PUBLIC HEALTH SERVICE QUALITY
AT THAI NGUYEN NATIONAL GENERAL HOSPITAL

A Dissertation Proposal
Presented to
the Faculty of the Graduate Program
of the College of Arts and Sciences
Central Philippine University, Philippines
In Collaboration with
Thai Nguyen University, Vietnam

In Partial Fulfillment
of the Requirements for the Degree
DOCTOR IN PUBLIC ADMINISTRATION

NGUYEN THI LAN ANH
December, 2016


ii

TABLE OF CONTENTS
ACKNOWLEDGEMENTS ............................................................................................................................................i
TABLE OF CONTENTS................................................................................................................................................ ii
LIST OF TABLES............................................................................................................................................................ iv
LIST OF FIGURES .......................................................................................................................................................... v
LIST OF ABRIVIATIONS ........................................................................................................................................... vi
ABSTRACT ....................................................................................................................................................................... vii
CHAPTER I. THE PROBLEM AND ITS SETTING......................................................................................... 1
1.1. Background and Rationale of the Study.......................................................................... 1
1.2. Objectives of the Study ................................................................................................... 4

3.3.2. Cronbach's Alpha ................................................................................................... 46
3.3.3. Likert Scale ............................................................................................................ 47
3.3.4. Exploratory Factor Analysis (EFA) ....................................................................... 48
3.3.5. Analysis of variance (ANOVA)............................................................................. 52
3.4. Ethical Considerations................................................................................................... 52
3.5. Data Gathering Procedure ............................................................................................. 53
3.6. Data Processing and Data Analysis ............................................................................... 54
CHAPTER IV. DATA PRESENTATION, ANALYSIS AND INTERPRETATION .......................... 57
4.1. Some health care indicators in Thainguyen province ................................................... 57
4.2. General information of Thai Nguyen National Hospital ............................................... 59
4.3. Current status of public health services at Thai Nguyen National Hospital ................. 67
4.4. Survey results about health services at Thainguyen National Hospital ........................ 71
4.4.1. General information of surveyed department ........................................................ 71
4.4.2. General information of respondents ...................................................................... 74
4.4.3. Analysis of service quality through SERVQUAL model ...................................... 77
4.4.4. Exploratory Factor Analysis (EFA) according to the patient‘s perception ............ 88
4.4.5. Regression analysis ................................................................................................ 97
4.4.6. Analyzing the difference in accordance with personal characteristics ................ 100
CHAPTER V. CONCLUSION AND POLICY RECOMMENDATION...............................................104
5.1. Summary of findings ................................................................................................... 104
5.2. Conclusions ................................................................................................................. 109
5.3. Policy recommendations ............................................................................................. 111
REFERENCES...............................................................................................................................................................117
APPENDIX ......................................................................................................................................................................121


iv

LIST OF TABLES
Table 2.1. Summary of service quality (SQ) definition ........................................................... 24

Table 5.1. Comparing Dimensions of service quality of the study with theories................... 107


v

LIST OF FIGURES
Figure 1.1. Donabedian‘s model in assessing quality of health services ................................... 7
Figure 1.2. Model of service quality by PZB ........................................................................... 10
Figure 1.3. Modified SERVQUAL model in health care sector .............................................. 12
Figure 1.4. The conceptual Framework .................................................................................... 12
Figure 2.1. Health care environment – setting system regulation ............................................ 21
Figure 2.2. Factors affecting services quality of Parasuraman ................................................. 26
Figure 3.1. Research process .................................................................................................... 44
Figure 3.2. Model of 5 factor affecting service quality at TNH ............................................... 49
Figure 4.1. Averge Yearly per capita GDP of Thainguyen and Vietnam ................................ 57
Figure 4.2. Health personnel density and Hospital bed density of Thainguyen ....................... 58
Figure 4.3. Image of Thai Nguyen National Hospital ............................................................. 59
Figure 4.4.Organizational structure of Thai Nguyen National Hospital .................................. 62
Figure 4.5. Number of patient from 2013 to 2015 ................................................................... 68
Figure 4.6. Total quality score of hospital according to 83 criteria.......................................... 69
Figure 4.7. Radar chart of quality score in 5 aspects of hospital quality.................................. 70
Figure 4.8. Figure of quality improvement in 2014 and 2015 via radar chart.......................... 71
Figure 4.9. Examination process maps ..................................................................................... 73
Figure 4.10. Electronic Table Name ......................................................................................... 73
Figure 4.11. Electronic transport system for patients ............................................................... 74
Figure 4.12. Survey result of using Health Insurance Card (HIC) ........................................... 74
Figure 4.13. Expectation and perception of Tangibility dimension ......................................... 78
Figure 4.14. Expectation and perception of Reliability dimension .......................................... 79
Figure 4.15. Expectation and perception of Responsiveness dimension .................................. 81
Figure 4.16. Expectation and perception of Assurance dimension .......................................... 83

IMS
HIC
PZB
QIP
TNH
JCI
EFA
VND

Electronic Health Record
Gross Domestic Products
Indicator Measurement System
Health Insurance Card
Parasuraman, Zeithaml and Berry
Quality Indicator Project
ThaiNguyen National Hospital
Joint Commission International
Exploratory Factor Analysis
Vietnam Dong

USD
SPSS
TAN
REL
RES
ASS
EMP
SAT
GSO


While quality in tangible goods has been thoroughly described and measured by
marketers, quality of services has yet a lot to be done. Accurate measurement of service
quality as perceived by patients has yet to reach a consensus for healthcare organizations.
Quality has not happen by chance; it needs to be systematically developed with objective
planning, staff involvement and considering patient need.
Today for the health service market in Vietnam and the all over the world, there is a
need for a health service quality model that takes into consideration a complete coverage of
the dimensions that consumers use in evaluating healthcare service quality. The research to
be conducted focuses on service quality, patient satisfaction and intentions to return, and the
consumer role in the health care service encounter.
The main objective of this research was to formulate and empirically investigate a
fully tested and applicable healthcare service quality model that encompasses the criteria
patient use in evaluating health services in Thainguyen province for public sector hospitals.
Also, research aims to provide a valid and reliable scale with which healthcare providers
can use for measurement of the service quality in their organizations.
The research was composed of two phases. The first phase aimed to assess health
service quality through SERVQUAL model using questionnaire and through a secondary
data gathering process, qualitative interviews with experts and Thainguyen patients. The
second phase was a full-fledged quantitative survey to test and verify the quality of health
service through EFA model and the scale developed for the health care market at Thai
Nguyen National Hospital.
The first phase has enabled the researcher to achieve several goals. The in-depth
interviews with patients enabled gathering their insight on what are the factors that patients
expected and perceived in their recent hospital experience and the secondary data gathering
process identified the dimensions uncovered by previous researchers for healthcare service
quality. A tentative questionnaire was constructed based on this and was further refined
through the pilot study and the in-depth interviews with healthcare experts. This further
developed the previous preliminary questionnaire and model constructs and final
modification were done on the questionnaire format preparing it for the next phase of
quantitative data collection.


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CHAPTER I
THE PROBLEM AND ITS SETTING
1.1. Background and Rationale of the Study
Health quality can be defined as the degree to which health services for individuals
and populations increase the likelihood of desired health outcomes and are consistent with
current professional knowledge (Institute of Medicine, 2001).
Major health care quality concerns (such as patient safety and effectiveness of care)
are basically the same across different types of countries. In a low – income country like
Vietnam, quality related problems are much more prevalent. Major factors that cause health
care quality problems in Vietnam are: Lack of sufficient management (clinical and
administrative); Inadequate medical staffs and training; Weak performance monitoring
systems; Non-empowered patients and families. Once we can assess the relative
appropriateness and effectiveness of health services, we can provide optimal care to patients
and maximize our use of scarce resources.
Because of increasing competition, service providers and more demanding patients,
service quality has become a watchword for healthcare service providers but as yet has
proven difficult to measure. Service quality has been directly linked to repeat sales, positive
word-of-mouth and recommendation. Consumer satisfaction is directly linked to service
quality thus perceived quality, patient satisfaction and behavioural intentions are concepts of
foremost importance to healthcare marketers (Ross et al., 1987; John Joby, 1992; Paul, 2003).
There exists number of shortcomings in medical policies and medical services
mechanisms in Vietnam. Large investment resources but effective use of resources to supply
medical services doesn‘t meet practical requirements posed. Currently, people assess the
quality of health services are implemented only sensible levels, mainly through external audio
visual facilities and the behaviour, reception and care of medical staffs. As for the quality of
technical, medical science, in fact, underestimate people. The provision of health services is
now revealing many negative issues such as drug abuse, chemical, laboratory ... to the

inferior to the advanced countries mentioned above. It is caused by overworked staff, poor
service quality, and complex administrative procedures; cumbersome ... A survey of over
700 patients taken by VN Express in Vietnam showed that 57 % Vietnamese people do not
want to use the services of hospitals in the country by the attitude and ethics of the medical
staffs. It is raising a question of ―Does the medicine of our country have won the confidence
of the patient?‖
Medical service is a very special service. In essence, health service includes activities
performed by medical staff as health examination and treatment for patients and families
(Journal of Marketing, 2009).
Institute of Medicine (2001) defines quality of health care is the degree to which the
health services are provided to individuals and the population to increases the desire of health
outcomes and match current professional knowledge. Quality of health services will
determine the existence of hospital and can be measured through the patients‘ satisfaction.
Previously, it is thought that the evaluation and quality assurance is limited in developed
countries (Thomason & Edwards, 1991), in the developing countries; the problem of improving


3

medical quality received little interest until recently (Reerinks and Sauerborn, 1996). For public
services, the quality assessment has also received little attention (Narang and Ritu, 2011). The
quality of medical services is assessed from two points of view: technical and functional
(Institute of Medicine, 2001). Technical quality refers to aspects related to the diagnosis and
procedures while functional quality refers to aspects related to the way services are provided to
the patients (Narang and Ritu, 2010). To be successful in long term a health care organization
must effectively monitor and manage both technical and functional quality (Babakus and
Mangold, 1992). Functional quality is often considered as the main key to determine the quality
by customer perception because it is difficult to precisely assess the technical quality due to lack
of professional experience (Donabedian, 1980).
Thai Nguyen is a large mountainous province in northern area of Vietnam with 1.2

Thai Nguyen National General Hospital (From October, 2016 has been renamed to Thai
Nguyen National Hospital) is located at Phan Dinh Phung ward, right center of Thainguyen City.
The hospital was established in 1951, this is a state own hospital – one of the largest hospital in
Thai Nguyen province and in North mountainous area. Thainguyen National Hospital (TNH) is
maintained the first class hospital with bed size of 1200 units, the highest level of treatment is
responsible for direct health care for more than 1.2 million people in Thainguyen province, and
the ultimate treatment venue in North mountainous provinces. The hospital has 40 wards,
department and centres with high quality medical staffs. In order to reach the mission of
deploying advanced techniques of thoracic surgeries, tumours, resuscitation, heart disease; the
satellite clinics of leading Central hospital in Northern mountainous area of Vietnam, the
completion of human resources and enhancing quality of hospital‘s health services is necessary.
Especially, in the coming competitiveness and higher demand as well as quality for health
services boost all hospital to a number of opportunities and threats.
Today for the healthcare services market in Thainguyen city, there is a need for a
healthcare service quality model that takes into consideration a complete coverage of the
dimensions that consumers use in evaluating healthcare service quality. Hence, the evaluations of
health services through the patients‘ satisfaction as well as health provider‘s perspective of
awareness and managing quality were needed. Provision of health service quality is the top
priority in hospital management, especially in public sector. That is why the topic ―Public health
service quality at Thai Nguyen National Hospital‖ was chosen as the dissertation title. The
research was conducted with focus on services quality, patient satisfaction and intentions to
return, as well as the patient role in the healthcare service encounter.
1.2. Objectives of the Study
1.2.1. General objective
This study concentrates on quality assessment of the public health services at Thai
Nguyen National Hospital. Thus, improving health service quality as well as the competition
ability of hospital and contributing to meet the strategic objectives of Vietnam in terms of
public health services quality up to 2020.
1.2.2. Specific objectives
Specifically, this study seeks to:

Tangibles, Reliability, Assurance, Responsiveness, and Empathy on patient‘s overall
perceived of health service quality.
+ H1.1. There is no significant effect of “Tangibility” on patient’s overall perceived
of health service quality.
+ H1.2. There is no significant effect of “reliability” on patient’s overall perceived of
health service quality.
+ H1.3. There is no significant effect of “Assurance” on patient’s overall perceived of
health service quality.


6
+ H1.4. There is no significant effect of “Responsiveness” on patient’s overall
perceived of health service quality.
+ H1.5. There is no significant effect of “Empathy” on patient’s overall perceived of
health service quality.
- Hypothesis 2 (H2): There are no significant different in overall perceived hospital service
quality of patient according to their personal characteristics as age, gender, occupation,
income and educational level.
+ H2.1. There is no significant different in overall perceived hospital service quality
of patient according to their age.
+ H2.2. There is no significant different in overall perceived hospital service quality
of patient according to their gender.
+ H2.3. There is no significant different in overall perceived hospital service quality
of patient according to their occupation.
+ H2.4. There is no significant different in overall perceived hospital service quality
of patient according to their income.
+ H2.5. There is no significant different in overall perceived hospital service quality
of patient according to their educational level.
- Hypothesis 3 (H3): The higher patients‘ perceive of overall quality of health service is, the
better their satisfaction would be.


PROCESS

OUTCOME

• Foucus on the care
delivered to patients
(services or treatments)

• Effects of health care on
the status of patients
and populations

Figure 1.1. Donabedian’s model in assessing quality of health services
This model can be used to category quality indicators and frame the outcomes of an
EBP implementation program. In the Donabedian model, structure refers to the setting in
which care is delivered, and includes the attributes of material resources (e.g. facilities,
equipment), of human resources (e.g. number and characteristics of personnel), and of
organizational structure (e.g. medical staff organization, methods of peer review). Process
refers to the approaches or means of providing health care which includes the services and
treatments the patients receive. Outcome refers to the result or impact of care on the health
status of patients and populations. It may also involve improvements in patient‘s knowledge
& behavior and degree of patient satisfaction.
In this research:
 Quality of structure is determined in terms of quality system and ability of quality
assurance.
 Quality of process including quality of monitoring, investigation, intervention, health
education, supervision.
 Quality of outcome is considered as quality of services.
Quality has not happen by chance; it needs to be systematically developed with

indications of quality, applicable to both inpatient and outpatient settings and across the
continuum of care. In addition to informing the quality improvement plan, these measures can
be used to evaluate the quality of the system‘s care over time, how it performs relative to
stated strategic planning goals, and how it performs compared to similar organizations.
1.4.2. Measuring service quality: SERVQUAL model
Service quality is an approach to manage business processes in order to ensure full
satisfaction of the customers and quality in service provided. It works as an antecedent of
customer satisfaction. Measuring service quality has been one of the most recurrent topics in
management literature (Parasuraman et al., 1988; Gronroos, 1984; Cronin et al., 1992).
SERVQUAL is a service quality framework, developed in the eighties by Zeithaml,
Parasuraman & Berry, aiming at measuring the scale of quality in the service sectors. It has
emerged as perhaps the most popular standardized questionnaire to measure service quality. The
concept of SERVQUAL model is generally based on GAP theory of Parasuraman, 1985.


9

Parasuraman et al. (1988, p.15) define perceived quality as a form of attitude, related but
not equal to satisfaction, and results from a consumption of expectations with perceptions of
performance. Therefore, having a better understanding of consumer‘s attitudes will help know
how they perceive service quality in grocery stores. We have adopted the definition by
Parasuraman et al. (1988, p.5), which defines service quality as the discrepancy between a
customers‘ expectation of a service and the customers‘ perception of the service offering.
Service quality = Perception - Expectation (of the attribute performance)
Weighted SERVQUAL model:
∑(
Where:

)


From the SERVQUAL model, it has showed that the key to ensuring good service
quality is meeting what customers expect from the service and that judgement of high and low
service quality depends on how customers perceive the actual performance in the context of
what thay expected.
Word-of-mouth
Communications

Past experience

Personal
Needs

Expected
Service
Gap 5
Perceived
Service
CUSTOMER

PROVIDER

Service
Delivery

External

Gap 4

Communication
To

Gap 2: not selecting the right service designs and standard.
It is the difference between management perceptions of consumer expectations and
service quality specifications;
Gap 3: not delivering to service standards
This gap reflects the difference between service quality specifications and the service
actually delivered;
Gap 4: not matching performance to promises
This is the difference between service delivery and what is communicated about the
service to consumers;
Gap 5: Service gap
Close gaps 1 to 4 to meet customer expectations consistently. This is on the consumer
side, and it shows the difference between a consumer‗s actual and perceived about quality of
service.
Closing the gap between what customers expect and what they perceive is critical to
delivering quality service. It forms the basis or the starting point for the GAPS model.
1.5. Conceptual Framework
In this study, the researcher uses 5 SERVQUAL factors or dimensions to analyze the
overall perceived service quality of patients and level of their satisfaction as well as their intent
to return and recommend the hospital services with 25 item scales.


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Overall perceived
service quality

SERVQUAL factors
• Tangibility
• Reliability



DEMOGRAPHIC
S

Overall
Perceived
Service Quality

Perceived Service Quality



Age
 Gender
Ethnic

Patient

Occupation
 Income

Satisfaction






Education
 Using HIC

different income groups: Group 1: ≤ 2.0 million; Group 2: 2.1 – under 5.0 million;
Group 3: 5.1 - under 10 million; Group 4: ≥ 10 million).
(2 million VND/month is poverty standard in Vietnam from 2016 - 2020; 5.0 million
VND/month is estimated average income per month of Thainguyen in 2020, equivalent
to 2200 USD per year)


Education: The highest level of education that respondent attained. Dividing the market
into different education groups: It is express in terms of number of year that patient had
been studied at school or college. (1. High school and under; 2: Diploma/Some College;
3: Completed College/University; 4: Ph.D. or Master‘s Degree)

 Using HIC: Whether the patient using health insurance card or not (1: Using HIC; 0:
Not using HIC)


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 Satisfactions: is as a judgment following a consumption experience-it is the consumer‘s
judgment that a product provided (or is providing) a pleasurable level of consumptionrelated fulfillment (adapted from Oliver 1997)
 Patient Satisfaction: Allows the patient to personally evaluate their interpersonal
aspects of their care. (Medicine, Admission, Food Services, Physical Setting).
 Patient expectation: means uncontrollable factors including past experience,
personal needs, word of mouth, and external communication about
healthcare services. Patient expectations are standards or reference points that patients
bring into the service experience.
 Patient perception: means patient‘s feelings of pleasure/displeasure or the
reaction of the customers in relation to the performance of the hospital
staffs in satisfying/dissatisfying the services. These are subjective assessment of actual
service experience.
 Tangibility: is defined as external representation of the physical facilities, equipment,

and their willingness to help the patient and provide prompt service as well as the
caring, individualized display of professional ability to the patient- physician reliability:
The ability to perform the promised service dependably and accurately. In this study,
empathy is measured by a five - items question on the questionnaire which are
answerable by 5 level of satisfaction from highly satisfied to highly dissatisfied as
described in the Likert scale. The mean value for the empathy items is the measure for
empathy. The higher the mean, the higher will be the perceived empathy of the
respondents.
The author try to access the overall service quality of the hospital through patients‘
expectation and perception directly. The answers are based on a five-point Likert scale of
patients‘ overall satisfaction and their intention to return and recommend to others.
1.7. Significance of the study
Significance to Theory: The study findings help to build on the body of the existing
literature and knowledge. This can help to provide reference for future researchers and they can
carry out research with ease since this study provides secondary data to the researchers. The
study helps to build on the researcher‘s knowledge and understanding of the study variables. It
also helps the researcher to gain more skills of conducting research. It is a reference the
researcher to appreciate the concept of health care services.
Significance to Practice: The study findings help to identify and highlight the weaknesses
in health care service of hospital and how is patients ‗satisfaction. The analysis of SERVQUAL
model indicates that all patient satisfaction dimensions positively and significantly contributes
to patient satisfaction and which also act as an important mediating factor between the
satisfaction dimensions and service quality. Hospital‘s board of manager can find their
strengths and weakness in delivering health services, improving their services quality and
enhancing competition capacity of hospital to utilize resources and meet the need of patients.
The patients would have chance to express their opinion to contribute to the continuously
improvement of health care services in public hospital.


16

types of outcomes are studied in health care evaluations: those related to patients, those
related to treatments, and those related to the system. Patient-related outcomes represent the
effects of delivering care. In this research, the author only concentrates on the outcomes
related to patients and the system, and set aside the outcomes which are related to treatments
because of technical issues.
Patient-related outcomes represent the effects of delivering care in a particular system
on the patient‘s ability for self-care, physical function and mobility, emotional and intellectual
performance, and self-perception of health. System-related outcomes represent the effect on the
health care system produced by the provision of medical services to a patient population.
Examples of the outcomes studied in health services research include performance benchmarks,
requirements for pain medication, length of hospital stay, waiting times, frequency of read
mission, and frequency and severity of secondary health complications.


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CHAPTER II
REVIEW OF RELATED LITERATURE AND STUDIES
2.1. Review of related literature
2.1.1. The concept of public health service
 Public services
A study carried out by Johns (1998, p.954) points out that the word ‗service‘ has many
meanings which lead to some confusion in the way the concept is defined in management
literature, service could mean an industry, a performance, an output or offering or a process.
He further argues that services are mostly described as ‗intangible‘ and their output viewed as
an activity rather than a tangible object which is not clear because some service outputs have
some substantial tangible components like physical facilities, equipment and personnel.
According to economics view, public services related with these basic characteristics:
(1) Non-excludable: is the attribute that was created when it is difficult to exclude
anyone from using it. These goods do not have to rule are those goods that everyone can