI: 10.1080/14783363.2012.661136

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Multi-criteria decision making methods

based weighted SERVQUAL scales to
measure perceived service quality in
hospitals: a case study from Turkey
a b c
Serkan Altuntas , Türkay Dereli & Mustafa Kemal Yilmaz
a
Department of Industrial Engineering, Bayburt University,
Bayburt, 69000, Turkey
b
Department of Industrial Engineering, University of Gaziantep,
Gaziantep, 27310, Turkey
c
Department of Business, Bayburt University, Bayburt, 69000,
Turkey
Version of record first published: 08 May 2012.

To cite this article: Serkan Altuntas , Türkay Dereli & Mustafa Kemal Yilmaz (2012): Multi-criteria
decision making methods based weighted SERVQUAL scales to measure perceived service quality
in hospitals: a case study from Turkey, Total Quality Management & Business Excellence, 23:11-12,
1379-1395

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 Total Quality Management
Vol. 23, No. 12, December 2012, 1379–1395

Multi-criteria decision making methods based weighted

SERVQUAL scales to measure perceived service quality in
hospitals: a case study from Turkey
Serkan Altuntasa∗ , Türkay Derelib and Mustafa Kemal Yilmazc
a
Department of Industrial Engineering, Bayburt University, Bayburt 69000, Turkey;
b
Department of Industrial Engineering, University of Gaziantep, Gaziantep 27310, Turkey;
c
Department of Business, Bayburt University, Bayburt 69000, Turkey

The main objectives of this study are to: (i) measure hospital service quality by using
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analytic hierarchy process (AHP) and analytic network process (ANP) as a multi-
criteria decision making method to acquire the relationship and the level of the
importance among service quality measurement (SERVQUAL) dimension; (ii) find
perceived service quality with respect to different hospital classes (A, B and C) in
Istanbul, Turkey; (iii) compare AHP- and ANP-based weighted SERVQUAL scales
with the unweighted SERVQUAL scale for public hospital service quality in terms of
different hospital classes (A–B and C). First, four hospitals are selected randomly for
each class and then, a questionnaire based on the SERVQUAL model is conducted for
each class to measure perceived service quality with respect to five major criteria,
namely tangible, reliability, responsiveness, assurance and empathy, from patients’
viewpoints at hospitals. Next, the second questionnaire based on ANP is developed to
evaluate the importance of criteria and construct the relations among the criteria. The
study sample contains 281 outpatients totally. Three important findings are obtained in
this study. First, there is a significant difference among different hospital classes
regarding the perceived service quality. Second, according to the patients, the most
important service quality dimensions are empathy, the knowledge of employees,
sympathetic and reassuring employees, services provided at the time promised to do so,
and safe feeling of patients in interactions with hospital employees. Thirdly, the,
perceived service quality through the AHP- and ANP-based SERVQUAL scale is
higher than that with the unweighted SERVQUAL scale.
Keywords: SERVQUAL; AHP; ANP; hospital service quality; patient satisfaction;
Turkey

1. Introduction
Measuring service quality is quite important to improve perceived service quality, make a
difference and to obtain superiority in competitive environments. Therefore, measuring
service quality in service systems has gained much attention from researchers and practitioners.
Perceived service quality in hospitals, as a service system, should be high for their
sustainability and preferability by patients and hospital attendants. Hence, the senior man-
agement of hospitals desires to decrease queues in front of medical departments, have up-
to-date equipment, visually appealing facilities, knowledgeable and polite employees etc.
Patient satisfaction can be increased if these are provided. Pakdil and Harwood (2005)
indicate that health care and hospital organisations have a significant role in the

∗
Corresponding author. Email: saltuntas@[Link]

ISSN 1478-3363 print/ISSN 1478-3371 online

# 2012 Taylor & Francis
[Link]
[Link]
 1380 S. Altuntas et al.

growing service industry and only they directly serve and affect human medical care. The
importance of perceived service quality in state hospitals affects not only patient satisfac-
tions but also governments due to the fact that patients select governments by using votes
during the election period. State hospitals in Turkey were divided into different classes
namely, A, B, C, D and E in the year 2010. Therefore, making recommendations
related to the perceived service quality to governments is quite important with respect
to different hospital classes. This study differs from the previous works because of the
way it researched to find the perceived service quality by different hospital classes and
compared them with each other and also used two most known multi-criteria decision
making (MCDM) methods-based scale. In this respect, the results obtained by this
research can provide important clues to improve the perceived service quality by patients
and suggest some recommendations for managers.
In total, $11790 was spent on the health industry in 1999, while this value increased to
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$44364 in 2008 (Turkish Statistical Institute, [Link]). Average expenditures

increased 276% in 8 years. This indicates that the total health expenditure to gross national
product ratio was 6.1% in 2008.
There are many different scales to measure patient satisfaction in hospitals. These
measurement scales use different dimensions. Zyzanski, Hulka, and Cassel (1974) used
three main dimensions: professional competence, personal qualities and cost/convenience.
Each dimension includes 14 sub-factors to measure satisfaction in hospitals. Baker (1990)
concentrated on three main dimensions: professional care, depth of relationship and perceived
time, while Reidenbach and Sandifer-Smallwood (1990) used seven dimensions: patient con-
fidence, business competence, treatment quality, support services, physical appearance,
waiting time and empathy. Goldstein, Farquhar, Crofton, Darby, and Garfinkel (2005) intro-
duced Consumer Assessment of Health Providers and Systems Hospital Survey to measure
patients’ perspectives on inpatient hospital care. Jacobson and Neumann (2009) developed
a framework for public health practitioners to measure the value of public health services.
Some studies use qualitative methods to analyse hospitals. For example, structural equation
modelling is used very extensively (Cho, Lee, Kim, Lee, & Choi, 2004; Douglas & Freden-
dall, 2004; Marley, Collier, & Goldstein, 2004). Asubonteng, McCleary, and Swan (1996)
indicated that the most popular scale to measure service quality is service quality measure-
ment (SERVQUAL) developed by Parasuraman, Berry, and Zeithaml (1985). Some research-
ers modified the SERVQUAL scale and then used it to measure patient satisfaction in the
literature. For example, Tomes and Peng Ng (1995) developed a questionnaire based on modi-
fied SERVQUAL and applied it to a hospital. Van Dyke, Prybutok, and Kappelman (1999)
also used modified SERVQUAL to analyse service quality. Wu, Hsiao, and Kuo (2004)
used fuzzy set and analytic hierarchy process (AHP) to assign a weight for each SERVQUAL
dimensions. Wang, Chang, Liu, and Chen (2007) utilised SERVQUAL scale to measure
service quality of long-term care institutions. They used simple additive weighting and
fuzzy AHP as a MCDM methods to determine the degree of importance of each criterion.
Tsaur, Chang, and Yen (2002) also used fuzzy set theory, AHP and technique for order pre-
ference by similarity to ideal solution (TOPSIS) methods to evaluate airline service quality.
Rahman, Erdem, and Devebakan (2007) measured service quality of four hospitals in
Elazıg, Turkey. They compared hospitals with each other from the view of levels of perceived
service quality based on dimensions in the unweighted and weighted SERVQUAL scores. At
the moment, there has been limited research on the hospital service quality in the literature,
therefore Turkey also increases its potential on the health sector, some of them can be referred
to Taner and Antony (2006), Caha (2007), Bakar, Akgün, and Al Assaf (2008) and Lonial,
Menezes, Tarim, Tatoglu, and Zaim (2010). There are many studies that have applied
 Total Quality Management 1381

SERVQUAL to different sectors in different countries. Details on them can also be found in
review studies (Asubonteng, McCleary, & Swan, 1996; Buttle, 1996; Coulthard, 2004;
Ladhari, 2008; Gilmore & McMullan, 2009; Ladhari, 2009). Like this study, there are
others using AHP and analytic network process (ANP) methods together to conduct their
work (Leung, Lam, & Cao, 2006; Chang, Wu, Lin, & Lin, 2007; Yang, Chuang, & Huang,
2009). Studies using AHP and ANP methods in the literature did not apply their work to
large-size samples. However, we applied our ANP-based questionnaire to very large
sample containing 281 usable respondents compared with the studies made in the literature.
Much effort has been made to address measuring service quality in hospitals, while the
number of studies on the application of weighted SERVQUAL in hospitals is also very
limited. Most of the studies assume that the dimensions are assumed to be independent
from each other. On the other hand, Parasuraman, Berry, and Zeithaml (1991) indicate that
there may be an inter-relationship among dimensions. Wu et al. (2004) claims that the
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studies in the literature cannot calculate which dimension is more important and effective
for hospitals. In this study, thanks to weighted SERVQUAL, each dimension is assigned a
weight according to its significance with respect to responds. To the best of our knowledge,
there is no other study in the literature that uses ANP to weight hospital service quality dimen-
sions. The objectives of the study are four-fold. First, it contributes to the research on the appli-
cation of the weighted SERVQUAL technique for hospitals. Second, it measures the hospital
service quality through the use of AHP/ANP as a MCDM method to find the relationship and
level of the importance among SERVQUAL dimensions. Third, it finds the perceived service
quality with respect to different hospital classes (A, B and C) in Istanbul, Turkey. It
compares the ‘AHP- and ANP-based’ weighted SERVQUAL scales with the unweighted
SERVQUAL scale for public hospital service quality in terms of different hospital classes
(A–B and C).
As mentioned above, there are different public hospital classes in Turkey. Republic of
Turkey, Ministry of Health classifies hospitals as A, B, C, D and E class according to some
criteria such as the number of medical departments, outpatient visits, number of doctors,
population of hospital’s established place, laboratory facilities etc. The details about these
differences among hospital classes can be found on website of Ministry of Health, Turkey,
[Link]
A real-world case study was conducted to illustrate the application of AHP- and ANP-
based weighted SERVQUAL scales and unweighted SERVQUAL scale. We conducted a
survey study in three different hospital classes; A, B and C, located at several locations in
Istanbul. Only A-, B- and C-class hospitals were selected because of the fact that there is
only one D-class hospital and no E-class hospital in Istanbul. First, four hospitals were
selected randomly for each class, and then, a questionnaire based on the SERVQUAL
scale was conducted for each class to measure perceived service quality with respect to
five major criteria, namely; tangibility, reliability, responsiveness, assurance and empathy,
from patients’ viewpoints at hospitals. Next, the questionnaire was developed and conducted
to evaluate the importance of criteria and construct the relations among the criteria.
The remainder of the study is organised as follows. In Section 2, the research method is
given. Then, the constructed model is given in Section 3. Application of the constructed
model is given in Section 4. The conclusions of the study are discussed in Section 5.

2. Research method
SERVQUAL scale is used to measure service quality in hospitals. The criteria weights are
then obtained through ANP by considering dependence and hierarchy, and through AHP
 1382 S. Altuntas et al.
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Figure 1. Research methodology.

by considering only hierarchy. In this section, we introduce research methods, namely

SERVQUAL scale, AHP and ANP methods basically. Figure 1 illustrates our conducted
research methodology for this study.

2.1 Servqual
Parasuraman et al. (1985) introduced service quality dimensions which consist of 10
dimensions, namely reliability, responsiveness, competence, access, courtesy, communi-
cation, credibility, security, understanding and tangibilities. Generally, these 10 dimen-
sions reduce to five factors, namely tangibilities, reliability, responsiveness, assurance
and empathy, and each dimension is composed of different numbers of sub-dimensions
 Total Quality Management 1383

that are named items in research study in the literature. Lam (1997) explained these dimen-
sions in detail as follows.
(1) Tangible: physical facilities, equipment and appearance of personnel.
(2) Reliability: ability to perform the promised service reliable and accurately.
(3) Responsiveness: willingness to help customers and provide prompt service.
(4) Assurance: knowledge and courtesy of employees and their ability to inspire trust
and confidence.
(5) Empathy: caring, individualised attention provided to customers.
Khan, Prasad, and Rajamanoharane (2010) used these five dimensions which consist of eight
items for service quality measurements in hospitals. Wang, Yan, and Liu (2010) also
measured the service quality of an e-learning system by using five dimensions, 11-item fra-
mework. Boyacıoglu (2008) used four dimensions, namely reliability, assurance, tangibles
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and responsiveness and 14 items to measure customer satisfaction for a new channel.
Yang and Zhu (2010) measured the quality of community-based service provided by univer-
sity-affiliated stadium using five dimensions and 16 items. Luo, Zhong, and Zhang (2010)
measured the satisfaction of outward bound tourists by using five dimensions and 20
items. Gotlieb (2000) measured the perceived quality of the hospital by using five dimensions
and 10 items (two items for each of the five dimensions) Bouman and van der Wiele (1992)
used three factors (customer kindness, tangibles and faith) which consist of 48 items spread-
ing over the five SEVQUAL dimensions to measure service quality in the car service industry.
Babakus and Mangold (1992) used five factors (tangibles, reliability, responsiveness, assur-
ance and empathy) which consist of 15 items for their hospital research. In this study, we use
five dimensions, which are shown in Figure 2, because these five dimensions were the most
used dimensions in literature to measure perceived service quality. Therefore, we consider
nine items to measure all of the reflections of these five dimensions correctly to perceived
service quality. We have to consider appropriate number of dimensions and items in this
study due to the fact that ANP-based pairwise comparison judgment matrixes and SERVQ-
UAL questions in the survey increase abnormally when dimensions and items increase.
Survey studies are conducted to measure service quality by using the SERVQUAL
scale in the literature. The gap between perceived and expected service quality is calculated
to interpret the analysed service system in these survey studies. Gilmore and McMullan
(2009) indicate that, according to some researchers, measuring expectations is unnecessary
and only measuring perceptions of outcomes should be enough. In this study, we conduct
our survey by considering perceived service quality only.

2.2 Analytic hierarchy process

AHP is the most extensively used MCDM method. The AHP is based on the human ability
to make sound judgments about small problems (Saaty, 1994). Handled problems should
be constructed in hierarchies as goal, criteria, sub-criteria and decision alternatives for
using AHP. A pairwise comparison judgment matrix is constructed by experts who are rel-
evant to the related decision area to express how much one element dominates another.
Consistency ratio (CR) is also calculated for each constructed pairwise comparison judg-
ment matrix. This ratio is generally expected to be less than 0.1 to be acceptable. However,
Saaty (2001) indicates that a CR about 0.2 or less may be tolerated. In this study, we take
our surveys having pairwise comparison matrix’ CR less than 0.2 into consideration
because of the fact that our surveys are conducted in hospitals (people do not have
enough time and their health is not good) and one survey takes 25 min at least. The sol-
ution steps for AHP are as follows:
 1384 S. Altuntas et al.

Step 1: Construct pairwise comparison judgment matrix. This matrix has to be like
following.
⎛ ⎞
1 X12 · X1n
⎜ X21 1 · X2n ⎟
[X] = ⎜
⎝ ·
⎟. (1)
· 1 · ⎠
Xn1 Xn2 · 1

There are n criteria in this matrix. X12 denotes how much the first criteria is more
important than the second criteria. This value change between 1 and 9 belongs to its impor-
tance. The remaining cell in the matrix can be introduced like this.
Step 2: Normalise pairwise comparison judgment matrix. All of the values in each
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column of the matrix are summed and each value in the column is divided by its
total column. Finally, average value is calculated in each row. Obtained value for
each row shows priorities of the criteria.
Step 3: Calculate consistency index (CI) for each pairwise comparison judgment
matrix. Following formula is used to calculate CI.
(lmax − n)
CI = , (2)
(n − 1)
where n is the number of criteria.
The calculating steps for lmax are as follows:
Step 3.1: Multiply constructed pairwise comparison judgment matrix obtained in Step
1 with the priorities of the criteria obtained in Step 2.
Step 3.2: Divide obtained each value from Step 3.1 by the corresponding priority of
each criteria.
Step 3.3: Calculate average values of the values obtained from Step 3.2 and denote
result as lmax.
Step 4: Calculate CR by using CR¼CI/RI formula.
RI is the random index. RI values belonging to number of criteria (n) are given in Table 1.
To find out more about AHP, the readers can refer to review studies (Vaidya & Kumar,
2006; Omkarprasad & Sushil, 2006; Ho, 2008; Liberatore & Nydick, 2008; Sipahi &
Timor, 2010).

2.3 Analytic network process

ANP is used when there are interdependent relationships among criteria. ANP has
superiority over AHP due to the fact that ANP considers interdependent relationships
among criteria. We do not go into the details of the technical component of ANP in this
study. The details on ANP can be found in the ANP book of Saaty (2001). However,
the procedure of ANP based on Hsieh, Lin, and Lin (2008) is explained briefly as follows:

Table 1. Random index.

n 1 2 3 4 5 6 7 8 9 10 11 12 13 14
RI 0 0 0.58 0.9 1.12 1.24 1.32 1.41 1.45 1.49 1.51 1.53 1.56 1.57
 Total Quality Management 1385

Step 1: Generate the super-matrix instead of pairwise comparison judgment matrix in

AHP. Pairwise comparison judgment matrix is constructed like AHP and then super-
matirx is constructed by using pairwise comparison judgment matrix. Super-matrix
shows all the relations and the relation values.
Step 2: Find the weighted super-matrix. All of the criteria in super-matrix are multi-
plied by a value which shows the importance of the corresponding criteria.
Step 3: Calculate the limited weighted super-matrix to get the relative weight. Raise
the super-matrix to an arbitrary number until the weights become stable for obtaining
weights the value of all the criteria.

3. Model construction
To construct an evaluation framework for this study, the five most widely used evaluation
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dimensions for hospital service quality in the literature and nine items measuring the
reflection of the dimensions for perceived service quality are taken into consideration.
First, three hospital managers and two doctors (experts) were invited to identify inner-
dependence relationships among dimensions and items. To do this, we conducted a
survey to determine which dimensions and items affect or are affected each other.
Experts said either yes or no to each survey question to indicate if there is a relationship
or not for the question answered. An evaluation framework was constructed after the
experts’ judge was utilised. Figure 2 illustrates the constructed evaluation framework.
As can be seen in Figure 2, there are six inner-dependence relationships among
empathy, assurance and responsiveness dimensions which are shown by discrete arrows
in Figure 2. As stated in Figure 2, empathy, assurance and responsiveness are also affected
by assurance and responsiveness, empathy and responsiveness, empathy and assurance,
respectively.
There are several criteria affecting customer satisfaction. Some of them are queue in
front of medical departments, up-to-date equipment, visual appeal of facilities, knowl-
edgeable and polite employees, etc. Ministry of Health in Turkey divides hospitals into
different classes to improve perceived service quality and satisfaction level of patients
according to some criteria such as the number of doctors, the number of medical

Figure 2. The evaluation hierarchy and network structure of hospital service quality.
 1386 S. Altuntas et al.

departments, and patient visits. There are 50 public hospitals in Istanbul, Turkey. To the
best of our knowledge, there is no other study researching perceived service quality in
terms of different hospital classes. Therefore, we wonder whether there is a significant
difference among different hospital classes regarding perceived service quality according
to the unweighted SERVQUAL scale, ANP-based weighted SERVQUAL scale, and AHP-
based weighted SERVQUAL scale or not. Therefore, we tested three primary hypotheses
in this study, namely:
H1: There is a significant difference among different hospital classes regarding
perceived service quality according to the unweighted SERVQUAL scale.
H2: There is a significant difference among different hospital classes regarding
perceived service quality according to the ANP-based weighted SERVQUAL scale.
H3: There is a significant difference among different hospital classes
regarding perceived service quality according to the AHP-based weighted SERVQ-
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UAL scale.

4. Application
There are many studies using survey instruments to collect data from hospitals. The details
about them can be found in Castle, Brown, Hepner, and Hays (2005) study. They reviewed
survey studies conducted in hospitals. At the beginning of this study, a protocol was organ-
ised between the provincial health directorate and us to carry it out. Then, we conducted a
survey through questionnaires. The general SERVQUAL questionnaire was first under-
taken and then an ANP-based questionnaire was done. The duration was approximately
two months (December 2010 – January 2011). The purpose of the first questionnaire is to
measure perceived service quality. The purpose of the second questionnaire is to find the
weight of each factor based on AHP and ANP methods. The method of questioning
chosen for SERVQUAL is a five-point likert-type scale asking for agreement or
disagreement. Data were gathered from patients in outpatient centres except birth clinic,
child clinic, psychiatry clinic and emergency service to get usable data. A pilot study
was first conducted in a hospital by applying 30 questionnaires to test the suitability and
to examine the comprehensibility of the questionnaire. Each survey in our research takes
25 min at least. Data for this study were gathered from face-to-face interviews by us. We
conducted a survey study in three different hospital classes, A, B and C, located at
several locations in Istanbul, Turkey. First, four hospitals were selected randomly for
each class, A, B and C. Total 12(4×3) hospitals’ perceived service quality was measured
in Turkey.
We used a convenience sampling method to decide the sample size. The result
obtained from its formula at 95% confidence level is 385. Outpatients were selected
from the total distribution of around 385 outpatients. However, some surveys were not
completed accurately and their CRs – which were higher than 0.2 – were used in AHP
and ANP methods. Thus, the number of usable respondents was 281 samples: 88
samples for A class, 88 samples for B class and 105 samples for C class. The main
tools used for data analysis are Microsoft Excel and SPSS software. In this study, we
use Cronbach’s Coefficient Alpha value to test the reliability of the conducted study. Gen-
erally acceptable level of reliability is above 0.70 in the literature. Here, the alpha is found
to be 0.90, which is above the 0.70 threshold by using SPSS.
This section presents the results of the analysis of the data and the collected data by
questionnaires consisting of two questionnaires: a general SERVQUAL questionnaire
and the ANP-based questionnaire.
 Total Quality Management 1387

Table 2. Respondents demographics.

Gender Total amount (%) Age Frequency (%)
Female 125 (44.5) 18 –23 41 (14.6)
Male 156 (55.5) 24 –29 52 (18.5)
Education Frequency (%) 30 –35 74 (26.3)
Primary school 12 (4.3) 36 –41 27 (9.6)
Junior high school 20 (7.1) 42 –47 21 (7.5)
High school 164 (58.4) 48 –53 31 (11.0)
University 63 (22.4) 53 –58 26 (9.3)
Postgraduate 22 (7.8) 59 + 9 (3.2)
Monthly income (TL) Frequency (%) Occupation Frequency (%)
1–600 49 (17.4) Public servant 20 (7.1)
601 –900 69 (24.6) Worker 64 (22.8)
901 –1200 80 (28.5) Teacher 20 (7.1)
1201–1500 41 (14.6) Retired 46 (16.4)
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1501–1800 21 (7.5) Housewife 17 (6.0)

1801–2100 14 (5.0) Trades people 27 (9.6)
2100 and + 7 (2.5) Other 87 (31.0)

Table 3. Respondents background.

Respondents who have ever come to the hospital Frequency (%)
The second time 7 (2.5)
The third time 146 (52.0)
The fourth time 36 (12.8)
The fifth time 16 (5.7)
More than five times 76 (27.0)

4.1 Respondents’ demographics and background

Respondents’ demographics are given in Table 2. The respondents consist of 55.5% males
and 44.5% females. Based on gender, the main respondents in this research are in the age
group 30– 35 years old, which is 26.3%. The age group of 24– 29, 18– 23, 48 – 53, 36 –41,
53– 58, 42– 47 and 59– 60 years old are followed, respectively. The salary of the respon-
dents in this research is between 901– 1200 Turkish Lira (TL) or approximately between
553 and 736 US dollars which is 28.5%. The salary groups 601 – 900 TL, 1 – 600 TL,
1201 – 1500 TL, and 1501 – 1800 TL, 1801 – 2100 TL and . 2100 TL follow. The edu-
cation level of the respondents is in the level of high school which is 58.4%. Finally, occu-
pation of the respondents is in the other group which is 31%. The occupation group of
worker, retired, trades people, public servant and housewife follow.
Amount and percentage of respondents who have ever come to the hospital are given in
Table 3. It is found that the most respondents come to the hospitals three times a year,
which is 52%.

4.2 Unweighted and weighted SERVQUAL scores for each hospital class
In this section, we discuss unweighted and weighted SERVQUAL scores for each hospital
class. Tables 4 – 6 show the results of SERVQUAL scores for A-, B- and C-class hospitals,
respectively. Individual dimension weights for all hospital classes show that empathy has
the highest weight for both ANP- and AHP-based importance weight. This implies that
 1388 S. Altuntas et al.

Table 4. Unweighted and weighted SERVQUAL scores for A-class hospitals.

Unweighted ANP-based ANP-based AHP-based AHP-based
SERVQUAL importance weighted importance weighted
Dimension score weights average score weights average score
Tangibles
T1 3.48864 0.04386 0.15301 0.04386 0.15301
T2 3.5 0.05371 0.18799 0.05371 0.18799
Reliability
R1 3.31818 0.08117 0.26934 0.08117 0.26934
R2 3.43182 0.05317 0.18247 0.05317 0.18247
Responsiveness
RS1 3.07955 0.05881 0.18112 0.07469 0.23002
RS2 3.14773 0.11502 0.36204 0.09914 0.31205
Assurance
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A1 3.5 0.08515 0.29802 0.09332 0.32661

A2 3.85227 0.20998 0.80889 0.20181 0.77742
Empathy
E 3.60227 0.29914 1.07757 0.29914 1.07757
Scores 30.92046/9 1 3.52044 1 3.51648
¼ 3.43561

Table 5. Unweighted and weighted SERVQUAL scores for B-class hospitals.

Unweighted ANP-based ANP-based AHP-based AHP-based
SERVQUAL importance weighted importance weighted
Dimension score weights average score weights average score
Tangibles
T1 3.07955 0.03574 0.11006 0.03574 0.11006
T2 3.07955 0.05192 0.15988 0.05192 0.15988
Reliability
R1 3.42045 0.11594 0.39656 0.11594 0.39656
R2 3.20455 0.07528 0.24125 0.07528 0.24125
Responsiveness
RS1 2.90909 0.07709 0.22427 0.0604 0.17572
RS2 3.125 0.10724 0.33513 0.12306 0.38455
Assurance
A1 3.43182 0.08256 0.28333 0.09474 0.32513
A2 3.56818 0.16941 0.6045 0.15923 0.56817
Empathy
E 3.30682 0.28481 0.94183 0.28369 0.93811
Scores 3.23611 1 3.29681 1 3.29943

patients for all hospitals place more importance on empathy than the other dimensions.
The lowest weight is allocated to tangibles for all hospital classes. The overall unweighted
SERVQUAL score is very close to the overall weighted SERVQUAL scores obtained by
both ANP- and AHP-based weighted SERVQUAL. These scores provide an overall indi-
cation of customers’ perceived service quality for all hospitals. The first four items’ (T1,
T2, R1 and R2) weights obtained from both AHP and ANP methods are the same because
of the fact that there is no inner-relation among considered nine items (see Figure 2).
Both the weighted and unweighted SERVQUAL scores for A- and C-class hospitals
indicate that patients are generally close to being satisfied with service quality.
 Total Quality Management 1389

Table 6. Unweighted and weighted SERVQUAL scores for C-class hospitals.

Unweighted ANP-based ANP-based AHP-based AHP-based
SERVQUAL importance weighted importance weighted
Dimension score weights average score weights average score
Tangibles
T1 3.6381 0.02093 0.07613 0.02093 0.07613
T2 3.30476 0.03272 0.10813 0.03272 0.10813
Reliability
R1 3.37143 0.07704 0.25974 0.07704 0.25974
R2 3.7619 0.03366 0.12662 0.03366 0.12662
Responsiveness
RS1 3.22857 0.05542 0.17893 0.07864 0.25389
RS2 3.74286 0.15082 0.56449 0.1276 0.47759
Assurance
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A1 3.73333 0.0593 0.22139 0.07358 0.27471

A2 4.13333 0.26024 1.07567 0.24596 1.01662
Empathy
E 3.85714 0.30987 1.19523 0.30987 1.19523
Scores 3.64127 1 3.80632 1 3.78867

Table 7. Unweighted and weighted SERVQUAL scores for all hospitals.

Unweighted ANP-based ANP-based AHP-based AHP-based
SERVQUAL importance weighted importance weighted
Dimension score weights average score weights average score
Tangibles
T1 3.41 0.03275 0.11167 0.03275 0.11167
T2 3.29 0.04531 0.14905 0.04531 0.14905
Reliability
R1 3.37 0.09052 0.30504 0.09052 0.30504
R2 3.48 0.05281 0.18376 0.05280 0.18376
Responsiveness
RS1 3.08 0.06328 0.19487 0.07169 0.22081
RS2 3.36 0.12596 0.42322 0.11726 0.39400
Assurance
A1 3.56 0.07468 0.26586 0.08639 0.30755
A2 3.86 0.21606 0.83398 0.20497 0.79119
Empathy
E 3.6 0.29866 1.07519 0.29831 1.07392
Scores 3.45 1 3.54264 1 3.53699

However, there is still need to work for increasing the quality of the hospitals. On the other
hand, B-class hospitals have the lowest perceived service quality scores, which range
between 3.299 and 3.236 compared to A- and C-class hospitals.
Summary results are given in Table 7. Generally, perceived service quality for 12 hos-
pitals is found to be 3.45 by using unweighted SERVQUAL, 3.542 by using ANP-based
weighted SERVQUAL and 3.53 by using AHP-based weighted SERVQUAL. The
sequences of all dimensions’ importance are the same for both ANP and AHP methods
and are also very close to each other. The highest weight is allocated to empathy
 1390 S. Altuntas et al.

(0.29866 and 0.29831). Knowledge of employees (A2) comes second (0.21606 and
0.20497), sympathetic and reassuring employees (R2) is the third (0.12596 and
0.11726), services provided at the time promised to do so (R1) is the fourth (0.09052
and 0.09052), safe feeling of patients in interactions with hospital employees (A1) is
the fifth (0.07468 and 0.08639), employees’ willingness (RS1) is the sixth (0.06328 and
0.07169), employees’ quickness (RS2) is the seventh (0.05281 and 0.05281), up-to-date
equipment (T2) is the eighth (0.04531 and 0.04531) and visual appeal of physical facilities
(T1) is the ninth (0.03275 and 0.03275). A comparison of dimensions indicates that though
employees’ willingness (RS1) has the lowest perception scores obtained from unweighted
SERVQUAL, its importance weights of 0.06328 and the score 0.07169 is higher than T1,
T2 and R2.
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4.3 Comparison using unweighted and weighted SERVQUAL scores

The ANOVA tests were conducted to decide whether there is a difference among perceived
service quality dimensions or not. The post hoc test was also conducted for the three hospital
classes to identify differences between the hospital classes. Tables 8 and 10 show the
obtained ANOVA and post hoc test results, respectively, at a 95% confidence level. The
ANOVA results for unweighted SERVQUAL indicate that there are statistically significant
differences in four dimensions (tangibles, responsiveness, assurance and empathy).
Reliability is the only dimension that is not significant. The ANOVA results for ANP-
based weighted SERVQUAL indicate that there are statistically significant
differences among all dimensions. Finally, the ANOVA results for AHP-based weighted
SERVQUAL indicate that there are statistically significant differences in four dimensions
(tangibles, reliability, responsiveness and assurance). Empathy is the only dimension that is

Table 8. ANOVA results.

ANP-based AHP-based
Unweighted weighted weighted
SERVQUAL SERVQUAL SERVQUAL
Dimensions F P F P F P
Tangibles 4.904 0.002 7.921 0.000 6.917 0.001
Reliability 2.036 0.132∗ 9.401 0.000 18.436 0.000
Responsiveness 5.862 0.003 8.227 0.000 4.81 0.009
Assurance 7.728 0.001 19.024 0.000 10.523 0.000
Empathy 7.978 0.000 8.357 0.000 1.441 0.239∗
∗
There is no significant difference among hospitals with respect to perceived service quality.

Table 9. Summary table obtained from Table 10.

Unweighted ANP-based weighted AHP-based weighted
SERVQUAL SERVQUAL SERVQUAL
Tangibles A.B and C.B A.C A.C and B.C
Reliability – B.A and B.C B.A and B.C
Responsiveness C.A and C.B C.A and C.B C.A and C.B
Assurance C.A and C.B C.A, C.B and A.B A.B and C.B
Empathy A.B and C.B A.B and C.B –
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Table 10. Post-hoc test results.

ANP-based weighted AHP-based weighted
Unweighted SERVQUAL SERVQUAL SERVQUAL
D Hospital classes MD SE p MD SE p MD SE p
Tangibles A class B class 0.415 0.130 0.002 – – – – – –
C class – – – 0.863 0.217 0.000 0.198 0.056 0.001
B class C class 20.392 0.125 0.002 – – – 0.153 0.056 0.007
Reliability A class B class – – – 20.927 0.286 0.001 20.256 0.063 0.000
C class – – – – – – – – –
B class C class – – – 1.139 0.275 0.000 0.362 0.061 0.000
Responsiveness A class B class – – – – – – – – –
C class 20.372 0.146 0.012 20.804 0.209 0.000 20.146 0.049 0.003
B class C class 20.469 0.146 0.002 20.609 0.209 0.004 20.103 0.049 0.037
Assurance A class B class – – – 1.073 0.317 0.001 0.185 0.067 0.006

Total Quality Management 1391

C class 20.257 0.112 0.022 20.798 0.304 0.009
B class C class 20.433 0.112 0.000 21.871 0.304 0.000 20.295 0.065 0.000
Empathy A class B class 0.295 0.144 0.041 1.441 0.613 0.020 – –
C class – – – – – – – – –
B class C class 20.550 0.138 0.000 22.399 0.588 0.000 – – –
Note: D, dimensions; MD, mean difference; SE, standard error.
 1392 S. Altuntas et al.

not significant for AHP-based weighted SERVQUAL. Therefore, H1, H2 and H3 are
accepted.
Table 10 presents the results obtained from the post hoc test for comparing the hospital
classes. Summary table, Table 9, is created from Table 10 to improve intelligibility of
Table 10. As can be seen from the Tables 9 and 10, there is a difference among A-, B-
and C-class hospitals under responsiveness dimension, and perceived service quality in
C-class hospitals is higher than in A- and B-class hospitals for all three types SERVQUAL
under this dimension. In addition, as can be seen from Table 10, there are no significant
differences between A- and B-class hospitals under responsiveness dimension and A-
and C-class hospitals under empathy dimension. Perceived service quality in C-class hos-
pitals is also higher than in A- and C-class hospitals for unweighted SERVQUAL and
ANP-based SERVQUAL under assurance dimensions. Similarly, perceived service
quality in A-class hospitals is higher than in B-class hospitals for unweighted SERVQUAL
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and ANP-based SERVQUAL under empathy dimensions.

5. Conclusions, limitations and future research directions

5.1 Conclusions
In this study, service quality in hospitals in Istanbul, Turkey, is measured by using
unweighted and weighted SERVQUAL scales. Two different and most popular
MCDM methods, ANP and AHP, are used to assign a weight for each SERVQUAL
dimension. Therefore, three SERVQUAL scales, namely unweighted SERVQUAL
scale, ANP-based SERVQUAL scale and AHP-based SERVQUAL scale are used to
measure perceived service quality with respect to different hospital classes (A, B and
C). AHP-based SERVQUAL scale considers the importance level of each item with
respect to each patient, while the ANP-based SERVQUAL scale also takes the impor-
tance level of each item with respect to each patient by considering inner relation
among items. There are different importance levels among items with respect to each
patient in practice. Therefore, the use of AHP and ANP as MCDM methods provides
reflection of this difference to perceived service quality. Their use also enables research-
ers to address the needs in practice easily. Two different questionnaires, namely the
SERVQUAL questionnaire and the ANP-based questionnaire were designed (ANP-
based questionnaire includes AHP-based questionnaire as well. Therefore, there is no
need to design AHP-based questionnaire additionally). Data were then collected using
the questionnaires for each hospital class (involving 281 samples: 88 samples for A
class, 88 samples for B class and 105 samples for C class). Comparisons were then under-
taken using ANOVA and post hoc tests to explore for differences in patients’ perceived
service quality dimensions and among hospital classes. Findings from this research study
are given as follows:
(1) Perceived service quality level is slightly above the middle level with respect to
obtained results from the unweighted SERVQUAL scale. On the other hand, per-
ceived service quality level is higher than obtained results from the unweighted
SERVQUAL scale with respect to the ANP- and AHP-based weighted SERVQUAL
scale. In practice, ANP-based weighted SERVQUAL results give more accurate
results than others because of the fact that ANP method considers inner relations
among dimensions and decreases real life assumptions in constructed models.
(2) Both the weighted and unweighted SERVQUAL scores for A- and C-class hospi-
tals indicate that patients are generally close to being satisfied with service quality.
 Total Quality Management 1393

However, there is still need to work for increasing the quality of hospitals. On the
other hand, B-class hospitals have the lowest perceived service quality scores
which range between 3.299 and 3.236 compared to A- and C-class hospitals.
(3) Comparisons of hospital classes show that there are some differences in service
quality dimensions’ importance level among hospital classes, but there is no
difference in the sequence of their importance.
(4) The most important items are empathy, knowledge of employees, sympathetic and
reassuring employees, services provided at the time promised to do so, safe feeling
of patients in interactions with hospital employees according to the patients. From
the management’s point of view, managers of the hospitals should pay attention to
these criteria to improve the perceived service quality and satisfaction level of
patients.
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5.2 Research limitations and future research directions

Data for this study were only collected from outpatients. Perceived service quality by inpa-
tients may be different from outpatients. Thus, more research and data obtained from both
inpatients and outpatients are needed for proper interpretation of perceived service quality
from hospitals. In future work, perceived service quality by inpatients and outpatients can
be compared to each other.
One of two limitations of the study is that it was only conducted for 12 hospitals in
Istanbul. Therefore, the results of this study are not generalised for all areas in Turkey.
For future research, similar studies need to be conducted in many other cities of Turkey
to measure perceived service quality in different hospital classes. MCDM-based SERVQ-
UAL scales, such as AHP- and ANP-based SERVQUAL, can be conducted in different
industries, namely hotels and banks. For example, the perceived service quality can be
measured with respect to the hotels having several stars, like different hospital classes con-
ducted in this study. Additionally, the methods used in this study can also be employed for
private and state banks and the corresponding ‘perceived quality of service levels’ could
be compared with each other.
The other limitation of this study is that data were gathered from patients in outpatient
centres except the birth clinic, child clinic, psychiatry clinic and emergency service.
Researchers could explore the constructed model in this study by adding new dimensions
and items and using different medical departments.

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