Journal of Medical Society

: 2020  |  Volume : 34  |  Issue : 1  |  Page : 17--24

Development and validation of a new tool (TerHosQual) for assessing service quality in a tertiary care hospital

Shalini Natarajappa1, MD Ravi2, Byalakere Rudraiah Chandrashekar3, P Nagesh4,  
1 Department of Health System Management Studies, JSS Academy of Higher Education and Research, Mysore, Karnataka, India
2 Department of Paediatrics, JSS Medical College, JSS Academy of Higher Education and Research, Mysore, Karnataka, India
3 Department of Public Health Dentistry, JSS Dental College and Hospital, JSS Academy of Higher Education and Research, Mysore, Karnataka, India
4 JSS Centre for Management Studies, Sri Jayachamarajendra College of Engineering, JSS Science and Technology University, Mysore, Karnataka, India

Correspondence Address:
Byalakere Rudraiah Chandrashekar
Department of Public Health Dentistry, JSS Dental College and Hospital, JSS Academy of Higher Education and Research, Mysore, Karnataka


Background: Evaluating service quality (SQ) is an important consideration in the era of ever-increasing inflow of patients through medical tourism. This not only influences the satisfaction of customers but also their purchase intentions. Objective: The objective was to develop and validate a new tool (TerHosQual) for assessing SQ in a tertiary care hospital in Mysore, India. Materials and Methods: Initial tool consisting of 72 items was drafted by synthesizing literature review and inputs from subject experts. The items were segregated into 13 dimensions in consultation with three internal experts. Content validation was done by 12 subject experts. Based on their inputs, 21 items were deleted from the initial tool (8 items for lack of relevance, 6 items for lack of appropriateness, 3 items for lack of clarity of words, and 4 items for redundancy). Response process validity of the final tool consisting of 51 items under 13 dimensions was done using cognitive interview (retrospective verbal probing method). Test–retest reliability assessment was done on ten prospective participants to assess the reliability of the tool before pilot testing the tool on 30 participants. Results: It was found that the Cronbach's alpha if item deleted did not show significant improvement for any of 51 items in the tool as well as for 13 dimensions. The Cronbach's alpha coefficient for 51 items in the tool was 0.95 and for 13 dimensions, it was 0.87, indicating a high degree of reliability of the items in the tool under these dimensions. Conclusion: The pilot study demonstrated the feasibility of using this new tool in a tertiary care hospital while indicating the reliability of the tool. However, the tool needs to be further evaluated using a larger sample size and factor analysis to validate these results of the pilot study.

How to cite this article:
Natarajappa S, Ravi M D, Chandrashekar BR, Nagesh P. Development and validation of a new tool (TerHosQual) for assessing service quality in a tertiary care hospital.J Med Soc 2020;34:17-24

How to cite this URL:
Natarajappa S, Ravi M D, Chandrashekar BR, Nagesh P. Development and validation of a new tool (TerHosQual) for assessing service quality in a tertiary care hospital. J Med Soc [serial online] 2020 [cited 2022 Jan 20 ];34:17-24
Available from:

Full Text


Health is a fundamental human right. Everyone aspires to live a long and healthy life which is one of the three basic dimensions of human development.[1] India has witnessed substantial increase in population as well as in the number of doctors in the last few decades with doctor population ratio at 1:1800.[2] The living standard of people has improved in the recent past compared to what it was a decade ago and with this, the demand for quality services also is increasing.[2] Improvement in quality and appropriate management of services are crucial for sustained success in any sector including the health-care sector. Services are deeds, process, and performances which are not tangible things that can be touched, seen, felt, but, rather are intangible deeds and performance. Health-care services are actions (e.g., examination, diagnosis, treatment, and surgery) performed by providers and directed toward patients and their families. Patient satisfaction is an authentic standard for guesstimating service quality (SQ). Evaluating SQ is important for hospitals to keep their patients satisfied and retain them for long-term follow-ups.[1],[2],[3]

Quality is simply the process of continuous improvements; it is doing the right thing, right the first time, and doing it better the next. Of several definitions, the WHO defines the quality of care as “the extent to which health care services provided to individuals and patient populations improved desired health outcomes.”[4] To achieve quality health care, delivery of care must be safe, effective, timely, efficient, equitable, and people-centered. Two types of quality are usually discussed under hospitals; technical quality referring to “what patients get” and functional quality indicating “how they get it.”[5] In simplistic sense, technical quality indicates the level of accuracy of diagnosis and procedures, whereas functional quality suggests the manner in which the services are delivered. Patient satisfaction is a valid indicator of measuring SQ, where dissatisfaction helps to improve service.[6] Patient satisfaction explains the degree to which expectations of a patient are fulfilled by medical services. Besides, patient satisfaction is a decisive indicator to understand the patients' expectations.[7]

Many tools have been used for assessing SQ in a health-care setting. SERVQUAL measures the gap between perception and expectations of patients, and this is considered to be the yardstick for judging quality of a hospital.[8] Parasuraman et al. in 1988 developed the SERVQUAL model to measure perception of SQ based on five attributes; reliability, assurance, tangibility, empathy, and responsiveness.[9] The Joint Commission on Accreditation of Healthcare Organization in 1990 suggested combining the SERVQUAL model with dimensions of Coddington and Moore (1987) to frame a dimension tool. According to Duggirala et al.,[10] hospital SQ in developing countries consists of seven dimensions (personnel quality, infrastructure, administrative process, process of clinical care, safety, overall experience of medical care, and social responsibility). Padma et al.'s eight dimensions cover perceptions of patients and attendants.[11] Aagja and Garg[2] developed public hospital SQ (PubHosQual) based on five dimensions (admission, medical service, overall service, discharge process, and social responsibility). Despite these tools, there was a need to develop a tool that comprehensively covered most of the dimensions included in all these tools. In this background, we developed and accumulated initial validity evidence for a tool (TerHosQual) designed for assessing SQ in a tertiary care hospital in Mysore city, India.

 Materials and Methods

This process of development and validation of the tool was carried out over a period of 6 months from September 2019 to February 2020 after obtaining ethical clearance from the institutional ethics committee.

Initial pooling of items

The literature assessing SQ was reviewed by two independent investigators and items that are included in the most popular scales used for assessing SQ in a hospital were identified and pooled together as a first step.[12] One of the investigators undertook personal interviews with three subject experts to get their inputs on dimensions and items to be included while assessing the SQ in a tertiary care hospital. The initial tool of 72 items was drafted by synthesizing literature review and inputs from subject experts. The items were segregated into 13 dimensions in consultation with three internal experts.

Content validation

A template for content validation by subject experts was prepared. The template included information on rationale for scale development and intended application of this tool (for assessing SQ in a tertiary care hospital) in the beginning and 72 items under 13 dimensions subsequently. The template was communicated to 12 subject experts and each expert was requested to rate the relevance, appropriateness, and clarity of wordings used in each item on a Likert scale of 1–5. The ratings for relevance were coded as 1 = Not at all relevant, 2 = Not relevant, 3 = Relevant, 4 = Quite relevant, and 5 = Very much relevant. Similarly, the ratings for appropriateness of each item under the dimension concerned were coded as 1 = Not at all appropriate, 2 = Not appropriate, 3 = Appropriate, 4 = Quite appropriate, and 5 = Very much appropriate. The coding for clarity of wordings used in each item was also coded as 1 = Not at all clear, 2 = Not clear, 3 = Clear, 4 = Quite clear, and 5 = Very clear. The score given by each subject expert for each item on the scale was dichotomized into relevant or not relevant, appropriate or not appropriate, clear or not clear. The dichotomization was done by segregating score 3 and above as relevant, appropriate, and clear. Rating of 1 or 2 for any item was considered as lacking relevance, appropriateness, and clarity. The item and scale level content validity index was computed based on inputs from subject experts. Item level content validity indicates the proportion of experts giving item a relevance rating of either 3 and above. The scale level content validity indicates the proportion of items on a scale that achieves a relevance rating of 3 and above by all experts (universal agreement calculation method).[13] Based on inputs from 12 subject experts, 21 items were deleted from initial scale. Among these 21 items, 8 items were deleted for lack of relevance, 6 items for lack of appropriateness and 3 items for lacking clarity in the wording of items. Besides, six subject experts identified 4 items as redundant with other items. Hence, the final questionnaire after content validation by 12 subject experts had 51 items under 13 different dimensions.

Response process validity

The response process validity assessment of the tool was undertaken by conducting cognitive interview among prospective participants. The retrospective verbal probing method was used to assess the interpretation of each item from the participant perspective. The wording in three items of the tool was slightly modified based on inputs provided by the participants of cognitive interview. All experts expressed consensus on the modifications in the wording of these three items in the tool.

Reliability assessment

Test-retest reliability assessment was done by collecting data from ten different participants with a time interval of 48 h between the two interviews which was undertaken by a trained investigator. The amount of time taken for completing the interviews was noted. The Cronbach's alpha value was determined to indicate the degree of reliability of items.

Pilot testing

The tool having 51 items under 13 dimensions was then pilot tested on a group of thirty participants selected from the patients admitted in general wards of medicine and surgery units in a tertiary care hospital. The pilot study was conducted to assess the feasibility of administering the tool and response rate of participants. The tool was named as TerHosQual. Data on SQ were collected using this new tool. A personal interview was conducted by a trained and calibrated investigator. Each participant was requested to indicate one score for each item in the tool using a Likert scale (1 = Strongly disagree, 2 = Disagree, 3 = Neutral [neither agree nor disagree], 4 = Agree, and 5 = Strongly agree). [Figure 1] is the diagrammatic representation of the validation process adopted while developing this new tool. The new tool (TerHosQual) used in the present study is attached as Annexure 1.{Figure 1}

Statistical analysis

Data analysis was done using SPSS Version 24 (IBM, Chicago, USA). The reliability assessment for each item and dimensions was done.


Test–retest reliability assessment on ten participants found the Cronbach's alpha value to be 0.93. Item-Total Statistics for 51 items under 13 different dimensions of TerHosQual during pilot testing is summarized in [Table 1]. It was found that the Cronbach's alpha if item deleted did not show significant improvement for any of the 51 items in the tool. Cronbach's alpha coefficient was 0.95 indicating a high degree of reliability of the items in the tool. Item-Total Statistics for 13 different dimensions of TerHosQual during pilot testing is summarized in [Table 2]. Here also, we found that the Cronbach's alpha if item deleted did not show substantial improvement for any of 13 dimensions in the tool. Cronbach's alpha coefficient was 0.87 indicating a high degree of reliability of the dimensions in the tool.{Table 1}{Table 2}


Medical tourism has gained remarkable thrust in recent years. India is considered a preferred destination for obtaining health-care services by neighboring and some western countries in recent times. This could be attributed to low cost and good quality of treatment offered by hospitals in India. Besides the definite financial benefit, the availability of well-trained and English-speaking workforce, a mix of contemporary and indigenous systems of medicine, and super specialty centers equipped with state of art technologies available in the world are probably the other factors favoring India for medical tourism.[14]

Hospitals which fail to understand the consequence of meeting customer satisfaction could possibly be facing the threat of extinction. Literature has established that SQ not only impacts on the contentment of customers but also their purchase intentions.[11]

Although many tools such as SERVQUAL[9] and PubHosQual[2] have been used for assessing SQ, the present study made an attempt to develop a new tool for assessing SQ in a tertiary care hospital by considering all the important dimensions included in different popular tools. The new tool had 51 items grouped under 13 dimensions which provided a comprehensive assessment of SQ.

Dimension 1 (admission)

Three items pertaining to the time taken for admission, behavior of admission staff, and ability of hospital to manage emergency services were included. The process of hospitalization includes three main stages: an admission, an inpatient period, and the discharge process as a final stage. Lack of proper management in any of these three stages can adversely affect the SQ of the hospital and thereby, the patient perception. A study by Ortiga et al. has found that the standardization of admission process can positively impact on patient flow to the hospital.[15]

Dimension 2 (medical services)

It had three items which encompassed the availability of experienced physicians, nurses, and skilled workers in the hospital.

Dimension 3 (overall services)

Five items were included under this dimension which specifically elicited information on infrastructure such as ambulance facility and prompt services offered by the hospital. A study by Abbasi-Moghaddam et al. has found patients' perceptions of physician consultation, provision of information to patients, and environment of delivering services to be the vital determinants of SQ.[16]

Dimension 4 (discharge)

It had three items focusing on the discharge process and instructions given by staff during discharge. The discharge process can significantly improve the patient perceptions on the quality of services offered in the final stage of hospitalization according to a study by Ortiga et al.[15]

Dimension 5 (social responsibility)

This had two items which focused on equality in offering services and punctuality in doing so.

Dimension 6 (staff conduct)

It contained eight items focusing on behavior of staff of the hospital while offering treatment including the scope for protecting privacy of patients.

Dimension 7 (service quality and service availability)

This dimension had nine items that focused on the availability of state of art equipment and technology, catering services, registration process, waiting period, appointment scheduling, and billing process. According to Liu et al., emphasis to law-abiding behaviors, cost-effective health services, and charitable works can enhance perceptions of hospitals' adherence to social responsibility.[17]

Dimension 8 (confidence)

It had two items to elicit information on what is level of confidence that the patient has on hospital and what the patient says about professionalism of hospital staff.

Dimension 9 (continuity)

It had two items that focused on how the patient felt in the first contact with hospital and what is the perception of the patient for staying in contact with the hospital for follow-up and future needs.

Dimension 10 (communication)

It had three items that elicited information on communication process adopted by hospital and hospital staff with regard to new and existing services.

Dimension 11 (conducive environment)

It includes four items focusing on availability, accessibility, and maintenance of hospital ambience. Mosadeghrad has highlighted the fact that the factors that influence the quality of medical services in a hospital can be considered under three categories, namely the patient-related factors which may be in the form of patient illness, patient cooperation, etc.; the physician-related factors which could be in the form of physician sociodemographic variables, physician competency, motivation, and satisfaction; and the environmental factors which could be the reflection of health-care system, resources, and facilities.[18]

Dimension 12 (health-care costs)

It had four items which focused on cost and ability to handle complaints related to the billing process. The association between health-care quality and cost of health-care service is an important consideration in policy debates on whether cuts in health-care expenditure will negatively impact the quality or whether quality enhancement will reduce health-care expenditure. A systematic review by Hussey et al. found that there is an association between health-care cost and quality which is still poorly understood.[19]

Dimension 13 (customer loyalty)

This dimension had four items that focused on perceptions of patients in referring the hospital to friends based on the availability of reliable and effective services in the hospital. A study by Arab et al. has found that the hospitals' services have strong influence on final outcome variables that include willingness to return to the same hospital and reuse its services or recommend them to others. They concluded that the relationship between the SQ and patient's loyalty is strategically important to improve the SQ and for retaining patients while expanding the market share.[20]

The pilot study using this novel tool found that the response rate by participants was 100%.


This was an initial attempt to consider all important variables from various popular tools used for assessing SQ while developing a new tool.


Factor analysis could have identified the items that significantly contributed toward assessing SQ in this tool. We could not undertake factor analysis in this pilot study owing to small sample size.

Future scope

A study with larger sample size among patients admitted to a tertiary care hospital using this new tool and factor analysis can validate the items and dimensions included for SQ assessment in the present new tool used in this pilot study.


The new tool has 51 items included under 13 dimensions. These items and dimensions are considered as most important in determining the SQ of a hospital. The pilot study demonstrated the feasibility of using this new tool in a tertiary care hospital while indicating the reliability of the tool.


We sincerely thank all the study participants, subject experts, and participants of JSS hospital for their kind cooperation and at different stages of this project.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


Annexure 1: Items in the final TerHosQual tool used in the pilot study for assessing service quality in a tertiary care hospital

Please rate each item on a scale of 1–5 (1 – Strongly disagree, 2 – Disagree, 3 – Neutral [Neither disagree nor agree], 4 – Agree, and 5 – Strongly agree)



1Chandra Shekar BR, Reddy C. Oral health status in relation to socioeconomic factors among the municipal employees of Mysore city. Indian J Dent Res 2011;22:410-8.
2Aagja JP, Garg R. Measuring perceived service quality for public hospitals (PubHosQual) in the Indian context. Int J Pharm Healthc Mark 2010;4:60-83.
3Amin M, Nasharuddin SZ. Hospital service quality and its effects on patient satisfaction and behavioral intention. An Int J 2013;18:238-54.
4Tunçalp O, Were WM, MacLennan C, Oladapo OT, Gulmezoglu AM, Bahl R, et al. Quality of care for pregnant women and newborns-The WHO vision. BJOG 2015;122:1045-9.
5Iqbal Q, Hassan SH. Service quality about health sector of UK and Pakistan: A comparative study. Int J Manage Account Econ 2016;3:473-85.
6Al-Abri R, Al-Balushi A. Patient satisfaction survey as a tool towards quality improvement. Oman Med J 2014;29:3-7.
7Lee WI, Chen CW, Chen TH, Chen CY. The relationship between consumer choice of channel types: The health food industry as an example. Afr J Bus Manage 2010;4:448-8.
8Nadi A, Shojaee J, Abedi G, Siamian H, Abedini E, Rostami F. Patients' expectations and perceptions of service quality in the selected hospitals. Med Arch 2016;70:135-9.
9Parasuraman A, Zeithaml VA, Berry LL. Servqual: A multiple-item scale for measuring consumer perc. J Retailing 1988;64:12-40.
10Duggirala M, Rajendra C, Anantharaman RN. Patient-perceived dimensions of total quality service in healthcare, Benchmarking. An Int J 2008;15:560-83.
11Padma P, Rajendran C, Lokachari PS. Service quality and its impact on customer satisfaction in Indian hospitals. Benchmarking: An Int J 2010;17:807-41.
12Artino AR Jr., La Rochelle JS, Dezee KJ, Gehlbach H. Developing questionnaires for educational research: AMEE Guide No. 87. Med Teach 2014;36:463-74.
13Polit DF, Beck CT. The content validity index: Are you sure you know what's being reported? Critique and recommendations. Res Nurs Health 2006;29:489-97.
14Hazarika I. Medical tourism: Its potential impact on the health workforce and health systems in India. Health Policy Plan 2010;25:248-51.
15Ortiga B, Salazar A, Jovell A, Escarrabill J, Marca G, Corbella X. Standardizing admission and discharge processes to improve patient flow: A cross sectional study. BMC Health Serv Res 2012;12:180.
16Abbasi-Moghaddam MA, Zarei E, Bagherzadeh R, Dargahi H, Farrokhi P. Evaluation of service quality from patients' viewpoint. BMC Health Serv Res 2019;19:170.
17Liu W, Shi L, Pong RW, Chen Y. How patients think about social responsibility of public hospitals in China? BMC Health Serv Res 2016;16:371.
18Mosadeghrad AM. Factors affecting medical service quality. Iran J Public Health 2014;43:210-20.
19Hussey PS, Wertheimer S, Mehrotra A. The association between health care quality and cost: A systematic review. Ann Intern Med 2013;158:27-34.
20Arab M, Tabatabaei SG, Rashidian A, Forushani AR, Zarei E. The effect of service quality on patient loyalty: A study of private hospitals in Tehran, Iran. Iran J Public Health 2012;41:71-7.