1. Introduction

The emergent of healthcare industries in Malaysia open up career opportunities for citizens and it also contributes to the country’s income as in[20]. The growth is influence by many forces that lead to the changes in directions of most healthcare industries in the world. Some of the forces include the monitoring by public and private groups, increased information availability and a markedly better-informed clientele have begun to exert significant pressures on healthcare providers to reassess their strategies[20]. The healthcare industries also realized that by improving and meeting the patient’s satisfaction can lead to success and allow them to remain competitive in the market.

Traditionally, research that has been done in the area of patient satisfaction mainly focusing on service improvement efforts by large public and private hospitals. Reference[9] indicate large hospitals often conduct patient satisfaction survey to fulfill accreditation requirements and also to tie patient satisfaction score to financial incentive such as bonus for all clinical and non-clinical workers.

At the moment, the Parasuraman model, which consists of five generic dimensions which are tangibility, reliability, responsiveness, assurance, empathy is widely being use to measure service quality.

Since, the 1Malaysia Clinic is a newly launch community clinics there is a need to ponder on some of its potential shortfall. As written in the Malay Mail (21st February 2010) 1Malaysia Clinics are operated by medical assistants and nurses only and this violates the Medical Act. The act stated that only licensed doctors can run a health clinic. In The Star (7^th January 2010), it stated that there was a study conducted in 2009 by a group of doctors in Penang revealed that medical assistants at government health clinics and hospitals were found to be liable for many medication errors.

Another issue that arises from the establishment of 1Malaysia Clinic is redundancy. The Malaysia Medical Association (2010) think that setting up 1Malaysia Clinic is redundant with the currently existing district health clinics and private clinics operated by many general practioners (GP) in most urban area in the country. Not only that it is redundant, the majority of 1Malaysia Clinics are sited at a highly populated area that consists of well off or middle class income earners and this group of people could at all times have the funds for treatment at a private clinics if they are unhappy with the services offered in the public facilities such as 1Malaysia Clinic.

Inequity is foreseen to happen as 1Malaysia clinic operates in urban areas whereas it should also include rural areas as part of its location. This is because of most of lower income earning citizen usually live in the rural areas.

Issues discussed above are just some of the problems that have been voiced out by some party at the commencement of 1Malaysia Clinic. As a starting point, this research could help to answer on the successfulness of 1Malaysia Clinic and at the same time could provide some recommendations for improvement. Therefore the objective of this research was to examine the relationship between patient satisfaction and service quality at 1Malaysia Clinic.

2. Literature Review

2.1. Patient Satisfaction

Customer satisfaction represents a profitable competitive strategy variable because studies shown that the public is tends to pay more for care from quality institutions which are better disposed to satisfy customers’ needs[3],[10]. Delivering customer satisfaction is also crucial because today’s buyers of healthcare services are better educated and more aware than in the past[20]. Plymire, (1991); Reiichheld & Sasser, (1990); Strasser, (1995), as referenced by[21], healthcare services are an industry where customer satisfaction is critical to building a customer franchise and word-of-mouth recommendations are crucial.

As in[7] refer to patient satisfaction as a function between orientation of patients and conditions provided by healthcare professionals, and in their view patients defer in what they want and expect from their encounters with healthcare professionals or healthcare institutions. On the other hand, Lebow (1983) as stated in[19] defines patient satisfaction as the extend to which service gratified the desires of patients regarding structure, process and outcome dimensions and characteristics.

In[17] illustrates that here is a number of different “definitions” as to what is meant by service quality. One that is commonly used defined service quality as the extent to which a service meets customers’ needs or expectations Service quality can thus be defined as the difference between customer expectations of service and perceived service. If expectations are greater than performance, than perceived quality is less than satisfactory and hence, customer dissatisfaction occurs[13],[11]. However, according to Strasser and Davies as stated in[17] considered patient satisfaction as a direct respond to situation experienced.

2.2. Service Quality

One service quality measurement model that has been extensively applied is the SERVQUAL Model developed by the Parasuraman,[13],[14],[15]. SERVQUAL is the most often used approach to measure service quality and to compare customers’ expectations before a service encounter and their perceptions of the actual service delivered: The SERVQUAL instrument has been the predominant method used to measure consumers’ perception of service quality. There are five generic dimensions or factors of SERVQUAL model as follows:

1) Tangibles: Physical facilities, equipment and ap pearance of personnel

2) Reliability: Ability to perform the promised service dependably and accurately

3) Responsiveness: Willingness to help customers and provide prompt service

4) Assurance: (Including competence, courtesy, credibility and security). Knowledge and courtesy of employees and their ability to inspire trust and confidence.

5) Empathy: (including access, communication, understanding the customer). Caring and individualized attention that the firm provides to its customers.

The popularity of SERVQUAL with researchers can be explained mainly by its ease of use and by its adaptability to diverse service sectors.

2.3. Relationship between Patient Satisfaction and Service Quality

Distinguishing between service quality as a cognitive construct and satisfaction as an effective construct suggests a causal order that positions service quality as an antecedent to satisfaction. This is consistent with the attitude theoretical framework proposed by Fishbein and Ajzen (1975) and refined further by Bagozzi (1992) as stated in[19]. Although not absolute, much evidence has been documented for the service quality to satisfaction link in recent consumer satisfaction studies including those in the area of health care marketing.

A basic agreement derived from the wide range of literature on service quality and customer satisfaction is that service quality and customer satisfaction are conceptually distinct but closely related constructs[15].

Traditionally, the quality of medical care has been described as its ability to increase the probability of desired patient outcomes and decrease the probability of undesired outcomes[6]. This approach implies that care quality can be measured by the extent to which patients’ physiological functions have improved as a consequence of receiving medical care services[22]. Therefore, there is a relationship between patient satisfactions and the outcomes received from the quality service[4].

Past research on patient satisfaction has also found a linkage between satisfaction and hospital utilization. While the majority of past findings supported a positive relationship[5], several studies presented evidence for an inverse relationship between satisfaction and the frequency of outpatient visits[11]. As patients gain experience, or as their medical condition change during the treatment process, patients may modify their expectations. It is also likely that their evaluation criteria or the priority placed on the outstanding service quality dimensions may evolve from the day they first visit the hospital[4].

3. Research Framework and Hypotheses

In the process of developing a research framework for determining the relationship between service quality dimensions and patient satisfaction which is adapted by[13], this study posit all five dimensions of SERVQUAL. The research framework served as a parameter to the variables involved in the study as follow Figure 1.

The independent variable was all five dimensions of service quality namely SERVQUAL Model adapted by Parasuraman, Berry, & Zeithaml. This study was to find out whether there exists relationship between service quality on patient satisfaction. Patient satisfaction was treated as the dependent variable of the study.

Figure 1. Conceptual Framework for The Relationship between service quality dimensions and patient satisfaction. (SERVQUAL Model by Parasuraman, Berry, & Zeithaml (1994))

3.1. Hypothesis

As in[13], the study found a significant relationship between pm staff and project management performance. Following this model, the researchers proposed the following hypothesis:

H₁ Service quality has a direct relationship with patient satisfaction.

4. Methodology

4.1. Contexts and Participants

The participants of this study were 366 outpatient of 1Malaysia Clinic in Gombak and Rawang, Malaysia. A total of 400 questionnaires were distributed through personally. However, only 366 questionnaires were obtained and valid. This is equivalent to 91.5% of the response rate and according to[2], if the response rate is 70% and above, it is very good. The respondents were asked to describe their personal opinion of the service obtain at 1Malaysia Clinic to a 5-point Likert-type scale with the value of: 1-strongly disagree, 2-disagree, 3-neutral, 4-agree and 5-strongly agree.

4.2. Instruments

A questionnaire was developed for examining the relationship between service quality and patient satisfaction. In doing so, 29 items of questionnaire was developed and adapted from previous research with response options ranging from 1-strongly disagree, 2-disagree, 3-neutral, 4-agree and 5-strongly agree and 4 items for demographic details. The questionnaire was based on the questionnaire developed by[13]. However, the questionnaire was slightly been modified based on the suitability and necessity of the study.

4.3. Reliability Test

The instruments used in this study were tested for validity and reliability to ensure a high-quality measure.

Cronbach Alpha was used for the purpose of reliability measurement. Cronbach Alpha coefficients of all the variables were well over 0.9 (α=.956) which indicated that the internal reliability of the individual constructs was high. This value indicated that the questionnaire was suitable for the purpose of study as value of 0.9 is considered as excellent[18]. The individual constructs reliability that range from 0.709 to 0.861. Table 1 is the summary of the construct and reliability test.

The study used both descriptive and inferential statistics. The descriptive statistic included mean, frequency, standard deviation, variance, range, min and max. The presentation of the descriptive statistics is in the form of tables. Statistical tool used was SPSS version 17.0 and the data have been analyzed using The Spearman Rho Correlation Coefficient and multiple regression.

Table 1. Construct And Reliability Test Construct Items in scale Cronbach's Alpha Tangibles 5 .709 Reliability 5 .838 Responsiveness 5 .840 Assurance 5 .861 Empathy 5 .831 Patient Satisfaction 4 .760

5. Findings

Preliminary analysis was performed to ensure no violation of the assumptions of normality, linearity, and homoscedasticity. However, the data is not normal, for this reason the researcher used Spearman Correlation. Based on the findings, the survey attempts to seek the relationship between these two categories. There was a negative, weak, and significant relationship between the two variables (r=-.304, n=366, p<.05). Therefore, the researchers reject the directional hypothesis. Table 2 is the result of the correlation indicating that the higher the service quality is associated with lower patient satisfaction.

Table 2. Correlation Patient Satisfaction Service Quality Spearman’s Rho Correlation -.304** Sig. (1-tailed)N .000366

Table 3. Hypothesis Results Hypothesis Result Beta t Sig. Result H1 -.405 -8.452 .000 Reject

Figure 2. Result of analysis

6. Discussion

Cronbach alpha value which was used to measure the reliability of the instrument was found to be highly satisfactory. But the hypothesis set in the study that there is a direct relationship between service quality and patient satisfaction is rejected by the findings.

The correlation value between service quality and patient satisfaction is -0.304. There was a negative, weak, and significant relationship between the two variables. Therefore, the researchers reject the directional hypothesis. Results of the correlation indicate that the higher the service quality is associated with lower patient satisfaction. This is supported by[8] as their research conducted in regional university hospital in southern Spain also reported that even the better the service quality provided the patient’s satisfaction tends to be lower. Analysis of covariance showed that the only factors significantly associated with lower patient satisfaction were female gender, higher educational level, lower overall satisfaction with the hospital.

7. Conclusions

The relationship between service quality and patient satisfaction was investigated in this study. According to[13], SERVQUAL is the most often used approach to measure service quality and to compare customers’ expectations before a service encounter and their perceptions of the actual service delivered. It was hypothesized that there is a significant relationship between service quality and patient satisfaction. In order to test this hypothesis, a questionnaire was administered to 366 outpatient of 1Malaysia Clinic in Gombak and Rawang, Malaysia. All five dimensions of SERVQUAL model developed by[13] was used to measure the items in this study. Cronbach alpha of all the variables were well over the 0.7 min set by[12], which indicated that the internal reliability of the individual constructs was quite high. The internal reliability of the overall model was also found to be 0.956 which is an excellent result. But the findings of this study indicate that correlation value between service quality and patient satisfaction is- 0.304 which shows that there was a negative and weak relationship between the two variables. In addition, regression analysis also reveals that factor of service quality was significantly has a negative relationship with patient satisfaction with the value of (t=-8.452, p-value<0.05). The Malaysia Ministry of Health should look at new areas that would affect patient satisfaction other than tangibility, reliability, responsiveness, assurance, and empathy.

ACKNOWLEDGEMENTS

The authors are gratefully acknowledged Research Management Institute (RMI, Universiti Teknologi MARAffor funding this full research under Dana Kecemerlangan (DKC).