Journal of Indian Academy of Oral Medicine and Radiology

ORIGINAL ARTICLE
Year
: 2020  |  Volume : 32  |  Issue : 3  |  Page : 209--215

Assessment of service quality in special care dentistry department using SERVQUAL model


Prasanthi Sitaraman1, Karpagavalli Shanmugasundaram2, Arvind Muthukrishnan1,  
1 Department of Oral Medicine and Radiology, Saveetha Dental College, Saveetha Institute of Medical and Technical Sciences (SIMATS), Chennai, Tamil Nadu, India
2 Department of Oral Medicine and Radiology, Seema Dental College and Hospital, Rishikesh, Uttarakhand, India

Correspondence Address:
Dr. Arvind Muthukrishnan
Professor and Head, Department of Oral Medicine and Radiology, Saveetha Dental College, Saveetha Institute of Medical and Technical Sciences (SIMATS), 162, Poonamallee High Road, Chennai - 600 077, Tamil Nadu
India

Abstract

Background: Special care dentistry, also known as special needs dentistry includes treating patients who are physically disabled (congenital, traumatic, and/or physiological), medically compromised (systemic, genetic, and/or acquired), and cognitive deficit (mental, sensory, emotional, and/or behavioral) who experience barriers to preventive and routine dental care. Aim: The purpose of this study was to assess the quality of treatment received by the patients in the special care dentistry department using SERVQUAL model. Setting and Design: This descriptive, cross-sectional study was conducted at the special care dentistry department, Unit of Oral Medicine and Radiology department. Materials and Methods: The study population consisted of 384 patients treated in the Special care dentistry department from December 2017 – December 2019. Each participant's demographic data and reason for referral was recorded. Participant or the participant's caregiver was asked to fill the expectation questionnaire of the SERVQUAL model and required dental treatment was provided. Post treatment, the participant was asked to fill up the perception questionnaire. Each question was assessed using a 5-point Likert scale. Multiple statistical analyses was done to calculate the discrepancy between perception and expectation scores which is denoted by the statistical term “Gap value.” Results: Most patients belonged to the age range of 51–60 years. The commonest reason for referral was being medically compromised. All five domains of the SERVQUAL model showed high expectation, perception scores, and positive gap values. Conclusion: The SERVQUAL model has been validated as an effective service assessment tool. In our study, this SERVQUAL model which was employed in the special care dentistry, Unit of Oral Medicine Department for patients with special needs showed positive expectation and perception scores in all five domains which denotes effective patient care.



How to cite this article:
Sitaraman P, Shanmugasundaram K, Muthukrishnan A. Assessment of service quality in special care dentistry department using SERVQUAL model.J Indian Acad Oral Med Radiol 2020;32:209-215


How to cite this URL:
Sitaraman P, Shanmugasundaram K, Muthukrishnan A. Assessment of service quality in special care dentistry department using SERVQUAL model. J Indian Acad Oral Med Radiol [serial online] 2020 [cited 2020 Nov 26 ];32:209-215
Available from: https://www.jiaomr.in/text.asp?2020/32/3/209/296591


Full Text



 Introduction



The Rights of Persons with Disabilities Act, 2016 defines a person with disability as, “a person with long term physical, mental, intellectual or sensory impairment which, in interaction with barriers, hampers his full and effective participation in society equally with others.”[1] According to Indian census 2016, 26.8 million (2.21%) of Indian population are disabled. A total of 20% of the disabled persons are having disability in movement, 19% have disability in seeing, and another 19% have disability in hearing. A total of 8% have multiple disabilities. Most of the disabled population are within the age group of 10–19 years (17%).[2] People with disabilities have a right for equal standards of health and care as the general population. However, the structural, financial, psychosocial, and cultural barriers have rendered the access to dental treatment difficult. Despite the fact that these barriers are established, little is known about the difficulties that these groups of patients experience during treatment. Disability of any kind can hinder the maintenance of oral health. The pattern of oral diseases is alike in both disabled and nondisabled population, but the treated disease is comparatively more in the nondisabled population. Providing dental care to a person with disability, may require modifications. Attending to the oral health needs of these patients requires special training and knowledge to cater to the increased number of patients with special needs.

The specialty of Special Needs Dentistry/Special care dentistry was introduced in the United States of America and the United Kingdom. Special Care Dentistry (SCD) is the branch of Dentistry, which provides preventive and treatment oral care services for people unable to receive routine dental care due to physical, intellectual, medical, emotional, sensory, mental, or social impairment, or a mixture of these factors. SCD deals with the improvement of oral health of individuals and groups in society who fall within these categories.[3] It requires a comprehensive approach that is specialized in order to meet the complicated requirements of people with impairments. The Joint Advisory Committee for Special Care Dentistry (JACSCD) was established in 2000 in London to publicize, introduce, and develop a curriculum, training standard, and assessment methods. In 2005, SCD was recognized as a specialty by the General Dental Council (GDC) in the United Kingdom. It is a registered specialty in four countries: Brazil, Australia, New Zealand, and the UK.[4],[5]

Special care dentistry, also known as special needs dentistry includes treating patients who are physically disabled (congenital, traumatic, and/or physiological), medically compromised (systemic, genetic, and/or acquired), and cognitive deficit (mental, sensory, emotional, and/or behavioral). These patients experience many barriers to preventive and routine dental care. Psychosocial issues include dental anxiety and past negative experiences, limited transportation—not all dental clinics are wheelchair accessible—and sensory impairments such as hearing and vision problems.[6]

SCD is an upcoming specialty in India. The knowledge of the dental professionals in treating special needs patients is very limited when compared to that of their peers from other countries. Sensitization of dental students for treating such patients is necessary for better understanding of their problems and provide necessary treatment.[7] Dental professionals recognize the lack of experience and clinical exposure to patients with disabilities for their inability to treat this patient cohort.[4],[7] Hence, changes in curriculum, both at UG and PG levels need to be done to enable dental professionals to be more competent to treat patients with special needs.

Patient expectations and needs toward healthcare needs to be the primary factor of consideration for effective healthcare delivery. Service quality assessment helps policy makers to assess effectiveness of healthcare functioning and for healthcare professionals to access the quality of work rendered by them. Integration of service quality in healthcare can lead to the enhancement of the treatment provided by medical professionals. The previous experiences of the patient would influence their current expectations. Eliciting the gap between the perception and expectation of the patient community can provide the professionals with ample evidence on which domain of service quality needs improvement and those domains that are satisfactory.[8]

From a business point of view, service quality is an achievement of consumer/customer satisfaction. A service with quality can satisfy the customers' needs and demands. One of the most validated methods of assessment is the SERVQUAL model devised by Parasuraman, Zeithaml and Berry in 1988.[9] The SERVQUAL model is based on five service quality dimensions—Reliability, Assurance, Tangibles, Empathy, and Responsiveness (RATER). Considerable changes were done to the original questionnaire based on research done to validate the model in different settings. The questionnaire has two sets of 22 identical statements. Each statement is graded on a Likert scale. One set is used to quantify the quality of services expected of the customer. In the other set, the customer rates the service received. The GAP model is used to calculate the disparity between two sets of the questionnaire.[10]

Use of SERVQUAL model in healthcare, including dentistry is well – established. The application of the SERVQUAL model in special care dentistry is next to nothing. Therefore, this study was designed to investigate the quality of service experienced by patients in the Special care dentistry department.

 Materials and Methods



This descriptive, cross-sectional study was conducted over 24 months (from December 2017 to December 2019) at the special care dentistry, Unit of Oral Medicine and Radiology department.

Patients referred to the Special care dentistry department were screened for eligibility to be included in the study. Patients who fulfilled the inclusion criteria were invited to take part in the study after an explanation of the objective and the methods to be adopted. Patients or the patients' caregiver signed a consent form before undergoing dental treatment. If patients were unable to sign a consent form, the patients' caregiver were informed about the purposes of the study and a signed consent was obtained.

After sample size calculation, 384 patients treated in the Special care dentistry department were included.

Inclusion criteria

Patients referred to the special care dentistry department for the following reasons:

Medically complex patients

On polypharmacy for various systemic disorders – cardiovascular, respiratory, musculoskeletal, genitourinary, gastrointestinal, and neurological disordersPatients with altered immune statusPatients who underwent organ transplantationsPatients under medication or with a history of various infectious diseases including Tuberculosis, Hepatitis B, and HIV/AIDSPatients under medication for various mental health-related issuesPatients who seek dental clearance prior to undergoing major surgeries such as Coronary artery bypass graft surgery

Geriatric patients - Patients over the age of 70 yearsAnxious and petrified - Patients who are exceedingly anxious to be treated in a regular dental setupPregnant patients - Patients at different stages of pregnancyMentally challenged patients - Syndromic and nonsyndromic patients with intellectual disabilitiesPhysically and verbally disabled patients

Patients bound to wheelchairSpeech, vision, and hearing impaired

Oncology patients

Patients who underwent chemotherapy/radiotherapy for cancer affecting different parts of the bodyPatients who are scheduled for surgery/chemotherapy/radiotherapy seeking dental clearance.

Exclusion criteria

Patients who are considered unfit/high risk for routine dental treatmentPatients whose dental treatment is deferred due to existing systemic conditionsPatients with special needs but could not be treated in routine outpatient setting.

Data collection and tools

The patient's interview and data collection was performed by the primary researcher. Each participant's demographic data and reason for referral to the Special Care dentistry department was recorded. Participants or the participants' caregiver was asked to fill the expectation questionnaire of the SERVQUAL model. The required dental treatment is provided to the participant. Post treatment, the participant is asked to fill up the perception questionnaire of the SERVQUAL model.

Both expectation and perception questionnaires consisted of 22 questions based on the 5 domains— Reliability, Responsiveness, Empathy, Assurance, and Tangibles (RATER domain). Questionnaires were prepared in both English and Tamil. The translation of the questionnaire was done by a Professor in Tamil with more than 20 years of experience in translation. If the patients are unable to fill the questionnaire, the patient's caregiver was asked to fill. In case of illiterate patients, the primary researcher explained the questions and recorded appropriate responses given by the patients.

Domain 1: Reliability

1. When treatment is promised, it is done

2. Discipline of staff

3. Delivery of treatment right in the first time

4. Provision of treatment at the time promised

5. Keeping patient records correctly without mistake

Domain 2: Responsiveness

6. Information provided on when treatment will be performed

7. Provision of prompt treatment

8. Doctors are always willing to help

9. Accessibility of doctors when needed

Domain 3: Empathy

10. Giving individual attention to each patient

11. Operating hours appropriate to all patients

12. Doctors give personal attention to patient

13. Doctors have patient's best interests at heart

14. Understanding of the specific needs of patients

Domain 4: Assurance

15. Feeling security and safety in receiving treatment and communication with staff

16. Adequate explanation related to health - related problems

17. Doctors' knowledge to answer patient questions

18. Courteous and polite behavior towards patient

Domain 5: Tangibles

19. Neat and professional appearance of doctors

20. Cleanliness of health center environment

21. Adequacy of equipment in health center

22. Visual appealing and comfort of physical facilities

Each question under all 5 domains was assessed in a 5 – point Likert scale

1 – Highly disagree

2 – Disagree

3 – Neutral

4 – Agree

5 – Highly agree

Each response was assessed and a total score in each domain was calculated for both expectation and perception as scored by the patients.

Wilcoxon signed rank sum test was done for individual questions obtained from the patient to calculate the discrepancy between perception and expectation scores which is denoted by the statistical term 'Gap value.' Paired t – test was conducted for comparison of expectation and perception scores between each domain. One way ANOVA was done was to analyze if there is a significant difference in mean Gap score based on the reason for referral for being treated in the Special care dentistry department.

 Results



A total of 384 patients were included in the study (M = 209, F = 175). [Table 1] and [Graph 1], [Graph 2], [Graph 3] represent the general patient characteristics and reasons for being treated in a special care dentistry department.{Table 1}[INLINE:1][INLINE:2][INLINE:3]

The most common reason for getting treated in a special care department was being medically compromised. Other common reasons include Oncology (history of treatment for cancer or cancer patients scheduled for surgery/chemotherapy or radiotherapy), Physical and sensory disability (patients bound to wheelchair for patients with speech, vision, or hearing impairment) and Geriatric patients (patients over the age of 70 years).

The results [Table 2], [Table 3], [Table 4] show that the highest and lowest means of patients' expectations and perceptions were in the order of tangibles, assurance, empathy, responsiveness, and reliability. All gap values were positive which reveals that all expectations were fulfilled. Furthermore, it should be noted that the least gaps were also related to tangibles.{Table 2}{Table 3}{Table 4}

Wilcoxon Signed Rank sum test indicated that median perception scores were statistically significantly higher than the median expectation scores for all questions except question 17. Paired t – test conducted to compare the mean scores between domains showed a statistically significant difference between the mean expected and perceived scores in all five domains.

To analyze if the reason of being treated in special care influences the gap score obtained, one-way ANOVA was carried out. There were no statistically significant differences between group means. In Tukey's HSD post hoc test, only the medically compromised and pregnancy groups were statistically significant.

 Discussion



One of the objectives of a dental department pertaining to the treatment of special needs patients, the knowledge and access to patient satisfaction is considered an important criteria for determining the success and quality of the services provided.[11] This study aimed to measure the quality gap in dental services provided at the special needs dentistry department using the SERVQUAL model through the viewpoints of treated patients.

The concept of quantification of patients' expectation and perception in the form of SERVQUAL gap score proved very successful in assessing the service quality. Parasuraman et al. designed the model in such a way that it can be used for any service organization. The large negative gaps facilitates prioritization and improvement of performance. The large positive gaps imply that not only the expectations are fulfilled, but exceeded. The SERVQUAL model has been used for closing Gap 5 – which is the difference in patients' expectation and perception.[12] As the service industry is largely based on individual perceptions, tools like SERVQUAL not only help in quantification of these perceptions but also in the identification of lacking domains. Based on the results provided by the model, service organizations can frame service agendas and improve access to existing services resulting in an improvement in the effectiveness and efficiency of services provided. Since SERVQUAL is an instrument with statistical validity and extensive field testing, it can be administered on a regular, repeated basis. It is used to determine if alterations brought about by the affected consumer perceptions and expectations have improved the perceptions over time and also allows yearly comparisons. It can also be used to determine the effectiveness of service development and improvement initiatives in different dimensions.[12]

The present study showed that the patients' perceptions were more than the expectations of the provided services. This means that the patients' underwent good quality care in the special care dentistry department. The overall means' of expectations and perceptions were found to be high which means that the patients had a high level of expectation and they were fulfilled. The highest mean of patients' expectation is related to the tangibles domain and is consistent to the study of Güllü et al.[13] The results can be considered inconsistent to the studies of Aghamolaei et al. and Dopeykar N et al.'s studies [Table 2].[14],[15]

The highest mean of patient's expectations and perception were related to assurance following tangibles. This result is similar to the study conducted in Poland by Manulik et al.[16] The results of studies by Naqavi and Bahadori, the highest and lowest means' of perceptions were also related to assurance and empathy.[17],[18] Reliability was ranked the highest and assurance the lowest service quality dimension in a study done by Ramez.[19] Responsiveness and reliability were regarded as the most and the least important dimensions in Abu Kharmeh's study.[20]

A number of studies have demonstrated a negative gap values in a number of items in five of the domains.[15],[21],[22],[23] This study has demonstrated a positive gap value unlike these studies, indicating the high service quality and hence high customer satisfaction.[24],[25],[26] This study demonstrated the largest positive gap in reliability and smallest gap in tangibles unlike Bahadori's study where the largest gap was identified in empathy.[17]

The hospital's physical environment plays a major role in service quality and acts as an important reason for the patients to come back to the hospital. Cleanliness of restrooms have been considered a second priority in tangible sections.[21] A gap in the tangible section should serve as an alarm for the administrative services of the hospital to drastically improve physical facilities. A least positive gap value of 0.10

was achieved for tangibles section in this study. The confidence and the trust of a patient can be gained with proper assurance. Assurance, as a domain, is concerned about how well the treating physician is able to communicate and give adequate explanation to the causal factors of the disease to the patient. Items 17 and 18 of assurance domain were recorded to have the highest mean expectation and perception scores. A gap value of 0.56 was recorded for assurance. The convergence of expectation and perception scores is evident across the dimension 'empathy.' This indicates that the OPD staff are giving the necessary attention and are compassionate towards patients. Giving individual attention to each patient and understanding the specific needs of the patients ranked to have the highest expectation and perception scores, respectively. A wide positive gap was noted in the dimension “responsiveness.” The items—provision of prompt treatment, information on when the treatments will be performed, Doctors are always willing to help, Accessibility of doctors when needed—had significantly higher perception scores. Dependable and helpful OPD staff are necessary for doctors to be able to provide prompt treatment.

 Conclusion



In conclusion, service quality assessment should be regularly employed in health care delivery. These service assessment tools help us to quantify the customer expectations and fulfilments. The SERVQUAL model has been validated as an effective service assessment tool. The special needs patients reporting for treatment experience many barriers for routine dental care. In Indian setting where dentists rarely make house visits, being treated in a special care department is their only chance for good quality dental care—both preventive and maintenance. Dentists, who are especially trained in treating patients with special needs are needed in our country where the population of disabled is on constant rise. In our study, this SERVQUAL model which was employed in the special care dentistry, Unit of Oral Medicine department for patients with special needs showed positive expectation and perception scores in all five domains which denotes effective patient care.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Ethical considerations

Approval for the study was obtained from the Scientific Research Board of the Institution and from the hospital administration (SRB/SDMDS11/17OMR/14) dated 28.11.2017.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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