Gap analysis of patient meal service perceptions
Li-Jen Jessica Hwang
School of Management, University of Surrey, Guildford, UK
Anita Eves
School of Management, University of Surrey, Guildford, UK
Terry Desombre
School of Management, University of Surrey, Guildford, UK
Keywords
Service quality,
Patients' expectations, Hospitals,
Meals, National Health Service,
Gap analysis
Abstract
The provision of food and drinks to
patients remains a largely
unexplored, multidimensional
phenomenon. In an attempt to
ameliorate this lack of
understanding, a survey utilising a
modified SERVQUAL instrument
measured on a seven-point Likert
scale was carried out on-site at four
NHS acute trusts for the purpose of
assessing the perceptions and
expectations of meal attributes and
their importance in determining
patient satisfaction. The results of
factor analysis found three
dimensions: food properties,
interpersonal service, and
environmental presentation, with a
high reliability (Cronbach's from
0.9191 to 0.7836). Path analysis
further established sophisticated
causal relations with patient
satisfaction. The food dimension
was found to be the best predictor
of patient satisfaction among the
three dimensions, while the
interpersonal service dimension
was not found to have any
correlation with satisfaction.
Bridging the gaps that exist
between perceptions and
expectations can improve the
quality of meal services for the
purpose of maximising patient
satisfaction and ultimately aiding in
patient recovery.
Introduction
The concept of service quality has been
established and examined in a number of
industries; however, it is only recently that
the service sector, and in particular hospital
meal services, have received the same
attention. Whilst the extant studies have
indicated divergent levels of attribute
specification in health care, most researchers
agree with the concept of measuring patient
satisfaction based on multi-attribute scales
that reflect the multifunctional nature of
hospitality service. Notwithstanding the fact
that the original assertions in these studies
varied in the number of factors and their
composition, no empirical tests of their
conjectures seem to be available to date. This
research intends to investigate the gaps
between patients' perceptions and
expectations of meal experiences and their
linkage with their satisfaction with the food
services; so that management can identify
problems with the service encounters and
then work to improve the provision of care.
Service quality in hospital care
Service quality, by its very nature, is difficult
to define and even more intangible to
measure. A number of conceptual models
have been developed in an attempt to
mitigate these difficulties:
.
the model of total service quality from
GroÈnroos (1990);
.
the expectancy-disconfirmation model
from Oliver (1993); and
.
the SERVQUAL model from Parasuraman
et al. (1985).
the health-care field (Babakus and Mongold,
1992; O'Connor et al., 1994; Tomes and
Ng, 1995; Youssef et al., 1996; Lam, 1997;
Fuentes, 1999). Youssef et al. (1996) concluded
that the SERVQUAL instrument had
powerful potential applications to NHS
hospitals through understanding quality,
market research, auditing quality, setting
standards, and measuring performance.
However, deficiencies in understanding
the quality of health care have been
highlighted:
(1) methodological dilemmas and a lack of
standardised approaches to patient
satisfaction survey research, (2) a lack of
clarity and consistency in understanding the
determinants of patient satisfaction, [ . . . ], (4)
a lack of an accepted conceptual or theoretical
model of the patient process, and (5) a lack of
consensus within the medical profession on
the role that patient satisfaction should play
in the assessment of quality of care (Aharony
and Strasser, 1993, p. 50).
Johns and Howard (1998) indicated that
hospitals and some restaurant services have
failed to provide clear SERVQUAL factor
patterns without considering the different
customer needs.
Catering services in the health-care
system
Of these, the SERVQUAL model is considered
to be one of the most scrutinised and
adaptable in providing a valid instrument for
measuring service quality and has been
International Journal of Health
tested extensively by empirical research in
Care Quality Assurance
As a result of the distinctive nature of the
National Health Service (NHS), as a
comprehensive and government-sponsored
public health-care system, the meal services
provided are available equally for every one
in the hospitals and the services have
ambitions of high quality. Debates over
whether or not resources are spent
effectively and efficiently to benefit and
satisfy the patients' expectations have
provided the impetus to improve procedures
and attitudes for serving meals as part of the
four waves of health-care reform (Levitt et
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[ 143 ]
al., 1995). The gradual recognition of food as
therapy (Maryon-Davis and Bristow, 1999)
reminds the NHS that basic essential care
includes not just medical procedures, but
International Journal of Health
also feeding their patients to help them
Care Quality Assurance
16/3 [2003] 143-153
regain their health. Guidelines and patient
charters have been instituted in an attempt
to ensure that high quality meals are
prepared and delivered to patients.
However, catering budget cutbacks have
resulted in an increase in the outsourcing of
catering services to contract caterers (a
result of the concept of internal markets),
which has created changes in the provision
of meal service in terms of separating the
management chain within the NHS
organisation. Based on the agreed budget and
service provision with the Trust, catering
managers have diversified their cooking
methods (batch cooking, cook-chill, or cookfreeze) and service procedures (plated-meal
or bulk-style of delivery) to achieve the best
they can for the patients, their customers
(Department of Health, 1995). The intangible
aspect of meal services has also shifted, with
the role and responsibility of staff at mealtimes a lower priority compared with other
procedures, regardless of its being seen to be
a valuable nursing task (Kowanko, 1997).
Contracted-caterers specialising in meal
provision have now stepped into hospitals
and their responsibility may extend to ward
level and serving the NHS patients (De
Raeve, 1994).
Li-Jen Jessica Hwang,
Anita Eves and Terry Desombre
Gap analysis of patient meal
service perceptions
Understanding food choices in the hospital
environment
Food choice models emphasise the multifactorial nature of food choice and
consequently the complicated nature of
patients' behaviour (Bareham, 1995), and
thus may provide some understanding of the
factors influencing patients' food intakes.
The unnatural hospital environment may
make patients' eating more difficult; such as
alien physical surroundings, the loss of
privacy and personal space, or being held to
restricted meal-time and medical routines
(Kipps and Middleton, 1990). The
physiological and psychological effects on
patients may cause the meal service not to
meet their expectations. Different patients'
ethnic backgrounds and preferences may not
be specifically considered in the menu
design, and the loss of control may add extra
frustration and pressure to both the system
and the patients themselves.
The hospital food chain (Archer, 2000)
requires each stage of the entire process of
food provision, from the patients making
appropriate choices right through to the
patient eating the food, to be linked with the
[ 144 ]
service provision. Any rupture of the chain
may result in either nutritional or financial
implications (for example: prolonged length
of stay, drug waste, and food waste). The 1997
report, Hungry in Hospital? (Burke, 1997),
outlined 14 factors in patients' food
consumption, later expanded to 16 items that
possibly contribute to patients not eating and
drinking in hospitals, including the quality
of food, menu ordering, and interpersonal
service. A total of 19 factor statements were
then developed for the purpose of
investigating these 16 items (Table I).
Methods
A modified SERVQUAL questionnaire was
then developed to assess the quality of meal
services through the patients' expectations,
perceptions, and view of importance of the 19
factors. The instrument utilised a sevenpoint Likert-type scale to determine the
levels of agreement with each statement. In
addition, the participants were asked for
their overall views of their meal experience,
satisfaction with services, appetite, timing of
meals, and also demographic information.
The questionnaire ended with an open-ended
question giving the respondents the
opportunity to comment on any additional
issues on the quality of meal services, which
would enhance the meaning of the
quantitative data.
Prior to the actual collection of the data,
the questionnaire was pre-tested with a
convenience sample of 105 subjects from two
hospitals to clarify potential areas of
misinterpretation, and administration and
data-scanning issues. Suggestions on how the
questionnaire could be presented in a clearer
manner were solicited. Minor changes were
made before the main study was conducted.
Procedure
After obtaining agreements from the
chairmen of the Local Research Ethics
Committee (LREC) and the hospital
managers, the ward sister of each of the
wards (chosen on the recommendations of
the hospital managers) was contacted to
arrange convenient times to administer the
questionnaire. Upon arrival at the wards, the
sisters were consulted to determine which
patients would be suitable under these
criteria: co-operative and capable of
answering questions. Patients with mental or
physical problems or with intravenous
feeding were not included. The selfadministered questionnaires, which were
anticipated to take only 15-20 minutes to
complete, were handed out and collected the
Food choices/variety of food
Availability
Attitude of delivery staff
Attitude of service staff
Usefulness of food and nutrition information
Explanation of diet
Timeliness of meal delivery
Accuracy of items on tray
Service reliability
Customisation
Individual attentiveness
Helpfulness for disabled patients
Communication
Reliability
Empathy
Responsiveness
Temperature of food (food served at right temperature)
Flavour of food/taste
Attractiveness of tray
Caring
Palatability
Physical and social eating environment/deÂcor
Hospitalisation
Q23 ± Staff should always be willing to help patients with eating difficulties
Q21 ± Other food should be provided when a patient misses the regular meal service
Q22 ± Patients should be given personal attention
Q18 ± Enough time should be given to eat the food
Q19 ± Meals should arrive exactly as ordered
Q20 ± Meals should be served around the same time each day
Q16 ± The menu should provide useful information on food and nutrition
Q17 ± Each dish on the menu should be clearly described
Q14 ± Staff should leave food within reach
Q15 ± Staff should be polite and pleasant
Q10 ± The food should taste good
Q11 ± The food should look good on the trays
Q12 ± The food should be freshly prepared
Q13 ± Food should be served at the correct temperature
Q7 ± Menu should offer a good selection of meals
Q8 ± Meals should smell delicious
Q9 ± Meal size should be according to individual needs
Q5 ± Pleasant eating surroundings should be offered to stimulate the appetite
Q6 ± Social contact should be part of the meal-time routine
Statements in study questionnaire
International Journal of Health
Care Quality Assurance
16/3 [2003] 143-153
Quantity of food/food size
Items
Dimensions
Table I
Factors possibly contributing to patients not eating and drinking in hospitals
Li-Jen Jessica Hwang,
Anita Eves and Terry Desombre
Gap analysis of patient meal
service perceptions
[ 145 ]
same day by the researcher, personally. The
process continued until reaching the target
numbers (150) from each of four hospitals.
The wards from which respondents were
International Journal of Health
drawn were medical, elderly care, or
Care Quality Assurance
16/3 [2003] 143-153
surgical. Any missed questionnaires could be
returned in envelopes provided to the wards.
Li-Jen Jessica Hwang,
Anita Eves and Terry Desombre
Gap analysis of patient meal
service perceptions
Results
With a 78.2 per cent response rate, the patient
characteristics of the 609 valid returns are
shown in Table II. The non-response could
have occurred when some patients changed
their mind and decided not to participate in
the survey, when questionnaires were lost at
the ward desk, or when patients were moved
Table II
Patient-specific characteristics of sample (n = 609)
Characteristics
Number
Per cent
Gender
Male
Female
279
330
45.8
54.2
Age
Under 16
16-30
31-50
51-70
71-90
91 and older
0
45
87
205
256
16
0
7.4
14.3
33.7
42
2.6
Specialty of warda
Surgical
Medical
Elderly
324
256
29
53.2
42
4.8
Expected length of stay
1-3 days
4-7 days
8-10 days
11-14 days
More than 15 days
76
203
120
73
136
12.5
33.4
19.7
12
22.4
Type of diet
Regular diet
Diabetic diet
Low-salt diet
PureÂed diet
Vegetarian diet and others
496
62
22
17
12
81.4
10.2
3.6
2.8
2
Gross income of head of household (£ per week)
A. 600 and over
B. 300-599
C. 150-299
D. 50-149
E. Less than 50
OAP
Not provided by respondent
45
82
75
50
12
283
62
7.4
13.5
12.3
8.2
2
46.5
10.2
Note: a Ward types: Surgical included surgical, orthopaedic, trauma, gynaecology, ear,
throat and nose. Medical included medical, haematology, cardiac, rehabilitation,
oncology, and gastrology
[ 146 ]
to other wards or transferred to other
hospitals without finishing or returning
their questionnaire.
Gaps between patients' expectations and
perceptions toward meal services
Using the paired samples t-test, a comparison
of each patient's paired ratings on their
expectations and perceptions of meal service
statements indicated that the 19 attributes
were all statistically significantly correlated.
Significantly higher expectations than
perceptions were found from most of the
paired attributes, except two items ± ``staff
being polite and pleasant'' and ``personal
attention'' (Table III).
In terms of expectations of meal services,
all 19 attributes received strong agreements
with the statements ranging from means of
5.32 to 6.65 out of seven. The comments
demonstrate some of the most positive
impressions, for example:
Considering the number of meals provided
throughout the day, and the allowances the
catering staff receive for each meal, this
hospital does remarkably well.
With budget constraints, they managed quite
well. Everyone is happy. They try the best to
provide what they can.
However, inconsistency in serving the meals
has troubled the patients. The respondents
expressed their highest expectations on
requiring food to be served at the proper
temperature.
In terms of the perception of meal services,
the means of the 19 attributes ranged from 4.9
(on ``social contact'') to 6.34 (on ``enough time
to eat''); which means that the respondents
generally agreed with all the statements.
This indicates that the execution of meal
service still needs to be improved to reach the
level of most patients' expectations, but for
some they both expected and received good
meal service ``like a five-star hotel service''.
Four attributes had over one point in mean
difference. They were the statements on the
``smell of food'', ``taste of food'', ``food freshly
prepared'', and ``temperature of food''; it
appeared that these four areas had the largest
discrepancy, as illustrated by comments of:
I dislike the bland tastelessness and oldfashioned recipes. Normal people don't eat
flavourless stews and mash ± I would like to
see more pasta, jacket potatoes, curries, and
pizza. The shoddy puddings are out-dated too.
The temperature of the meals still too cool!!!
Remember, a patient cannot always eat
immediately, it is served so timing is so
important.
6.17
6.52
6.44
6.65
5.88
6.34
6.37
6.31
6.25
6.32
6.46
6.21
5.32
6.60
5.63
6.43
6.51
5.68
6.57
Meals should smell delicious
Food should taste good
Food should be freshly prepared
Food should be served at proper temperature
Menu should provide useful information on nutrition and food
Menu should offer a good selection of meals
Each menu item should be clearly described
Other food should be provided when a patient misses the regular meal services
Food should look good on the tray
Meals should arrive exactly as ordered
Staff should always be willing to help patients with eating difficulties
Meal size should be according to individual needs
Social contact should be part of the meal-time routine
Staff should leave food within reach
Pleasant eating surroundings should be offered to stimulate the appetite
Meals should be served around the same time each day
Enough time should be given to eat the food
Patients should be given personal attention
Staff should be polite and pleasant
4.95
5.33
5.32
5.48
4.91
5.39
5.44
5.45
5.41
5.66
5.84
5.73
4.90
6.36
5.43
6.24
6.34
5.63
6.53
1.77
1.72
1.81
1.69
2.00
1.74
1.82
1.75
1.67
1.73
1.44
1.70
1.91
1.25
1.71
1.27
1.17
1.60
0.97
Perceptions
Mean
SD
Notes: a Scale ranged from 1 = completely disagree to 7 = completely agree; b SD = standard deviation; * p 0.05; ** p 0.01; *** p 0.001
1.27
1.08
1.18
1.07
1.37
1.18
1.18
1.25
1.29
1.17
1.16
1.26
1.68
1.00
1.49
1.07
1.08
1.48
1.01
Expectations
Meana
SDb
1.22
1.20
1.12
1.09
0.97
0.96
0.93
0.85
0.83
0.66
0.62
0.48
0.41
0.24
0.20
0.19
0.16
0.052
0.039
2.00***
1.92***
2.04***
1.89***
2.10***
1.92***
1.99***
1.92***
1.88***
1.94***
1.62***
1.92***
1.84***
1.23***
1.90*
1.34**
1.25**
1.82
1.16
Paired differences
Mean
SD
International Journal of Health
Care Quality Assurance
16/3 [2003] 143-153
Attributes
Statements
Table III
Gaps between patients' expectations and perceptions toward meal services (n = 609)
Li-Jen Jessica Hwang,
Anita Eves and Terry Desombre
Gap analysis of patient meal
service perceptions
[ 147 ]
Li-Jen Jessica Hwang,
Anita Eves and Terry Desombre
Gap analysis of patient meal
service perceptions
International Journal of Health
Care Quality Assurance
16/3 [2003] 143-153
Three dimensions of weighted gaps
measures (WGM) of meal service
attributes
Since the gaps between expectations and
perceptions were significant for most
attributes, an equation to measure these gaps
weighted by importance was calculated
within each individual participant for
further factor analysis (as per the following
equation):
X
WGM ˆ
Expectations Perceptions†
importance of the Attributes
The results showed that the WGM of all 19
attributes presented varying degrees of gaps.
However, some similarities emerged as the
food characteristics (e.g. flavour, aroma,
freshness, temperature, variety) were
considered to be far from meeting
expectations, and the intangible aspects of
service (e.g. staff attitudes) were much closer
to what the respondents expected.
Using Cronbach's coefficient to test the
internal consistency of the scale instrument,
the results found an extremely high
reliability was achieved among the 19
attributes in identifying the four aspects
(expectations, perceptions, importance, and
WGM) of meal services in hospitals, proving
that the scale measured the same
homogeneous variables. The results first
revealed that the appropriateness of the
factor analysis was satisfied under the
Kaiser-Meyer-Olkin measure of sampling
adequacy (0.941) of inter-correlation among
the variables and Bartlett's test of sphericity
being significant (2 = 5940.916, df = 171,
p < 0.001). The outcome found that the
varimax rotation showed the best fit,
reducing the 19 attributes into three
dimensions that accounted for 58.23 per cent
of the common variances. Table IV shows the
correlation (or factor loadings) between each
food service attribute and each dimension
only when the factor loading was larger than
0.45 ± a cut-off point based on a 0.05
significance level and a power level of 80 per
cent within 150 samples per group (Hair et al.,
1998).
The first dimension accounted for 26.6 per
cent of the common variance and was
labelled food properties. It focused mostly on
food characteristics such as the flavour,
aroma, freshness, presentation, temperature,
and variety of food, as well as the description
of food content on the menu and getting what
you ordered. The second dimension
accounted for 16.99 per cent of the common
variance and was labelled interpersonal
service. It consisted of statements describing
the attitude of staff, timing of meal delivery,
[ 148 ]
placing of food, helpfulness of staff,
individual attentiveness, length of meal-time,
and any alternative food provided if a meal
was missed. The remaining attributes (mealtime surroundings, social contact during
meal-times, quantity of food, and information
about food and nutrition) were included in
the last dimension, which accounted for 14.64
per cent of the common variance and was
labelled environmental presentation. An
analysis of reliability was performed for each
sub-scale, and Cronbach's (0.9191- 0.7836)
demonstrated the internal consistency of
each dimension. The factor scores were then
selected for the attributes included in each of
the three dimensions and were used in
subsequent analyses. With zero correlation
indicated by the Pearson product-moment
correlation coefficient, the three dimensions
have been successfully separated.
Modelling patients' satisfaction toward
hospital meal services
Many WGM attributes and the two
dimensions reflecting characteristics of food
and service quality were significantly
(p < 0.05) related to satisfaction with overall
hospital meal service (Table V). Patient
satisfaction was positively correlated with all
WGM attributes on the food property
dimensions (flavour, aroma, freshness,
presentation, temperature, and variety of
food, description of food content on the menu,
and getting what you ordered) and the food
properties dimension itself. Although the
interpersonal service dimension did not have
a significant correlation with satisfaction, its
sub-scale of WGM attributes (attitude of staff
on polite, pleasant, helpfulness, timing of
meal delivery, time to eat, and alternative
food provided if a meal was missed) all
showed significant relationships with
satisfaction. In addition, all the WGM
attributes in the environmental presentation
dimension and the dimension itself presented
a positive correlation to satisfaction. These
correlations may give some indication that
patients looked forward to meals and were
interested in all the aspects of meal services
in hospital.
A step-wise multiple regression analysis is
then the next step to verify the strength and
causal relationships in order to predict the
outcomes of meal services ± patient
satisfaction. A path diagram (Figure 1)
illustrates the complexities of meal service
quality as suggested by the results of the stepwise regression analysis on the three final
outcomes of meal services:
1 patient satisfaction with meals;
2 the regularity of finishing the food; and
3 appetite.
Li-Jen Jessica Hwang,
Anita Eves and Terry Desombre
Gap analysis of patient meal
service perceptions
Table IV
The factor loadings of 19 attributes of meal services
International Journal of Health
Care Quality Assurance
16/3 [2003] 143-153
Items/factors
Food
properties
WGM ± Flavour of food
WGM ± Aroma of food
WGM ± Freshness of food
WGM ± Presentation of food
WGM ± Temperature of food
WGM ± Variety of food
WGM ± Description of food content on menu
WGM ± Getting what you ordered
WGM ± Attitude of staff
WGM ± Timing of meal delivery
WGM ± Placing of food
WGM ± Helpfulness of staff
WGM ± Individual attentiveness
WGM ± Length of meal time
WGM ± Alternative food provided if a meal is missed
WGM ± Meal-time surroundings
WGM ± Social contact during meal-times
WGM ± Quantity of food
WGM ± Information about food and nutrition
Per cent variance
Cronbach's 0.848
0.814
0.802
0.790
0.751
0.734
0.508
0.470
26.60
0.919
Interpersonal
service
Environmental
presentation
0.715
0.706
0.644
0.590
0.584
0.547
0.450
0.766
0.727
0.662
0.600
14.64
0.784
16.99
0.800
Note: Measure of sampling adequacy (MSA) = 0.941; extraction method: principal component analysis, cut-off at
0.45; data obtained by factor analysis with orthogonal rotation (Varimax)
Table V
Correlation between the level of patients' satisfaction and each WGM
attribute and the three dimensions of meal services
Items/factors
r
Food properties
WGM ± Flavour of food
WGM ± Aroma of food
WGM ± Freshness of food
WGM ± Presentation of food
WGM ± Temperature of food
WGM ± Variety of food
WGM ± Description of food content on menu
WGM ± Getting what you ordered
0.452**
0.473**
0.418**
0.382**
0.404**
0.366**
0.421**
0.260**
0.349**
Interpersonal service
WGM ± Attitude of staff
WGM ± Timing of meal delivery
WGM ± Placing of food
WGM ± Helpfulness of staff
WGM ± Individual attentiveness
WGM ± Length of meal time
WGM ± Alternative food provided if a meal is missed
0.042
0.104*
0.165**
0.110**
0.194**
0.177**
0.084*
0.263**
Environmental presentation
WGM ± Meal-time surroundings
WGM ± Social contact during meal-times
WGM ± Quantity of food
WGM ± Information about food and nutrition
0.181**
0.233**
0.190**
0.277**
0.320**
Note: Based on Pearson's correlation coefficient; * p < 0.05, ** p < 0.01
The convenience of meal timing had the most
impact, followed closely by the food
properties dimension and regularity of
finishing the food. The fourth variable was
the environmental presentation dimension.
The last variable was catering systems being
contracted-out, which has a negative
influence on satisfaction:
Predicted overall satisfaction
ˆ 0:249 …Regularity of finishing the food†
‡ 0:385 …Convenience of meal timing†
‡ 0:595 …Food properties†
0:304
1†
Catering system† ‡ 0:116
Environmental presentation† ‡ 2:207
Some variables indicated a direct causal
relation and some an indirect one. A solid-line
arrow represents the path coefficients of the
variables that had a direct causal relation on
the dependent variables, e.g. satisfaction. The
relationship between patient satisfaction with
meals and the regularity of finishing the food
and the relationship between the appetite and
the regularity of finishing the food were found
to be an instantaneous reciprocal interaction,
as shown by two opposing arrows.
Discussion
Results of this research found that patients'
expectations exceeded their perceptions for
[ 149 ]
Li-Jen Jessica Hwang,
Anita Eves and Terry Desombre
Gap analysis of patient meal
service perceptions
Figure 1
Causal model of patient satisfaction with hospital meal services
International Journal of Health
Care Quality Assurance
16/3 [2003] 143-153
hospital meal services; consequently, the
gaps that existed between their expectations
and perceptions serve to lower their
satisfaction level. These findings can be
linked to Parasuraman et al. (1988)'s five gaps
theory, where gap five is the consumer
expectation-perception gap. This could
suggest areas where the catering managers
should focus to meet their patients'
expectations.
Reaffirm results of previous researches
The food properties dimension was the most
powerful indication of patients' satisfaction
toward meal services (Figure 1). The greatest
number of negative comments, which can be
seen to be roughly analogous to a gap
between expectations and perceptions, were
on issues associated with food quality. This
confirms previous research (DeLuco and
Cremer, 1990; Dube et al., 1994; O'Hara et al.,
1997; Lau and Gregoire, 1998) that food
quality is the best predictor of overall
satisfaction. This suggests that food
properties should be the most important area
for catering managers to monitor and on
which to concentrate.
From the patient perspective, the Food
properties dimension and Interpersonal
service dimension that emerged from the
[ 150 ]
factor analysis appear to have a similar
pattern to two previous pieces of research:
DeLuco and Cremer's study (1990), which
separated the quality characteristics for
hospital meals into food characteristics and
services characteristics, and Gregoire's
study (1994), which found two factors on
patients' assessment of the quality of meal
services to be meal tray delivery and food
quality. This may relate to GroÈnroos's (1990)
concept that the two basic quality
dimensions are what the patient receives and
how the patient receives it. This suggests that
meal services should be measured as a
product of both the meals themselves and the
service process through which they are
received.
The environmental presentation
dimension had a causal relation with overall
satisfaction with meal services, though not as
strong as that of food properties. These
findings were also supported by the
comments of both the patients and the
service staff. Environmental issues also had
a number of negative comments, though not
to the same extent. This also serves to
confirm results from the study of Millar
(1998) that environmental factors are
important when evaluating hospital food and
food services. This further illustrates the
three-cornered nature of the phenomenon, as
satisfaction with meal services is thus
dependent on influences outside the catering
manager's control, as the environment is
International Journal of Health
largely a product of the medical and
Care Quality Assurance
16/3 [2003] 143-153
institutional nature of the facilities and the
atmosphere created by the ward staff. This
suggests that efforts spent on improving the
ward surroundings can have a direct impact
on improving meal service satisfaction and
therefore food intake.
Li-Jen Jessica Hwang,
Anita Eves and Terry Desombre
Gap analysis of patient meal
service perceptions
Dimensions constituting service quality
still problematic
No agreement has been found over which
dimensions of meal services should
constitute which attributes. The three
patient dimensions from the factor analysis
were different from the proposed structure in
Table I, which consisted of eight dimensions
(hospitalisation, availability, palatability,
caring, communication, reliability, empathy,
and responsiveness) amalgamated from the
SERVQUAL model and food choice model.
This seems to agree with the conclusion that
no consensus has been reached on the
dimensionality to be used to measure quality,
since varying factor-loading patterns and
inconsistencies in the number of factors have
emerged from previous research.
However, the high reliability of scale
indicates the applicability of the scale. The 19
attributes of patient meal services used in
this research showed a high internal
consistency for the scale instrument.
Although other researches assessing the
quality of meal services used, for example, 21
items in DeLuco and Cremer (1990)'s study,
26 items in Dube et al. (1994), 16 items in
Gregoire (1994), seven items in Gregoire
(1997), 11 items in Lau and Gregoire (1998),
and seven items in O'Hara et al. (1997), each
demonstrated a high reliability of scale. The
number of attributes does not seem to have
an effect on the reliability of scale. This
verifies the integrity of this research and
reaffirms the value inherent in the
theoretical structure and the method utilised.
Relationships to patient satisfaction
Although meal service timeliness has not
consistently been found to be significantly
associated with satisfaction, the results of
this research showed that the convenience of
the meal timing was a strong predictor of
patients' satisfaction. This confirms the
findings of Dube et al. (1994) that meal service
timeliness was associated with patient
satisfaction. The patients' appetite has been
suggested as an intermediate agent between
some meal service attributes and
satisfaction. This research found that the
patients' appetite was partially correlated
with both food properties and environmental
presentation, had a causal relationship with
the convenience of the meal service timing
and had an impact on satisfaction. The
findings were partially similar to Dube et al.
(1994), where patients with positive appetites
were more satisfied with the dimension of
food quality, meal service reliability, and
attitude of the staff who serve meals.
Nevertheless, this research went further,
finding that patients' appetite had a
reciprocal relationship with how often the
patient would finish their food. This suggests
that patients' appetite can serve as an index
of the food intake by patients. This in turn
suggests that food wastage could be used as a
rough measure of patient satisfaction, with
decreases in food wastage serving to indicate
an increase in satisfaction.
It was unclear from the secondary research
whether aspects of a patient's background
might be expected to have a certain
association with the satisfaction when
evaluating meal services. Results of this
research found that most patients' individual
characteristics (e.g. age, gender, length of
stay, and the gross income of head of
household) and their contextual factors (e.g.
type of ward and diet) had no direct influence
on overall satisfaction. This appears to run
counter to the findings of Dube et al. (1994),
that individual characteristics and
contextual factors influence patient
satisfaction, but to be similar to the results of
O'Hara et al. (1997), who found that patientspecific characteristics were not related to
overall satisfaction. While there was no
direct connection to satisfaction, gender, the
type of ward and the patient's appetite were
associated with the regularity of finishing
the food, and thus had an indirect influence
on their overall satisfaction toward meal
services. This then partially confirms the
results of Dube et al. (1994), as they indicated
that many individual and contextual factors
have the potential to influence satisfaction
with patients' diets. What this also indicates
is that generalisations made regarding
certain sectors of the patient population are
not likely to be valid with respect to
satisfaction.
Some results of this research did not agree
with the findings from previous research.
These results found that the interpersonal
service dimension, which received generally
positive comments, was not found to be a
significant predictor of patient satisfaction
toward meal services. This differs from the
results of BeÂlanger and Dube (1996) that
interpersonal aspects largely accounted for
satisfaction, Gregoire (1994) that attributes of
[ 151 ]
services are more important than food
attributes, and Dube et al. (1994) that attitude
of the staff who deliver meals would
influence satisfaction. This could suggest
International Journal of Health
that the intangible factor of personal service
Care Quality Assurance
16/3 [2003] 143-153
has largely been satisfied for patients in NHS
hospitals.
Li-Jen Jessica Hwang,
Anita Eves and Terry Desombre
Gap analysis of patient meal
service perceptions
Conclusion and recommendations
The results of this survey showed that
patients had higher expectations toward the
meal services than perceptions. After being
weighted by the importance, the WGM of 19
attributes were factored into three
dimensions: food properties, interpersonal
services, and environmental presentation
and verified with a high score of reliability of
scale. A causal model established the
complex influences on patients' satisfaction
and food intake.
In considering how to approach the
challenges of the future in light of this
research, businesses should remember:
.
Identify the gaps and minimise them.
Results suggest a relationship between the
gaps between patients' expectations and
perceptions and their satisfaction. The
smaller the gaps, the more satisfied they
appeared to be. The hospital catering
managers who are striving to improve
patient satisfaction with their services
should focus their effects on clearly
defining patient expectations and how
service can be improved to better meet the
expectations against their performance.
Gap theory can assist the catering
manager with more analytical techniques
to identify the service areas in need of
improvement.
.
Utilise the audit results. Although catering
managers utilised their own patient
surveys to monitor their performance, the
measurement system appears to be weak
and low in quality for retrieving feedback.
The measurement system should provide
information on the level of satisfaction
and its determinants for each significant
sub-group of patients in a hospital.
Effective resource-planning decisions and
constructive action plans in measuring
systems would maximise the return on
investment in patient satisfaction.
.
Food wastage serves as an instant index of
patient satisfaction. Results of this
research found the regularity of the
patient finishing their meal had a direct
causal relationship with patient
satisfaction. Perhaps, if no research
assistance is available, the catering
manager can simply measure food
[ 152 ]
wastage to achieve a rough and quick
index of the patient satisfaction (for
continuing improvements).
References
Aharony, L. and Strasser, S. (1993), ``Patient
satisfaction: what we know about and what
we still need to explore'', Medical Care Review,
Vol. 50 No. 1, pp. 40-79.
Archer, C. (2000), ``Nutrition as part of
treatment'', Nursing Times Plus, Vol. 96 No. 8,
24 February, p. 12.
Babakus, E. and Mangold, W.G. (1992), ``Adapting
the SERVQUAL scale to hospital services: an
empirical investigation'', Health Service
Research, Vol. 26 No. 6, February, pp. 767-86.
Bareham, J. (1995), Consumer Behaviour in the
Food Industry: A European Perspective,
Butterworth-Heinemann, Oxford.
BeÂlanger, M. and DubeÂ, L. (1996), ``The emotional
experience of hospitalisation: its moderators
and its role in patient satisfaction with food
service'', Journal of the American Dietetic
Association, Vol. 96 No. 4, April, pp. 354-60.
Burke, A. (1997), Health News Briefing: Hungry in
Hospital?, Association of Community Health
Councils for England and Wales, London.
DeLuco, D. and Cremer, M. (1990), ``Consumers'
perceptions of hospital food and dietary
services'', Journal of the American Dietetic
Association, Vol. 90 No. 12, December,
pp. 1711-15.
De Raeve, L. (1994), ``To feed or to nourish?
Thoughts on the moral significance of meals
in hospital'', Nursing Ethics, Vol. 1 No. 4,
December, pp. 237-41.
Department of Health (1995), Nutrition Guidelines
for Hospital Catering, Department of Health,
London.
DubeÂ, L., Trudeau, E. and BeÂlanger, M. (1994),
``Determining the complexity of patient
satisfaction with food services'', Journal of
the American Dietetic Association, Vol. 94
No. 4, April, pp. 394-8.
Fuentes, C.M. (1999), ``Measuring hospital service
quality: a methodological study'', Managing
Service Quality, Vol. 9 No. 4, pp. 230-9.
Gregoire, M.B. (1994), ``Quality of patient meal
service in hospitals: delivery of meals by
dietary employees vs. delivery by nursing
employees'', Journal of the American Dietetic
Association, Vol. 94 No. 10, October,
pp. 1129-34.
Gregoire, M.B. (1997), ``Do inpatients rate hospital
food and nutrition services differently than
discharged patients?'', Journal of Foodservice
Systems, Vol. 9, February, pp. 245-50.
GroÈnoos, C. (1990), Service Management and
Marketing: Managing the Moments of Truth
in Service, Lexington Books Ltd., Lexington,
MA.
Hair, J.E. Jr, Anderson, R., Tatham, R.L. and
Black, W.C. (1998), Multivariate Data Analysis
with Readings, 5th ed., Prentice-Hall,
Englewood Cliffs, NJ.
Li-Jen Jessica Hwang,
Anita Eves and Terry Desombre
Gap analysis of patient meal
service perceptions
International Journal of Health
Care Quality Assurance
16/3 [2003] 143-153
Johns, N. and Howard, A. (1998), ``Customer
expectations versus perceptions of service
performance in the food service industry'',
International Journal of Service Industry
Management, Vol. 9 No. 3, pp. 248-65.
Kipps, M. and Middleton, V. (1990), ``Achieving
quality and choice for the customer in
hospital catering'', International Journal of
Hospitality Management, Vol. 9 No. 1, pp. 69-83.
Kowanko, I. (1997), ``The role of the nurse in food
service: a literature review and
recommendations'', International Journal of
Nursing Practice, Vol. 3 No. 2, June, pp. 73-8.
Lam, S.S. (1997), ``SERVQUAL: a tool for
measuring patients' opinions of hospital
service quality in Hong Kong'', Total Quality
Management, Vol. 8 No. 4, pp. 145-52.
Lau, C. and Gregoire, M.B. (1998), ``Quality rating
of a hospital food service department by
in-patients and post-discharged patients'',
Journal of American Dietetic Association,
Vol. 98 No. 11, pp. 1303-7.
Levitt, R., Wall, A. and Appleby, J. (1995), The
Reorganised National Health Service, 5th ed.,
Chapman & Hall, London.
Maryon-Davis, A. and Bristow, A. (1999),
Managing Nutrition in Hospital, Nuffield
Trust, London.
Millar, B. (1998), ``Dying for a good meal?'', Health
Service Journal, 23 April, pp. 24-7.
O'Connor, S.J., Shewchuk, R.M. and Carney, L.M.
(1994), ``The great gap: physicians'
perceptions of patient service quality
expectations fall short of reality'', Journal of
Health Care Marketing, Vol. 14 No. 2, pp. 32-9.
O'Hara, P.A., Harper, D.W., Kangas, M., Dubeau,
J., Borsutzky, C. and Lemire, N. (1997), ``Taste,
temperature, and presentation predict
satisfaction with food services in a Canadian
continuing-care hospital'', Journal of the
American Dietetic Association, Vol. 97 No. 4,
pp. 401-5.
Oliver, R. (1993), ``A conceptual model of service
quality and service satisfaction: compatible
goals, different concepts'', Advances in
Services Marketing and Management, Vol. 2,
pp. 65-85.
Parasuraman, A., Zeithaml, V.A. and Berry, L.L.
(1985), ``A conceptual model of service quality
and its implications for future research'',
Journal of Marketing, Vol. 49, pp. 41-50.
Tomes, A.E. and Ng, S.C.P. (1995), ``Service
quality in hospital care: the development of
an in-patient questionnaire'', International
Journal of Health Care Quality Assurance,
Vol. 8 No. 3, pp. 25-33.
Youssef, F.N., Nel, D. and Bovaird, T. (1996),
``Health care quality in NHS hospitals'',
International Journal of Health Care Quality
Assurance, Vol. 9 No. 1, pp. 15-28.
Further reading
Cortis, J.D. (1997), ``Nutrition and the hospitalised
patient: implications for nurses'', British
Journal of Nursing, Vol. 6 No. 12, pp. 666-74.
Lee-Ross, D. (1999), ``A comparison of service
predispositions between NHS nurses and
hospitality workers'', International Journal of
Health Care Quality Assurance, Vol. 12 No. 3,
pp. 92-7.
Lin, B. and Kelly, E. (1995), ``Methodological
issues in patient satisfaction surveys'',
International Journal of Health Care Quality
Assurance, Vol. 8 No. 6, pp. 32-7.
Oliver, R.L. (1997), Satisfaction: A Behavioral
Perspective on the Consumer, McGraw-Hill,
New York, NY.
Steiber, S.R. and Krowinski, J. (1990), Measuring
and Managing Patient Satisfaction, American
Hospital Publishing, Chicago, IL.
Taylor, S.A. and Cronin, J.J. Jr (1994), ``Modelling
patient satisfaction and service quality'',
Journal of Health Care Marketing, Vol. 14
No. 1, pp. 34-44.
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