An analysis of service quality at a student health center

at a student health center Cem Canel Associate Professor of Operations Management, Department of Information Systems and Operations Management, Cameron School of Business, The University of North Carolina at Wilmington, Wilmington, North Carolina, USA Elizabeth A Associate Professor of Operations Management, Department of Decision and Information Sciences, CT Bauer College of Business, University of Houston, Houston, Texas, USA Keywords Service quality, Quality management, Health care, Students Abstract This study provides an analysis of the quality of service provided by a university health care center Students' expectations and perceptions of the center's services are identified by a survey A second survey was administered to the employees of the center to compare student perceptions to those of the employees Based on the results of this study, specific recommendations are made to improve the performance of the center The implementation of these recommendations should also reflect a change in the students' perceptions about the quality of service provided by the center The authors would like to thank Ms Judy Bowers, the director of Student Health Center at UNCW for her collaboration in this research # MCB University Press [ISSN 0952-6862] [ 260 ] Introduction Quality management has become an important issue to both the academic community and practitioners in the health care industry Under the increasingly prevalent managed care model, health care providers are being forced to drive down costs, while at the same time maintain acceptable levels of quality These pressures are especially acute for public university health clinics, which must survive with decreased state funding and limited student service fees Thus, health care administrators must contain costs, yet not allow the quality of care to suffer Consequently, the ability to define, measure, and monitor quality is critical to the survival of university health clinics, as well as other public health care institutions This paper describes research undertaken to assess the quality of service provided by a university health clinic Due to the intangible nature of health care service provision, objective measures of service quality levels are scant However, research has shown that patients can provide valuable information regarding their expectations and perceptions of health care service delivery Moreover, within the university clinic setting, students' importance-performance evaluations of service delivery are useful in resource allocation decisions Kennedy and Kennedy, 1987; Anderson, 1995) The SERVQUAL instrument, developed by Parasuraman et al 1988), was administered at the University of North Carolina at Wilmington's UNCW) Student Health Center during Spring 1996 semester to assess the quality of service provided by the clinic The research register for this journal is available at http://wwwmcbupcom/research_registers The results are currently being incorporated into the clinic's strategic planning process, specifically with respect to budgeting for quality improvement projects The most important outcome of this research is the linking of student perceptions of service quality to resource allocation decisions Specifically, the results of this study indicate areas in which UNCW Student Health Center must allocate more funds to improve performance, as well as areas in which additional investment is unnecessary, and perhaps even counterproductive Background The University of North Carolina at Wilmington UNCW) has defined itself as a ``total quality university'', and is committed to continuous, university-wide improvement in the products and services it provides It seeks to achieve this objective by meeting customers' expectations and ``doing the right thing right the first time'' Moving toward fulfilling its role as a total quality service provider on the UNCW campus, the Student Health Center has formed a Quality Assurance Team QAT) consisting of volunteers from the center's staff The UNCW Student Health center is a university health clinic providing noncritical health care to the approximately 9,000 UNCW students through walk-in and appointment services The center treats walk-ins on a first-come, first-serve basis Services offered by appointment include: gynecological examinations, physical examinations and counseling prior to receiving oral contraceptives, and examinations for sexually transmitted diseases In addition to appointment The current issue and full text archive of this journal is available at http://wwwemerald-librarycom/ft

services, the center provides inoculations and weekly orthopaedic clinics Emergency and critical care cases receive immediate treatment and are then referred to fullservice health care units in the Wilmington area The Student Health center is organized within the UNCW Division of Student Affairs To provide these services, the university has contracted with a local hospital The center has a staff of 15: the director, two half-time physicians, two fulltime nurse practitioners; two full-time registered nurses; two full-time licensed practical nurses; a half-time nurse practitioner; a full-time medical technologist, receptionist, transcriptionist, and records/ office assistant; a half-time clerk, and the center's director Between July 1995 and June 1996 the center treated 3,731 students in 9,880 visits, averaging over 800 visits monthly Visits to date in 2001 are exceeding 1,000-1,200 monthly The center is focusing on delivering services in a timely manner and meeting or exceeding students' expectations Presently the center does not have information on student expectations or perceptions of its services This information would allow the center to focus more clearly on service quality and to allocate its resources more effectively Kennedy and Kennedy, 1987) This study seeks to identify student expectations and perceptions of service quality delivered by the center, identify student user demographics, identify employee perceptions of services delivered, and if there is a difference between student and employee perceptions, determine the causes of these differences The next section provides the methodology used for the student and employee surveys with results from two surveys, section three describes the differences between the two surveys and the last section provides conclusions and recommendations Methodology Past studies of health care quality measurement emphasize the use of the SERVQUAL method of analysis Babakus and Mangold, 1992; Donthu, 1991; Reidenbach and Sandifer-Smallwood, 1990) The SERVQUAL instrument, developed by Parasuraman et al 1988), is a 22-item questionnaire covering five dimensions of service quality; tangibles, reliability, responsiveness, assurance, and empathy Customers' perceptions of service quality are compared with their prior expectations to identify gaps SERVQUAL is also useful in determining the relative importance of these five dimensions in influencing customer perceptions and tracking quality trends over time In this study, the SERVQUAL instrument, as modified for health care by Mangold and Babakus 1991), was administered to approximately 500 UNCW students Part I of the survey asked students about their contact frequency with the center as well as their estimate of the time spent at the center Part II required students to rank the five service quality attributes related to university health clinics in general, based on the attribute's relative importance to them Part III focused on students' expectations of university health clinic in general on 22 items within the five service quality dimensions, while Part IV focused on students' perceptions of the UNCW Student Health Center in particular For each question in Parts III and IV, a five-point Likert scale of ``strongly agree'' to ``strongly disagree'' was used Finally, Part V of the survey collected demographic information such as student classification, age, gender, and medical insurance status The surveys were administered by various faculty members throughout the university in their respective classes The faculty members were specifically chosen to ensure a representative sample of students based on their major and classification ie freshman[1], sophomore, etc) Each faculty member was instructed to read the directions and provide no additional information or comments Students completed the survey using general purpose National Computer Standards Institute answer sheets form number 30423) The scan sheets were processed by Academic Computing Services at UNCW Service gap scores were calculated by subtracting perceptions from the corresponding expectations E-P) Thus, negative gap scores indicate that perceptions exceeded expectations, and positive gap scores indicate that perceptions fell short of expectations The data was analysed using SPSS by examining frequencies, cross tabulations, Pearson R correlations and regression analysis In addition to the existing survey variables, new service quality differential variables gap variables) were generated and examined These gap variables were derived by subtracting the variable for a given student's perception from the corresponding expectation variable Much research on service quality focuses on the evaluation of this gap between customer expectations and perceptions [ 261 ]

[ 262 ] Parasuraman et al, 1988; Donthu, 1991; Mangold and Babakus, 1991; Reidenbach and Sandifer-Smallwood, 1990) However, Parasuraman et al 1985) suggest that management policies and processes can affect customer satisfaction They further suggest that there are ``gaps'' between management's perceptions of service performance and customers' perceptions and expectations In their study, it was shown that a customer's level of satisfaction is determined by the summation of these gaps Therefore, if the various gaps between management perceptions, policies, and actual service delivered and customer perceptions and expectations could be minimized, then customer satisfaction would increase Babakus and Mangold 1992) took the SERVQUAL model one step further by soliciting the opinions of health care personnel They not only evaluated the patients' expectations and perceptions, but compared these to employees' perceptions of the quality of care provided They were building on Gronroos' 1984) belief that there are two forms of quality that are relevant to service-providing organizations: technical quality and functional quality Technical quality refers to the technical accuracy of the diagnosis, while functional quality is the manner in which the health care service is provided to the consumer Babakus and Mangold's 1992) study not only evaluated the consumers' expectations and perceptions of the health care environment, but also used hospital management to help address the practical and user-related aspects of the evaluation To identify the center employees' perceptions of service delivery, a modified SERVQUAL survey was administered to all 14 employees This survey paralleled that of the student survey in format and question wording, but did not include demographic information The first portion of the survey asked them to rank order the five service quality determinants tangibles, reliability, responsiveness, assurance, and empathy) as they related to university health care clinics in general Employees were then asked to indicate to what extent they perceived their level of service delivery based on a five-point Likert scale with anchors ranging from strongly agree designated as a 1) to strongly disagree designated as a 5) Information from the student survey was compared with that of the employee survey A series of T-tests were then conducted to determine the statistical significance of the differences between these scores A confidence level of 095 was used throughout the analysis At this point it should be noted that no statistically significant differences can be claimed between student and employee responses, largely due to the small number of employees In addition to the SERVQUAL questionnaire, the employees participated in an informal interview The employees were reassured that their responses would remain anonymous, and would be used to improve the quality of the overall service provided Initially, employees were asked general questions pertaining to job satisfaction In the second part of the interview the employees were given the results of the survey, followed by a discussion of differences with the students' responses The third part of the interview highlighted any perceived outliers in the responses in the employee survey as well as the differences between their responses and those of the students Results Student survey A total of 405 per cent of the respondents to the survey were seniors, 214 per cent were juniors 216 per cent were sophomores and 149 per cent were freshmen A total of 647 per cent of the respondents were female, and 932 per cent were full-time students Table I shows these student demographics A total of 654 per cent of the respondents lived off campus in Wilmington There were no significant differences in ages, 865 per cent of the students had health insurance, with 726 per cent of those insured through their family, 909 per cent of the respondents were white and 655 per cent of those responding to the survey had used the clinic, with 781 per cent of these having used it four times or less A total of 813 per cent of the respondents estimated their total time in the clinic during their last visit at 15 hours or less, with 28 per cent estimating one hour, while 776 per cent of the students estimated they waited 30-44 minutes or less during their last visit The forced choice rating scale in Part II showed that students rated the ability of the center to deliver services dependably and accurately as the most important item 536 per cent) Students chose the knowledge and courtesy of the center's employees as the second most important item 333 per cent), and willingness to help and promptness of service were rated as the third most important items 30 per cent) In Part III of the survey, which identified the expectations of the students, the respondents chose ``strongly agree'' for:

Table I Student demographics Percentage Classification Freshmen 149 Sophomore 216 Junior 214 Senior 405 Gender Female 647 Male 353 Status Full-time 932 Part-time 68 Knowledgeable: 819 per cent Safe with interactions: 789 per cent Willingness to help: 65 per cent Up-to-date equipment: 661 per cent When services will be performed: 633 per cent In Part IV of the survey, which identified the perceptions of the students, the respondents chose ``strongly agree'' for: Knowledgeable: 129 per cent Safe with interactions: 14 per cent Willingness to help: 133 per cent Up-to-date equipment: 101 per cent When services will be performed: 116 per cent The most significant computed differences between the indicated expectations of the students and their perceptions of how well the center was meeting those expectations at a ±2 or less value) were: Knowledgeable: 224 per cent Safe with interactions: 264 per cent Willingness to help: 222 per cent Up-to-date equipment: 184 per cent When services will be performed: 372 per cent Table II shows the ``strongly agree'' responses to the students' expectations and perceptions to five areas, and the differences between them Figure 1 shows the relative differences between students' expectations and perceptions concerning the five most important areas designated by students Employee survey The rank order portion of their survey allowed employees to express what they believed should have been the most important criteria for evaluating university health care clinics, in general In this section, employees felt that students valued the dimension of reliability most of all This was followed by assurance, empathy, responsiveness, and tangibles It is interesting to note that the students' responses support the findings of Parasuraman et al 1985), in what they believed should have been the order of importance for service quality determinants: reliability, responsiveness, assurance, empathy, and tangibles Although there were some differences as to the statistical modes of the individual rankings, both groups most frequently listed reliability as the most important determinant and tangibles as the least important determinant of service quality in a university health care environment The second portion of the employee survey referred to the same five key determinants as in the first portion, but asked specific questions relating to the employee's perceptions of the quality of service provided by UNCW's Student Health Center Statistically significant differences were found at a confidence level of 095 for all but one of the areas Differences in the mean scores for questions were discussed in a follow-up interview with the employees In the interview, the employees were asked questions pertaining to job satisfaction They expressed that their biggest challenge as a care provider was working in the environment of contracted services and having to remain flexible in the event of a change of Medical Director who traditionally set the policies for the clinic The employees also felt pressure to satisfy a diverse customer base For instance they felt a need to please their direct customers the students), in addition to meeting the expectations of the parents of those students and the university in general The employees expressed that medical policies and a lack of protocol for patients added to job dissatisfaction However, they suggested that team-building exercises would lessen some of the job-related anxiety The employees stated that the most enjoyable part of their job was working with their co-workers and the students, who they described as being challenging and teachable The desire to join the health care profession seemed to be based on the employee's desire to fulfill their potential The second portion of the interview related to the employee survey, particularly focusing on the differences between student and employee responses The first difference was found in response to the question, ``The UNCW Health Center has up-to-date equipment'' Although a majority of the students believed the center to have modern equipment, 214 per cent of the employees [ 263 ]

Table II Students' ``strongly agree'' responses Knowledgeable Safe with interaction Willingness to help Up-to-date equipment When services will be performed Expectation 819 789 65 661 633 Perception 129 14 133 101 116 Difference 69 649 517 561 517 Figure 1 Students' ``strongly agree'' responses [ 264 ] disagreed Upon discussion, it was discovered that the definition of ``up-to-date equipment'' was unclear Some of the employees viewed their medical equipment to be sufficient, but felt that the definition of equipment should also encompass office equipment and personnel skills A second question where there was just one outlier pertained to the employees' willingness to help patients Ninety-three percent of the employees surveyed either strongly agreed or agreed It was hypothesized, however, that at times the employees felt that their ``hands were tied'' by policies A related question, concerning employees having the patients' best interests in mind, resulted in the same approval rate with the same reasoning At the end of the interview, the employees expressed their beliefs that they seemed to meet the emotional needs of the students despite policies that may have made them feel otherwise Comparison of student and employee results Most of the students and employees believed that the tangible aspects of the center were met That is, the respondents generally agreed that the center was visually appealing and that the employees were neat in appearance A third question relating to the tangible component, referred to the center having up-to-date equipment This had the strongest difference between the means of the data in this area, but was not statistically significant when tested Students also felt that the center was responsive in relation to being told when the services would be performed and the receipt of prompt service from the center employees However, there was a significant difference between the mean perceptions of the employee's willingness to help patients The mean perception for students in this area was 2307, meaning they were between agreeing and neither agreeing nor disagreeing On the other hand, the employees felt they did show willingness to help with a mean of 150, meaning that they were between strongly agree and agree Strong differences in the mean scores from the respondents, both statistically and visually, were shown in the areas of reliability, assurance, and empathy These concerns also appeared in the different scores for employees and students Generally, the employees were between

strongly agree and agree for the questions pertaining to their ability to make the patients feel safe with their interactions with clinic staff Mean responses were similar regarding the staff's knowledge, politeness, ability to answer questions, provide personal attention and having the patients' best interests in mind The mean student perceptions of the center, on the other hand, were between agree and neither for the same questions, with a majority of the mean scores in the range of 220-230 These results support findings by Gillette et al 1982) that client satisfaction is correlated with perceived technical competence and interpersonal skills of the health care provider Some of the differences in these areas were discovered in the expectation-perception gap of the earlier student survey Most noteworthy from that survey were the large gaps between the expectations and perceptions of the students in whether the employees appeared to be knowledgeable and the patients felt safe in their interactions with clinic staff There was a significant difference in the scores for the overall rating of the service quality Students rated the overall quality of the center at a mean of 2391, meaning that they believed the service to be between good and average On the other hand, the employees felt that they were providing a level of service between good and excellent The difference in these perceptions was found to be statistically significant and the reasons can be attributed to a combination of the key quality determinants Conclusions and recommendations The literature suggests that the service dimensions crucial to patient satisfaction are patient confidence, staff competence, interest in the patient's well-being, and a sense of security The expectations of the students validated these findings with the majority of students strongly agreeing that staff members should be knowledgeable and willing to help Likewise, students indicated that they expect to feel safe with interactions, should be told when services will be performed and that the clinic's equipment should be up-to-date However, it is also obvious that students' perception of the center's performance does not match their expectations Based on the student survey results, recommendations for addressing these concerns are listed as follows: 1 Change students' expectations: educate students, make them more aware of services; provide center information on waiting room TV similar to preview guide); distribute mailings at beginning of each semester; provide information on VAX; leave tent cards on table in dining hall; and Make information available in the waiting room 2 Change student perceptions: Up-to-date equipment concerns: ± Are employees grumbling about equipment? ± Is the low perception of equipment more a function of the university than the Center? ± If the service the student requests is beyond the capability of the Center, could this be perceived as an up-todate equipment concern? ± Reality ± Is the equipment up-to-date? put employee diplomas on walls throughout the center; move clock in waiting room to an out of the way location; ensure up-to-date magazines are in the waiting room; ensure that the TV works and interesting programming is available; revise forms to reduce redundancy and increase efficiency 3 Overall management considerations: set aside a period each week, during normal work hours to hold meetings; survey employees to determine their perceptions of the quality of their service performance and compare the results with the student survey results; survey employees to determine their knowledge of the importance of customer satisfaction; based on the above surveys, determine what training would be appropriate to ensure the employees have the knowledge, attitude, and skills to improve customer satisfaction; interview students to get their opinion of ways to improve the center; identify peak hours and seasonal trends to allow the use of flex time, or to add staff to satisfactorily meet demands; place a suggestion box in the waiting area; and purchase a label maker to increase record keeping efficiency The findings of this study provide a baseline comparison for future research [ 265 ]

[ 266 ] and evaluation To continue with the research, the following actions were recommended: Conduct a follow-up student survey within one year A majority of the recommendations pertaining to the modifying of the students' perceptions and expectations have been implemented and should be reflected in a follow-up survey In the same respect, another employee survey should be conducted to determine if there have been any changes in attitudes over that time If there has been a change in staff, the survey should definitely be conducted to determine a basis of comparison The follow-up survey will need to clarify the definition of ``up-to-date equipment'', allowing for a more accurate reading of the perception gap An attempt should be made to improve the quality determinants of assurance and empathy Students should be surveyed to determine how the center can improve these areas As a result of the center's continuous efforts to improve the quality of service provided to the students, the center conducts student surveys about the health services they receive The center uses the results of the students' responses to analyze how they can improve the health care services provided by the health care providers In addition, the center also participates in the American College Health Association benchmarking studies The center continues to focus on quality health care that is convenient, efficient, accessible, and cost-effective for the students, which is evidenced by the following list of recent accomplishments: Existing services have been expanded and enhanced with the addition of new services including: HIV testing, male health screening, pre-participation screening of all athletes and interdisciplinary prevention and education The 1998 time study conducted by the center indicated that 96 per cent of Student Health Center patient visits were completed within 60 minutes or less The Student Health Center user evaluation 2000) indicated that 985 per cent of the students visiting the center were satisfied to very satisfied with the services that they received The center ranked second out of 16 universities in the North Carolina senior survey 2000) in patient satisfaction with quality of care Students have access to information regarding health services through brochures, presentations, and the center's Web site The physical environment has been enhanced with new signage, equipment, and furnishings Changes in the health care industry have given health care providers the ongoing challenge of providing quality care to patients while maintaining cost-cutting effectiveness How patients feel about the quality of care received at a clinic will determine the future success or failure of a clinic In the case of those providers who are contracted by a university, the provision of quality service will determine the likelihood of contract renewal In order to improve upon the current level of service, quality must be defined and measured And, in defining and measuring this level of quality, a health care provider must know the patients' perceptions As contracted service providers, employees of the UNCW Student Health Center are very concerned with customer perceptions and expectations As health care providers, they realise the need for continuous quality improvement It is through this pro-active approach to improvement that they will be able to provide the university with the highest level of quality health care Note 1 Freshman, less than 27 semester hours credit SHC); sophomore, between 27 and 58 SHC; junior, between 59 and 88 SHC; senior, more than 89 SHC References Anderson, EA 1995), ``Measuring service quality at a university health clinic'', International Journal of Health, Vol 8 No 2, pp 32-7 Babakus, E and Mangold, G 1992), ``Adapting the SERVQUAL scale to hospital services: an empirical investigation'', Health Services Research, Vol 26 No 6, pp 767-86 Donthu, N 1991), ``Quality control in services industry'', Journal of Professional Services Marketing, Vol 7 No 1, pp 31-54 Gillette, JL, Byrne, TJ and Cranston, JW 1982), ``Variable affecting patient satisfaction with health care services in the college health setting'', Journal of American College Health, Vol 30 No 4, pp 67-170 Gronroos, C 1984), ``A service quality model and its marketing implications'', European Journal of Marketing, Vol 18 No 4, pp 36-44

Kennedy, DW and Kennedy, SL 1987), ``Using importance performance analysis for evaluating university health services'', Journal of American College Health, Vol 36 No 1, pp 27-31 Mangold, WG and Babakus, E 1991), ``The front stage vs the back stage perspective'', The Journal of Services Marketing, Vol 5 No 4, pp 59-70 Parasuraman, A, Zeithaml, V and Berry, LL 1985), ``A conceptual model of service quality and its implications for future research'', Journal of Marketing, Vol 49, pp 41-50 Parasuraman, A, Zeithaml, V and Berry, LL 1988), ``SERVQUAL: a multiple-item scale for measuring consumer perceptions of service quality'', Journal of Retailing, Vol 64, pp 12-37 Reidenbach, RE and Sandifer-Smallwood, B 1990), ``Exploring perceptions of hospital operations by a modified SERVQUAL approach'', Journal of Health Care Marketing, Vol 10 No 4, pp 47-55 [ 267 ]