the last couple of decades, service quality got significant attention and
interest of both researchers and practitioners in the literature of service
quality. Service quality is idealized as the consumer’s perception about the
degree of services either it is of high quality or low quality.7
Service quality is a distinctive and intellectual concept which is difficult to
define and measure. To that end, different scholars have presented different
definitions.5 Headley and Bowen have defined service quality as “the
difference between the needs of customers and what they actually receive.”8
Berry and colleagues have described service quality as “the level of service
compliance with the customer preferences.”9 The US National
Institute of Health, in 1983, highlighted that all health care organizations in
the United States should use the patients’ perspective in development of their
strategies and pay attention to them in evaluation of the employees’ training


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has been appreciable progress in the literature for the measurement of service
quality perceptions. There are mainly two conceptualizations. The first is the
“Nordic” perspective (Gronroos 1982), according to which the dimensions of service
quality consist of functional and technical quality.  The second, the “American” perspective
(Parasuraman, Zeithaml, and Berry 1988), includes five service quality
dimensions to assess the performance of service quality on the basis of each
dimension independently as well as the overall standard.1, 10 These
tools differ in their definitions, content, and measuremnent.11 

1. Two Dimensional Quality Model:

 Gronroos presented a
two-dimensional quality model that has two distinct facets, namely technical
quality and functional quality.12 The technical quality of
healthcare services refers to the accuracy of medical diagnosis, treatment and
procedures. The functional quality is related to non-clinical aspects like
conduct, behavior of staff during service provision, quality of food, and
cleanliness etc.13, 14, 15, 16 Patients can only assess the
functional quality of services rather than evaluating the technical services
because of deficit knowledge in medical services.14


2. Importance-Performance Analysis

assess the service quality, Importance-Performance Analysis Method has recently
been used in healthcare systems. This method identifies the strengths and
weaknesses of services and determines the improvement opportunities to develop
strategic planning. It interprets the current situation of each healthcare
provider from the perspective of different quality dimensions. This technique
is also helpful for administrative purposes such as allocating inadequate
resources to those areas of performance with considerable effect on consumer

3. Service Quality Gap Model:

 One of the best and
most widely used models for assessing the quality of healthcare services is the
Service Quality (SERVQUAL) model which was originated by Parasuraman and
colleagues in the mid-1980s.18 According to him, the service quality
is defined as “the difference between expectations and perceptions of
patients.”13, 19, 20 This model is also recognized as the gap
analyzer model.18 This model initially had 10 dimensions, now they
have been reduced to 5 which are described as follows: 21

Tangibles: Physical facilities, equipment and appearance of staff.

Reliability: Ability to perform the promised service dependably and precisely.

Responsiveness: Willingness to help the consumers and provide prompt service.

Empathy: Condolence and individualized attention.

Assurance: Knowledge and courtesy of employees and their ability to inspire
trust and confidence.

gap between the customers’ perceptions and expectations can have 3 states. 1.
When the consumer’s perceptions are higher than their expectations, the quality
is excellent. 2. When the consumer’s perceptions are at the level of their
expectations, the quality is good. 3. When the consumer’s perceptions are lower
than their expectations or do not meet their expectations, the quality is poor.4

number of studies have been done to measure the service quality from the
patients’ perspectives.19 Borie and Damanhouri had conducted a study
on inpatients in both the private and public hospitals and identified that the
association between demographic factors, except age, with the service quality
was satisfactory.22 Yesilada and Direktor showed that people are
more satisfied with the services provided by private hospitals as compared to
the public hospitals.23 Bowling’s study conducted on outpatients and
general practices in UK showed that older British females were more satisfied
with general practices compared with hospital outpatient services.24
Kumaraswamy conducted a study in corporate and non-corporate healthcare centers
using a service quality model. He showed that the patients are more satisfied
with 4 service quality factors; physician attitude, supportive staff,
environment, and service provision.25


Pakistan hospital service quality is a neglected area and much research is
needed to move towards continuous quality improvement. Several studies in
Pakistan have evaluated the service quality in hospitals using SERVQUAL model
and identified the gap to measure service quality using particular dimensions.
They found that private sector hospitals provide better quality services than
public sector hospitals.26 In Pakistan most of the public hospitals are
located in urban areas but still they are insufficient even for the people
living in urban areas. According to economic survey of Pakistan (2009), total
number of registered doctors in the country is 139,555, total number of
dentists 9,822 and registered nurses 69,313. Population per doctor is 1,183 27
and population per bed is 1,592.22 In Pakistan the total cost on
healthcare is still lowest as compared to the same income level countries in
the region which was 0.54 percent during the year 2012.26

to World Health Systems’ ranking of World Health Organization, Pakistan’s
health system is 122nd which is a grave concern indeed. For the
success and prosperity of such country, a healthy population is needed to
enhance and achieve sustainable growth in every field of life.13
Therefore the focus is on a tertiary care teaching hospital’s service quality
by investigating the perceptions of patients about the medical services

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