Up to scratch?

Nottingham Occupational Health puts its quality of service to the test with
the Parasuraman’s Servqual tool.  By
Lesley Baxter

Are you providing an excellent quality of service for your occupational
health clients? The Servqual tool proved a useful way to explore the quality of
service provided by an OH department, and highlighted areas that could be
improved to increase customer satisfaction.

Nottingham Occupational Health (OH), which looks after the hospital and the
university, decided to measure the quality of service being offered to OH
clients by using Parasuraman’s Servqual model of service quality.1

Customer satisfaction and service quality (SQ) has been studied since the
early 1980s,2 and until recently, private retail industries were the main

Further research in the late 1990s related to the public service sector,
7,8,9 and subsequent research within healthcare settings is demonstrated in the
literature. 10,11,12,13

Despite this improved measurement of customer satisfaction from a patient’s
perspective, there is still a dearth of research in the occupational health
(OH) setting related to this topic.14

Measurement of service quality

The Servqual model addresses five aspects (or dimensions) of SQ of
importance to the customer (see box below).

The Servqual instrument comprises 22 statements used to assess SQ across the
five dimensions, with each statement used twice: once to measure expectations,
and once to measure perceptions.7

Although the Servqual model has been heavily criticised and debated for most
of the 1990s, it still dominates as a reliable and valid SQ measure.

Although Servqual has been successfully applied within a variety of private
and public sector settings, very little evidence exists of its use in an OH
setting. However, its benefits have been recognised, and consequently it may be
of great interest to the occupational health community if it proves to be a
valuable measure of SQ.

Study implementation

Due to the size and diversity of our OH client base, it was decided to
concentrate this study on the population of one NHS hospital (approx. 8,000
staff), half of whom attended the OH department over one year (October

Through a process of systematic sampling, 400 questionnaires were
distributed to the randomly selected subjects. Thirty were returned undelivered
and 115 were returned for analysis.

Of the sample group targeted, 18 per cent were male and 82 per cent were
female. This is not unusual, considering that the majority of participants hold
jobs that remain predominantly female-orientated. The mean age was 35.

It was useful to note (Figure 1, page 25) the fairly even response rate
across the range of healthcare professionals, which indicates that all workers
are interested in having their opinions considered, and that the less academic
still found the questionnaire easy to attempt.

Figure 2 (page 25) shows the health professional within the OH department
that the respondent saw at the time of their visit. The number seen by an OH
nurse is higher than any of the other categories, and this has a bearing on
future education and training priorities.


Table 1 (page 26) shows the questions asked and the five dimensions that
each item belongs to. The expectation section shows what the customers of the
NHS OH department would expect to encounter, and the perception section shows
what their perceptions of the department were after their experience. It is
clear that what the customer expected and what they received was not
dissimilar, but overall, the service provided was below their expectations.

Table 2 (page 26) demonstrates that the SQ areas of reliability and
assurance were equally the most important, with responsiveness and empathy a
joint second, while tangibility (appearance) was the least important factor for

Having identified what the customers think are the most important aspects of
SQ, Table 3 (see page 27) shows whether the OH department is meeting the
requirements of the customers. It compares their perceptions of the service
received and their ranking in importance of the five quality aspects.

As the perceptions section and the ranked statements section were separate
entities within the collected data, it proved difficult to compare with any
certainty whether or not the department is meeting the SQ needs of the customer
in accordance with what they consider important. However, it is evident that
perceptions of the service are positive, and in the areas of reliability and
assurance (the two most important features for customers), it seems the service
is delivering according to expectations.

Further breakdown of the questionnaires revealed some interesting findings.
The admin and clerical staff scored the lowest for satisfaction, but there is
no real evidence why this may be so. But the author notes that although the
administration and clerical staff attend the OH service for routine health
screening, they rarely require health surveillance intervention, advice or care
after, for example, a needle-stick injury.

Perhaps this more personalised care is what slightly improves satisfaction
scoring among the other job category respondents. There was no dissatisfaction
towards any particular aspect of the service, although there was a slightly
higher overall satisfaction rate in attendees for immunisation and health
screening, as opposed to referral by manager, nurse advice or counselling. It
is evident from the data displayed in Table 1 (left) that workers’ perceptions
of the ‘tangibility’ element of SQ within the OH department scored slightly
lower than other aspects of service quality. This correlates with the fact that
the OH department is old and requires some modifications.

The OH department’s opening hours are 8.30am to 5pm. Qualified nurses’
perceptions of the OH department’s opening hours were compared with the views
of the admin and clerical category (who mainly work within normal working
hours). The qualified nurses remain satisfied, as do the admin and clerical
staff, and while there is slightly more satisfaction among workers with normal
working hours, there is no great difference in the two opposing job categories.


The results show that it is possible to adapt a standard SQ tool (Servqual)
and apply it within an OH setting.

There was a concern that the questionnaire may appear too complicated, but
91 per cent of the respondents completed all three sections.

Overall, staff satisfaction scores were between five and six, which shows
satisfaction with the service, although it did not quite meet staff
expectations of an OH service. Following consideration of the findings, a
number of changes have been implemented. While it is vital to remain fully
staffed during normal daytime hours, work is underway to take the service to
the user. For example, more screening and health surveillance programmes are
being set up in the ward areas to improve staff morale and increase the ease of
access to our OH service.

Monthly nurse meetings have been set up covering a variety of topics, to
allow as many staff as possible to attend (admin staff and doctors are also
free to attend if the subject is of interest to them). The department has been
decorated, areas re-carpeted and plants purchased to make it more visually

A process of benchmarking will allow a long-term view of how the OH service
is performing, which will be far more valuable than one set of data. It will
enable the identification of the impact of positive and negative changes, and
determine future plans for the benefit of the OH service and its customers.

Further adaptations to the Servqual tool, for use in the OH setting, would mean
considering a more statistically robust method for gathering data when
comparing staff perceptions of service quality and the ranking of important
aspects. This would more effectively demonstrate whether staff believe there is
a provision of an excellent service in the areas they find most important. The
application of the adapted tool within another OH setting would also be useful,
as it would start the process of external benchmarking of similar data and
would help establish whether the tool can be replicated with reliability and


Continually monitoring and improving the OH service will ensure the
attainment of excellence and provision of a high quality service to the staff,
contributing significantly to their health, safety and well-being.

With foresight and slight adaptations, tools such as Servqual can be
extremely valuable in the field of healthcare, and certainly in an OH setting
where the emphasis is on income generation, business needs and value for money.
It is important to note that the response rate of the questionnaires is only 31
per cent, so care must be taken not to read too much into the data as the
larger number of non-responders may have a different view to the responders.
The rate of response in each category is also too low to make a meaningful
comparison of their satisfaction level. However, this tool could be easily
replicated in another OH department and used internally as a means for
improving the OH service and proving its worth.

Following this study, we have implemented a number of changes and plan to
replicate the study. There are also plans to modify the questionnaire and
target the management population to ascertain their views of the service.

If the ‘quality’ message is not heeded by our organisations, and other more
quality-focused organisations enter the marketplace, our business might not be
as secure as it has been in the past.15

Lesley Baxter is an OH adviser at Nottingham Occupational Health


1. Refinement and reassessment of the SERVQUAL scale – Parasuraman A, Berry
LL and Zeithaml VA, 1991, Journal of Retailing, 67(4), pp420-451

2. Improving the quality of services marketing: service (re) design is the
critical link – Ballantyne D, Christopher M and Payne A (1997) Advances in
relationship marketing (2nd edition), London: Kogan Page Ltd, pp183-198

3. Another look into the agenda of customer satisfaction: focusing on
service providers’ own and perceived viewpoints – Athanassopoulos AD, 1997,
International Journal of Bank Marketing, 15(7), pp264-278

4. ‘Interrogating Servqual: a critical assessment of service quality
measurement in a high street retail bank’ – Newman K, 2001, International
Journal of Bank Marketing, 19(3), pp126-139

5. Understanding customer satisfaction – a UK food industry case study –
Adebanjo D, 2001, British Food Journal, 103(1), pp36-45

6. Customer satisfaction – lip service or management tool? – Broetzmann SM,
Kemp J, Rossano M and Marwaha J, 1995, Managing Service Quality, 5(2), pp13-18

7. Using SERVQUAL to assess customer satisfaction with public sector
services – Wisniewski M, 2001, Managing Service Quality, 11(6), pp380-388

8. Continuous improvement in public services: a way forward – Curry A and
Herbert D, 1998, Managing Service Quality, 8(5), pp339-349

9. Service improvements in public services using Servqual – Brysland A and
Curry A, 2001, Managing Service Quality, 11(6), pp389-401

10. Measuring customer satisfaction: how do you measure customer
satisfaction? – Zimmer-man PG, 1998, Journal of Emergency Nursing, 24(3),

11. The service quality approach to developing user satisfaction tools –
Roberts P, 1998, Nurse Researcher, 5(3), pp43-50

12. Measuring service quality at a university health clinic – Anderson EA,
1995, International Journal of Health Care Quality Assurance, 8(2), pp32-37

13. Patient perceptions of service quality: combining the dimensions –
Carman JM, 2000, Journal of Management in Medicine, 14(5/6), pp339-356

14. Client Satisfaction with Nursing Services: Evaluation in an occupational
health setting – Mitchell R, Leanna JC and Hyde R, 1999, AAOHN Journal, 47(2),

15. Quality – why do organisations still continue to get it wrong? – Dale
BG, van der Wiele A and Williams ART, 2001, Managing Service Quality, 11(4),

16. Evaluation, quality assurance, quality improvement and research –
Verbeek J, Hushof C and van der Weide W, 1999, Evaluation in Occupational
Health Practice, Oxford: Butterworth-Heinemann, pp21-37

17. Quality and audit in occupational health nursing – Maynard L, 2002,
Occupational Health Nursing (2nd Edition), London, Whurr Publishers Ltd,

Measure of service quality

– Tangibles – physical facilities,
equipment and appearance of personnel

– Reliability – ability to perform the promised service
dependably and accurately

– Responsiveness – willingness to help customers and provide
prompt service

– Assurance – knowledge and courtesy of employees and their
ability to inspire trust       and

– Empathy – caring, individualised attention the firm provides
to its customers

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