ii

iii

ACKNOWLEDGEMENTS

First and foremost I would like to thank Allah SWT for making this journey possible

and blessing me with family, friends and colleagues who have helped me in their

different ways in completing this thesis. My deepest and sincerest thanks to my

distinguish supervisor, Prof. Dr. Razli Che Razak, UMK’s Registrar (January 2012-

January 2015), who invaluable advice and critical evaluation over numerous meetings

regarding this thesis is greatly appreciated. Thanks for his constant and abundant

resource for guidance, support, enthusiasm and learning. Your deep and insightful

views over our numerous discussions have definitely helped to shape this thesis.

I must also thank the academicians and practitioners who at various stages were

involved in discussing and commenting on this research. My special thanks and sincere

gratitude to A/Prof.Dr.Mohammad Ismail, Prof.Dr.Murali Sambasivan, A/Prof.Dr.

Nizar Abdul Jalil (MD), A/Prof.Dr.Mohammad Iqbal Omar (MD), Dr.Abdul Aziz

Abdullah, Prof.Dr.Harshita Aini Haroon, Prof.Dr.Abdul Hamid Adom,

Prof.Dr.Mohd.Yusoff Mashor, Prof.Dr.Sazali Yaacob, Dr. Abd. Rahim Romle,

Sharmini Abdullah, Nur Syuhadah Kamaruddin, Dr. Syed Zulkarnain Syed Idrus,

Hafizah Abdul Rahim, and others who always support me with deepest motivation ever

after to complete this study. A special thanks to Prof. T.Ramayah for his valuable

comments and suggestions especially with regard to the research findings.

Thank you also for Ministry of Health (MOH) Malaysia, in specific, National Medical

Research Register (NMRR), Institute for Health Behavioural Research (IHBR) and

Medical Research Ethics Commitee (MREC) for the approval letter in conducting this

research. Thank you for Ministry of Higher Education (MOHE), Malaysia for giving me

the great opportunity till the end to finish this study.

Last but not least, my very special heartfelt thanks are reserved for my beloved

charming and tremendous husband, Ruslizam Daud (PhD) and my greatest children

Afifah An-Nur (2000), Afif Al-Ikhlas (2003), Afif Luqman (2007) and Afifah As-Syura

(2008) whose prayers and support helped to encourage me and make things just that bit

easier. Thanks for all your sacrifices and patience especially during the dreadful

moments. Thanks to stood with me with your full understanding and constant

encouragement during the study. I wish to express my sincere gratitude to my caring

and loving mother Hjh.Che Esah Hj.Nor and my great father Hj.Nordin Hj.Ismail and

my siblings Hjh.Norshazwani, Mohd Shahril, Mohd Hafiz, and Nailul Amal for their

golden advice whenever I needed them. I am also deeply indebted to my late mother and

late father-in-law and families for their continual supports and assistance.

iv

TABLE OF CONTENTS

PAGE

THESIS DECLARATION ii

ACKNOWLEDGEMENT iii

TABLE OF CONTENTS iv

LIST OF TABLES xi

LIST OF FIGURES xx

LIST OF ABBREVIATIONS xxiii

DEFINITION OF TERMS xxvi

ABSTRACT xxviii

ABSTRAK xxix

CHAPTER I INTRODUCTION 1

1.1 Chapter Overview 1

1.2 Motivation of the Study 1

1.2.1

Non-linearity Behaviour of Patient Service Fulfilment

2

1.2.2 Local Healthcare Service Provider Constraints and Limitations 5

1.2.3 Rising Complaints Frequency 8

1.2.4 Levels of Compliments and Complaints 11

1.3 Problem Statements 12

1.4 Research Questions 16

1.5 Research Objectives 17

1.6 Significance of the Study 18

1.7 Research Scope 20

1.8 Thesis Organization 21

v

CHAPTER II LITERATURE REVIEW 22

2.1

Introduction

22

2.2

Malaysian Healthcare System

22

2.2.1 Public Healthcare Admission 24

2.2.2 Healthcare Capacity and Constraint 26

2.3 Complaints and Compliments in Healthcare Service 29

2.3.1

Complaints through Public Complaints Bureau (PCB)

31

2.3.2 Complaints through Ministry of Health, Malaysia 33

2.3.3 Complaint Issues in Malaysia Healthcare Service Delivery 37

2.3.4 Complaint based on Healthcare Service Delivery

Department

42

2.4

Non-Linear Relationship in Service Satisfaction Model

44

2.5

Quality Function Deployment

49

2.5.1 QFD definition 49

2.5.2 History of QFD 52

2.5.3 QFD General Framework 53

2.5.4 General QFD Research Classification 56

2.5.5 QFD Application in Product Development 59

2.5.6 QFD Application in Services 62

2.5.7 Integrated QFD in New Service Development 63

2.5.8 QFD Application in Healthcare Services 64

2.6 Patient Satisfaction Model in Healthcare 69

2.6.1

Integrated Patient Satisfaction Model in Healthcare

74

2.6.2 QFD in Services and Healthcare Services 79

2.6.3 The Development of Kano-QFD Model 83

2.6.4 Kano-QFD in Healthcare Service 87

vi

2.7 Patient Dissatisfaction Model in Healthcare 88

2.8 Kano-QFD Non-Linear Methodological Assumption 90

2.9 Proposed Concept of Kano-QFD Service Satisfaction Model 94

2.9.1 Conventional Kano Questionnaire Design 97

2.9.2 Kano-Service Satisfaction (Kano-SS) 99

2.9.3 Kano-Services Satisfaction Evaluation Table Development 106

2.10 Summary 114

CHAPTER III RESEARCH METHODOLOGY 115

3.1 Introduction 115

3.2 Research Design 115

3.3 Development of Kano-QFD Model Integration 117

3.3.1 Kano-QFD Phase I 117

3.3.2 Kano-QFD Phase II 121

3.3.3 Kano-QFD Phase III 122

3.4 Sampling Design 124

3.4.1 Population Definition 125

3.4.2 Sampling Frame and Respondents 127

3.4.3 Sampling Technique 128

3.4.4 Sample Size 129

3.5 Research Instrument Design 133

3.5.1 Questionnaire Design and Development of Kano-SS

Questionnaire

133

3.5.2 Service Variable Measurement 137

3.5.3 Pilot Survey: Phase 1 138

3.5.4 Pilot Survey Reliability Testing 140

vii

3.5.5 Service Variable Construct Validity by Exploratory Factor

Analysis (EFA)

142

3.5.6 Kano-QFD Instrument 143

3.6 Data Analysis: Phase 1, 2 and 3 147

3.6.1 Berger’s Coefficient and Kano Attribute Category 149

3.6.2 Kano’s Statistical Significant 149

3.6.3 Patient’s Attributes into QFD (Step 1) 151

3.6.4 Service Compliment and Service Complaint Indexes (Step 2) 152

3.6.5 Defining the Healthcare Service Attributes (Step 3) 153

3.6.6 Relationship Matrix between Patient’s Attributes and Service

Attributes (Step 4)

154

3.6.7 Correlation Matrix of Service Attributes (Step 5) 154

3.6.8 Calculation of Prioritized Patient Attributes by Compliment

and Complaint Indexes

155

3.7 Summary 156

CHAPTER IV RESULTS AND DISCUSSION 157

4.1 Introduction 157

4.2 Profile of Respondents 157

4.3 Instrument Reliability 160

4.4 Construct Validity using Confirmatory Factor Analysis (CFA) 161

4.5 Non-linear Kano Quality Attributes of Phase I 163

4.5.1 Data Analysis Berger’s Mass Coefficient and Kano Attribute

Category

163

4.5.2 Data Analysis Kano’s Statistical Significant 189

4.5.3 Data Analysis Kano Quality Attributes Grid Mapping 201

4.5.4 Data Analysis Service Complaint Index and Service 215

viii

Compliments Index

4.5.5 Data Analysis of Service Gap and Service Effective 225

4.6 Non-linear Kano Quality Attributes Analysis of Phase 2 and 3 248

4.6.1 Kano-QFD HOQ for Doctor Care 250

4.6.2 Kano-QFD HOQ for Nurse Care 255

4.6.3 Kano-QFD HOQ for Surgery Care 259

4.6.4 Kano-QFD HOQ for Doctor Attitude and Personality 263

4.6.5 Kano-QFD HOQ for Nurse Attitude and Personality 266

4.6.6 Kano-QFD HOQ for Appointment 270

4.6.7 Kano-QFD HOQ for Medical Communication 273

4.6.8 Kano-QFD HOQ for Admission 278

4.6.9 Kano-QFD HOQ for Discharge 281

4.6.10 Kano-QFD HOQ for Mortuary 285

4.6.11 Summary of Kano-QFD HOQ and Service Prioritization 287

4.7 Comparison of Kano-QFD Satisfaction Model with Other Models 291

CHAPTER V CONCLUSION AND RECOMMENDATIONS 300

5.1 Introduction 300

5.2 Addressing the Research Questions 301

5.3 Contribution of Present Kano-QFD Satisfaction Model and Comparison 314

5.3.1 Theoretical Contribution 314

5.3.2 Methodological Contribution 318

5.3.3 Managerial Contribution 320

5.4 Limitations and Recommendations 321

5.4.1 Limitations 321

5.4.2 Future Research 321

ix

REFERENCES 324

APPENDIX - A 366

A.1 Letter from Director General of Health Malaysia 366

A.2 Institute for Health Behavioural Research (IHBR) and National

Institute of Health (NIH) Approval for Research

A.3 Official Approval Letter from Medical Research & Ethics Committee

(MREC), MOH, Malaysia

368

369

A.4 National Medical Research Register (NMRR) High Level Workflow 370

APPENDIX - B Kano-QFD Questionnaire 371

APPENDIX - C Exploratory Factor Analysis (EFA) for Pilot Survey 386

C.1 Measurement model for Doctor Care 386

C.2 Measurement model for Nurse Care 387

C.3 Measurement model for Surgery Care 388

C.4 Measurement model for Doctor Attitude and Personality 389

C.5 Measurement model for Nurse Attitude and Personality 390

C.6 Measurement model for Appointment 391

C.7 Measurement model for Medical Communication 392

C.8 Measurement model for Admission 393

C.9 Measurement model for Discharge 394

C.10 Measurement model for Mortuary 395

Table C.1 Summary of Exploratory Factor Analysis (EFA) 396

APPENDIX - D Reliability Test Results for Pilot Survey 397

Table D.1 Cronbach’s α for Kano-Q and Kano-SS (N = 50) 412

x

APPENDIX - E Confirmatory Factor Analysis (CFA) for Data Analysis 413

E.1

Measurement model for Doctor Care

413

E.2 Measurement model for Nurse Care 414

E.3 Measurement model for Surgery Care 415

E.4 Measurement model for Doctor Attitude and Personality 416

E.5 Measurement model for Nurse Attitude and Personality 417

E.6 Measurement model for Appointment 418

E.7 Measurement model for Medical Communication 419

E.8 Measurement model for Admission 420

E.9 Measurement model for Discharge 421

E.10 Measurement model for Mortuary 422

Table E.1 Summary of Confirmatory Factor Analysis (CFA) 422

APPENDIX - F

Reliability Test Results for Data Analysis

423

Table F.1

Cronbach’s α for Kano-Q and Kano-SS (N=300)

438

APPENDIX - G

Demographic Data

439

APPENDIX - H

QFD House of Quality for Data Analysis

H.1

QFD HOQ of Doctor Care

442

H.2 QFD HOQ of Nurse Care 443

H.3 QFD HOQ of Surgery Care 444

H.4 QFD HOQ of Doctor Attitude and Personality 445

H.5 QFD HOQ of Nurse Attitude and Personality 446

H.6 QFD HOQ of Appointment 447

H.7 QFD HOQ of Medical Communication 448

H.8 QFD HOQ of Admission 449

H.9 QFD HOQ of Discharge 450

H.10 QFD HOQ of Mortuary

451

xi

LIST OF TABLES

NO. PAGE

1.1

Development of non-linear satisfaction model in service due to

inaccuracy and deficiency of linear relationship between service

delivery and customer expectation

4

1.2

Summary of healthcare system for 2011-2015 Country Health Plan

6

1.3

Area of concern that affects the healthcare service delivery

6

1.4

Public Complaint Report and Total on Malaysian Healthcare

Services which adapted from Public Complaints Bureau (PCB) (i-

Aduan) through MESRA Programme, Mobile Complaints Counter

(MCC) and Integrated Mobile Complaints Counter (IMCC)

10

2.1

Number of inpatient beds, bed occupancy rate (BOR) and total

admission to MOH hospitals and institutions, 2007-2011

26

2.2

Summary of healthcare capacity and constraints

28

2.3

Category of complaints in Year 2008

35

2.4

Summary of service delivery variables in healthcare

40

2.5

Kano evaluation (KE) table

49

2.6

QFD penetration

50

2.7

QFD advantages

51

2.8

QFD disadvantages

51

2.9

QFD research classification

56

2.10

QFD top 10 articles most published

58

2.11

QFD research classification by publications

59

2.12 Conventional QFD for new product development 60

2.13

QFD integration for new product development

61

2.14

QFD research classification in product development

63

2.15

Conceptual requirements

64

2.16

Operational requirements

65

2.17

Selected operational requirements for design process

65

2.18

Important parameters for new service design

66

2.19

QFD advantages in healthcare service

67

2.20

QFD drawbacks in healthcare service

67

2.21

QFD possible problem arise in implementations

67

2.22

Stakeholders target for hospitals

68

2.23

QFD research classification in services

68

2.24

Respondents number for satisfaction model in healthcare

71

2.25

Summary of satisfaction measurements in healthcare

73

2.26

Summary of previous study on satisfaction model in healthcare

78

2.27

QFD basic for new service development

80

2.28

QFD extension for new services development

81

2.29

Kano-QFD research model and objectives (1998-2011)

85

2.30

Expression of conventional Kano Answer

97

2.31

Seven point service satisfaction scale

101

2.32

Assumption of CIT and ACC

103

2.33

New Kano-SS equivalence scale assumptions

104

2.34

Importance scale and satisfaction scale reference

107

xii

xiii

2.35 Refined KQA by Yang (2005) 108

2.36

Refined KQA by Shahin & Nekuie (2011)

108

2.37

Comparison of satisfaction impact k

111

2.38 Proposed satisfaction impact coefficient μ

112

2.39

Refined Kano evaluation (KE) table (Kano et al., 1984) with service

satisfaction scale and proposed satisfaction impact coefficient μ

112

3.1

Population description

125

3.2

Survey population

126

3.3

Sample size of the survey (N=300)

130

3.4

Sampling size summary sources of service variable

132

3.5

Sub-variable of personal details, and visiting history

135

3.6

Main sources of service attributes based on complaints local

healthcare, Malaysia Public Complaints Bureau, Ministry of Health

and published satisfaction model

138

3.7

Cronbach’s alpha for pilot survey Kano-Q and Kano-SS

(N = 50)

141

3.8

Summary of Exploratory Factor Analysis (EFA)

143

3.9

Summary of frequency agreement for functional question

144

3.10

Summary of frequency agreement for dysfunctional question

146

3.11

Main sources of service attributes based on complaints local

healthcare, Malaysia Public Complaints Bureau, Ministry of Health

155

4.1

Demographic profile of respondents (N=300)

158

4.2

Cronbach’s α for Kano-Q and Kano-SS (N=300)

160

4.3

Summary of Confirmatory Factor Analysis (CFA) results

162

xiv

4.4 Kano-SS KQA for Doctor Care 164

4.5

Kano-SS KQA for Nurse Care

167

4.6

Kano-SS KQA for Surgery Care

170

4.7

Kano-SS KQA for Doctor Attitude and Personality

173

4.8

Kano-SS KQA for Nurse Attitude and Personality

176

4.9

Kano-SS KQA for Appointments

177

4.10

Kano-SS KQA for Medical Communication

179

4.11

Kano-SS KQA for Admission

182

4.12

Kano-SS KQA for Discharge

184

4.13

Kano-SS KQA for Mortuary

185

4.14

Summary of overall service index for mass survey

187

4.15

Summary of KQA for data analysis (N = 300)

188

4.16

KQA Kano-SS statistical significant for Doctor Care

191

4.17

KQA Kano-SS statistical significant for Nurse Care

191

4.18

KQA Kano-SS statistical significant for Surgery Care

192

4.19

KQA Kano-SS statistical significant for Doctor Attitude and

Personality

193

4.20

KQA Kano-SS statistical significant for Nurse Attitude and

Personality

194

4.21

KQA Kano-SS statistical significant for Appointments

195

4.22

KQA Kano-SS statistical significant for Medical Communication

196

4.23

KQA Kano-SS statistical significant for Admission

198

4.24

KQA Kano-SS statistical significant for Discharge

199

4.25

KQA Kano-SS statistical significant for Mortuary

200

xv

4.26 Summary of KQA significant for data analysis (N = 300) 200

4.27

Summary of KQA for data analysis (N=300)

214

4.28

Doctor Care SCi and SCa Index

216

4.29

Nurse Care SCi and SCa Index

217

4.30

Surgery Care SCi and SCa Index

218

4.31

Doctor Attitude and Personality SCi and SCa Index

219

4.32

Nurse Attitude and Personality SCi and SCa Index

220

4.33

Appointment SCi and SCa Index

220

4.34

Medical Communication SCi and SCa Index

221

4.35

Admission SCi and SCa Index

222

4.36

Discharge SCi and SCa Index

223

4.37

Mortuary SCi and SCa Index

223

4.38

Summary of KQA, SCi and SCa

224

4.39

Service Gap and Service Effective for Doctor Care

226

4.40

Service Gap and Service Effective for Nurse Care

228

4.41

Service Gap and Service Effective for Surgery Care

231

4.42

Service Gap and Service Effective for Doctor Attitude and

Personality

233

4.43

Service Gap and Service Effective for Nurse Attitude and

Personality

235

4.44

Service Gap and Service Effective for Appointment

237

4.45

Service Gap and Service Effective for Medical Communication

240

4.46

Service Gap and Service Effective for Admission

243

4.47

Service Gap and Service Effective for Discharge

245

xvi

4.48 Service Gap and Service Effective for Mortuary 247

4.49 Prioritized patient attributes ( ) index by compliments for Doctor Care

251

4.50 Prioritized patient attributes ( ) index by complaints for Doctor Care and minimum improvement required

251

4.51 Prioritized service attributes ( ) index by compliments for Doctor Care

253

4.52 Prioritized service attributes ( ) index by complaints for Doctor Care

253

4.53 Prioritized patient attributes ( ) index by compliments for Nurse Care

256

4.54 Prioritized patient attributes ( ) index by complaints for Nurse Care and minimum improvement required

256

4.55 Prioritized service attributes ( ) index by compliments for Nurse Care

258

4.56 Prioritized service attributes ( ) index by complaints for Nurse Care

259

4.57 Prioritized patient attributes ( ) index by compliments for Surgery Care

260

4.58 Prioritized patient attributes ( ) index by complaints for Surgery Care and minimum improvement required

261

4.59 Prioritized service attributes ( ) index by compliments for Surgery Care

261

4.60 Prioritized service attributes ( ) index by complaints for Surgery Care

262

4.61 Prioritized patient attributes ( ) index by compliments for Doctor Attitude and Personality

263

4.62 Prioritized patient attributes ( ) index by complaints for Doctor Attitude and Personality and minimum improvement

required

264

4.63 Prioritized service attributes ( ) index by compliments for Doctor Attitude and Personality

265

4.64 Prioritized service attributes ( ) index by complaints for Doctor Attitude and Personality

266

4.65 Prioritized patient attributes ( ) index by compliments for Nurse Attitude and Personality

267

4.66 Prioritized patient attributes ( ) index by complaints for Nurse Attitude and Personality and minimum improvement required

267

4.67 Prioritized service attributes ( ) index by compliments for Nurse Attitude and Personality

268

4.68 Prioritized service attributes ( ) index by complaints for Nurse Attitude and Personality

269

4.69 Prioritized patient attributes ( ) index by compliments for Appointment

271

4.70 Prioritized patient attributes ( ) index by complaints for Appointment and minimum improvement required

271

4.71 Prioritized service attributes ( ) index by compliments for Appointment

272

4.72 Prioritized service attributes ( ) index by complaints for Appointment

273

xvii

xviii

4.73 Prioritized patient attributes ( ) index by compliments for Medical Communication

274

4.74 Prioritized patient attributes ( ) index by complaints for Medical Communication and minimum improvement required

276

4.75 Prioritized service attributes ( ) index by compliments for Medical Communication

277

4.76 Prioritized service attributes ( ) index by complaints for Medical Communication

278

4.77 Prioritized patient attributes ( ) index by compliments for Admission

279

4.78 Prioritized patient attributes ( ) index by complaints for Admission and minimum improvement required

279

4.79 Prioritized service attributes ( ) index by compliments for Admission

280

4.80 Prioritized service attributes ( ) index by complaints for Admission

281

4.81 Prioritized patient attributes ( ) index by compliments for Discharge

282

4.82 Prioritized patient attributes ( ) index by complaints for Discharge and minimum improvement required

283

4.83 Prioritized service attributes ( ) index by compliments for Discharge

284

4.84 Prioritized service attributes ( ) index by complaints for Discharge

284

4.85 Prioritized patient attributes ( ) index by compliments for

285

xix

Mortuary

4.86 Prioritized patient attributes ( ) index by complaints for Mortuary and minimum improvement required

286

4.87 Prioritized service attributes ( ) index by compliments for Mortuary

286

4.88 Prioritized service attributes ( ) index by complaints for Mortuary

287

4.89

Summary of prioritized service attributes categories in ranking

290

4.90

Comparison of non-linear satisfation model using Kano and Kano-

QFD based on Kano Quality Attribute satisfaction impact

292

4.91

Service gap comparison of present non-linear satisfaction model

with other models for Tangibility and Reliability

294

4.92

Service gap comparison of present non-linear satisfaction model

with other models for Responsiveness

296

4.93

Service gap comparison of present non-linear satisfaction model

with other models for Assurance

297

4.94

Service gap comparison of present non-linear satisfaction model

with other models for Empathy and Accessibility

298

5.1

Average of service satisfaction index

302

5.2 Summary of , , , and

304

5.3

Summary of satisfaction gap and service effective

306

5.4

Summary of prioritized patient attributes and service attributes based

on complaint and compliment (Top Rank)

310

5.5

Summary of modified Kano-QFD Model with statistical approach

312

5.6

Summary of effective service attribute

313

xx

LIST OF FIGURES

NO. PAGE

1.1

Complaints frequency received by public hospital from year 2000 –

2014 based on Malaysian Public Complaints Bureau

9

2.1

Complaints frequency received by public hospital from year 2000 –

2014 based on government, state and public health sector

32

2.2

Complaints frequency received by public hospital from year 2005 –

2008 by Ministry of Health

33

2.3

Complaints fraction received by public hospital for 2008

34

2.4

Complaints frequency resources in public hospital (2006 – 2008)

36

2.5

Complaint frequency resources based on health institution, clinic and

hospital from year 2006 - 2008

37

2.6

Distribution of complaints by department

42

2.7

Classification of complaints

44

2.8

Kano’s model of customer satisfaction

46

2.9

Example of functional and dysfunctional form in Kano questionnaire

48

2.10

Basic components of QFD or HOQ

54

2.11

Eight steps of QFD diagram for mechanical design process

55

2.12

Nine steps QFD model

55

2.13

Summary of general Kano-QFD integration model

84

2.14

QFD research problem and issues

93

2.15

Preliminary concept of Kano-QFD integration

96

3.1

Research design

116

xxi

3.2 Kano-QFD integration framework 118

3.3

Questionnaire design in Phase 1

134

3.4

Sample of Kano-Q (DCK 1-2) questions

136

3.5

Sample of Kano-SS (DCQ3-11) question

137

3.6

Phase I Kano-QFD Step 1 flow chart for pilot survey

139

3.7

Data analysis framework of phase 1, 2 and 3

148

3.8

Kano-QFD Step 1 and 2

152

3.9

The flow of information from Kano-QFD Step 1 to Step 2

153

3.10

Service attributes category and elements

156

4.1

Service satisfaction and service dissatisfaction index for Doctor Care

166

4.2

Service satisfaction and service dissatisfaction index for Nurse Care

169

4.3

Service satisfaction and service dissatisfaction index for Surgery Care

172

4.4

Service satisfaction and service dissatisfaction index for Doctor

Attitude and Personality

174

4.5

Service satisfaction and service dissatisfaction index for Nurse

Attitude and Personality

175

4.6

Service satisfaction and service dissatisfaction index for Appointment

178

4.7

Service satisfaction and service dissatisfaction index for Medical

Communication

181

4.8

Service satisfaction and service dissatisfaction index for Admission

183

4.9

Service satisfaction and service dissatisfaction index for Discharge

185

4.10

Service satisfaction and service dissatisfaction index for Mortuary

186

4.11

Grid mapping for Kano-SS Doctor Care

203

4.12

Grid mapping for Kano-SS Nurse Care

204

4.13 Grid mapping for Kano-SS Surgery Care 205

4.14

Grid mapping for Kano-SS Doctor Attitude and Personality

207

4.15

Grid mapping for Kano-SS Nurse Attitude and Personality

208

4.16

Grid mapping for Kano-SS Appointment

209

4.17

Grid mapping for Kano-SS Medical Communication

210

4.18

Grid mapping for Kano-SS Admission

211

4.19

Grid mapping for Kano-SS Discharge

212

4.20

Grid mapping for Kano-SS Mortuary

213

4.21

Chart of service gap and service effective for Doctor Care

227

4.22

Chart of service gap and service effective for Nurse Care

229

4.23

Chart of service gap and service effective for Surgery Care

232

4.24

Chart of service gap and service effective for Doctor Attitude and

Personality

234

4.25

Chart of service gap and service effective for Nurse Attitude and

Personality

236

4.26

Chart of service gap and service effective for Appointments

238

4.27

Chart of service gap and service effective for Medical Communication

241

4.28

Chart of service gap and service effective for Admission

244

4.29

Chart of service gap and service effective for Discharge

246

4.30

Chart of service gap and service effective for Mortuary

247

5.1

Mapping of satisfaction and dissatisfaction coefficient and service

satisfaction scale

303

5.2 Relationship of satisfaction gap and service effective with Kano

Model

307

xxii

xxiii

LIST OF ABBREVIATIONS

A Attractive Attribute

ACC Analysis of Complaints and Compliments

ADMK Admission Kano

ADMQ Admission Question

AHP Analytical Hierarchical Process

ALOS Average Length of Stay for Acute Care

ANN Artificial Neural Network

ANP Analytical Network Process

APDK Attitude and Personality Doctor Kano

APDQ Attitude and Personality Doctor Question

APNK Attitude and Personality Nurse Kano

APNQ Attitude and Personality Nurse Question

APPK Appointments Kano

APPQ Appointments Question

BOR Bed Occupancy Rate

CA Customer Attribute

CD Customer Dissatisfaction

CFA Confirmatory Factor Analysis

CIT Critical Incident Technique

CKA Customer Kano Attribute

CKAD Customer Kano Attribute Dysfunctional

CKAF Customer Kano Attribute Functional

CKAS Conventional Kano Answer Scheme

CKQ Conventional Kano’s Questionnaire

CPD Complainant Personal Details

CQI Continuous Quality Improvement

CS Customer Satisfaction

CVI Clinical Visit Information

DC Degree of Confidence

DCK Doctor Care Kano

xxiv

DCQ Doctor Care Question

DISCK Discharge Kano

DISCQ Discharge Question

DP Desired Precision

ED Extent of Dissatisfaction

ES Extent of Satisfaction

FMEA Failure Mode Effect Analysis

HC Healthcare Customer

HSP Healthcare Service Provider

HSV Healthcare Service Variables

HOQ House of Quality

I Indifferent Attribute

IMCC Integrated Mobile Complaints Counter

IOP Inpatients and Outpatients

KAS Kano Answers Scale

KE Kano Evaluation

KEA Kano Evaluation Answer

KGM Kano Grid Mapping

KQ Kano Question

KQA Kano Quality Attribute

KSAS Kano Satisfaction Answer Scheme

KSS Kano Statistical Significant

M Must be Attribute

MCC Mobile Complaints Counter

MDCOMK Medical Communication Kano

MDCOMQ Medical Communication Question

MODM Multi Objective Decision Making

MOH Ministry of Health

MORTK Mortuary Kano

MORTQ Mortuary Question

O One dimensional Attribute

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PA Patient Attribute

PACap Prioritized Patient Attributes Index by Complaints

PACip Prioritized Patient Attributes Index by Compliments

PCA Patient Care Attributes

PCB Public Complaints Bureau

PD Patient Dissatisfaction

Pi Performance Index

PS Patient Satisfaction

PSA Prioritized Service Attribute

QA Quality Attribute

QBD Quality Benchmarking Deployment

QCC Quality Control Circle

QFD Quality Function Deployment

QI Quality Improvement Index

R Reversed Attribute

SACap Prioritized Service Attributes Index by Complaints

SACip Prioritized Service Attributes Index by Compliments

SCa Service Complaints

SCi Service Compliments

SCK Surgery Care Kano

SCQ Surgery Care Question

SD Service Dissatisfaction

SDDM Service Design Decision Making

SS Service Satisfaction

SV Service Variables

TQM Total Quality Management

TV True Variability

UQ Ultimate Question

USDF Uncertainty Service Delivery Feedback

VOP Voice of Patient

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DEFINITION OF TERMS

Attractive Attribute (A) These attributes provide satisfaction when achieved fully, but do not cause dissatisfaction when not fulfilled. These are attributes that are not normally expected. Since these

types of attributes of quality unexpectedly delight

customers, they are often unspoken. It can be neither

explicitly expressed nor expected by the customer and by

fulfilling these requirements, the more customer satisfaction

can be achieved.

Average Length of Stay

for Acute Care (ALOS)

Bed Occupancy Rate

(BOR)

Average length of stay is computed by dividing the number

of days stayed (from the date of admission in an in-patient

institution) by the number of discharges (including deaths)

during the year.

The total beds available in the hospital by number of days in

the year it would be available

Customer Attribute Customer attributes includes the way the business is working and the way the customers are buying the products and the regular occasional shoppers form family status- like

children's and adults.

Customer

Dissatisfaction

Confirmatory Factor

Analysis

Critical Incident

Technique

Continuous Quality

Improvement

One with the ability, means and desire to buy that does not

for a reason of dissatisfaction

Is a special form of factor analysis, most commonly used in

social research. It is used to test whether measures of a

construct are consistent with a researcher's understanding of

the nature of that construct (or factor). As such, the

objective of confirmatory factor analysis is to test whether

the data fit a hypothesized measurement model. This

hypothesized model is based on theory and/or previous

analytic research.

A set of procedures used for collecting direct observations

of human behaviour that have critical significance and meet

methodically defined criteria. These observations are then

kept track of as incidents, which are then used to solve

practical problems and develop broad psychological

principles. A critical incident can be described either as one

that makes a significant contribution positively or

negatively to an activity or phenomenon.

Is a process to ensure programs are systematically and

intentionally improving services and increasing positive

outcomes for the families they serve. Is a cyclical, data-

driven process, it is proactive and ongoing process that

involves the Plan, Do, Study, and Act cycle.

http://en.wikipedia.org/wiki/Factor_analysishttp://en.wikipedia.org/wiki/Constructhttp://en.wikipedia.org/wiki/Procedure_(term)http://en.wikipedia.org/wiki/Human_behaviorhttp://en.wikipedia.org/wiki/Psychological

Customer Satisfaction The number of customers or percentage of total customers,

whose reported experience with a firm, its products, or its

services (ratings) exceeds specified satisfaction goals.

Degree of Confidence Is a type of interval estimate of a population parameter and is used to indicate the reliability of an estimate.

Failure Mode Effect

Analysis

Is often the first step of a system reliability study. It involves reviewing as many components, assemblies, and

subsystems as possible to identify failure modes, and their

causes and effects.

House of Quality Is a diagram, resembling a house, used for defining the relationship between customer desires and the firm/product

capabilities.

Indifferent Attribute These attributes refer to aspects that are neither good nor bad, and they do not result in either customer satisfaction or

customer dissatisfaction.

Kano Model A theory of product development and customer satisfaction developed in the 1980s by Professor Noriaki Kano which

classifies customer preferences into five categories; Must be

Attribute, One dimensional Attribute, Indifferent Attribute,

Attractive Attribute and Reversed Attribute

Must be Attribute These attributes are taken for granted when fulfilled but result in dissatisfaction when not fulfilled. An example of

this would be package of milk that leaks. Customers are

dissatisfied when the package leaks, but when it does not

leak the result is not increased customer satisfaction.

One dimensional

Attribute

These attributes result in satisfaction when fulfilled and dissatisfaction when not fulfilled. These are attributes that

are spoken of and ones which companies compete for. An

example of this would be a milk package that is said to have

10% more milk for the same price will result in customer

satisfaction, but if it only contains 6% then the customer

will feel misled and it will lead to dissatisfaction.

Quality Control Circle Is a management approach that involves input from a number of different sources within the structure of a

company. Is to identify the presence of specific performance

issue within the company, determine the origins of the

issue, and then develop a process that helps to correct or

resolve the problem without triggering additional issues

elsewhere within the operational structure.

Reversed Attribute These attributes refer to a high degree of achievement resulting in dissatisfaction and to the fact that not all

customers are alike. For example, some customers prefer

high-tech products, while others prefer the basic model of a

product and will be dissatisfied if a product has too many

extra features

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http://en.wikipedia.org/wiki/Customer_satisfactionhttp://en.wikipedia.org/wiki/Noriaki_Kano

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Development of Kano Model and Quality Function Deployment Integration to

Assess Customer Satisfaction and Dissatisfaction of Service at Local Public

Hospital

ABSTRACT

The intensifying patient complaints on service delivery performance of local public

healthcare institution are critical and incrementally raised. New methodologies are

needed to address the complexity of patient expectation before the quality of service

delivery can be improved. This issue needs to be solved instantly by establishing the

service satisfaction model to understand the nature of patient’s expectation towards

service delivery. As a result, the developed service satisfaction model has contributed to

be inaccurate to understanding of patient’s behavior towards healthcare service. The

non-linear assumption should be considered for better accuracy since the non-linear

patient’s expectation remains undefined. This thesis aims to develop the non-linear

service satisfaction model that assumes patients are not necessarily satisfied or

dissatisfied with good or poor service delivery. With that, compliment and compliant

assessment is considered, simultaneously. Non-linear service satisfaction instrument

called Kano-Q and Kano-SS is developed based on Kano model and Theory of Quality

Attributes to define the unexpected, hidden and unspoken patient satisfaction and

dissatisfaction into service quality attribute. A new Kano-Q and Kano-SS algorithm for

quality attribute assessment is developed based satisfaction impact theories and found

instrumentally fit the reliability and validity test. The results were also validated based

on standard Kano model procedure before Kano model and Quality Function

Deployment (QFD) is integrated for patient attribute and service attribute prioritization.

An algorithm of Kano-QFD matrix operation is developed to compose the prioritized

complaint and compliment indexes. Finally, the results of prioritized service attributes

are mapped to service delivery category to determine the most prioritized service

delivery that need to be improved at the first place by healthcare service provider. The

results of this study indicate that the new satisfaction model is significantly effective in

differentiating Kano dimensions and provides more accurate prioritization of the

dimension and attribute compared to the traditional Kano approach. Although the new

methodology evaluates the Kano methodology with QFD integration, the methodology

is limited to a particular service industry that always encountered high dissatisfaction

which expected to compose the Must-be, Attractive and One-dimensional quality

attribute by ranking. As a conclusion, the new non-linear Kano-QFD service satisfaction

model has been developed, tested and validated with Kano model to facilitate the

analysis and decision making for better service delivery improvement. Comparison with

other models has shown well agreement in terms of Kano quality attributes satisfaction

impact and service gaps in healthcare service. As for future work, the comparison study

on linear and non-linear patient expectation based on Kano-QFD integration is

essentially recommended.

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Pembangunan Model Kano dan Integrasi Pertukaran Fungsi Kualiti untuk

Menilai Kepuasan dan Ketidakpuashatian Pelanggan Perkhidmatan di Hospital

Awam Tempatan

ABSTRAK

Pertambahan aduan pesakit terhadap prestasi penghantaran servis yang dilaporkan oleh

institusi kesihatan tempatan adalah pada tahap kritikal dan meningkat naik. Kaedah baru

diperlukan bagi mengetengahkan kehendak pesakit yang kompleks sebelum kualiti

penghantaran servis boleh dipertingkatkan. Isu ini perlu diselesaikan dengan segera bagi

membangunkan satu model kepuasan servis untuk memahami kehendak pesakit

terhadap penghantaran servis. Model kepuasan servis terdahulu adalah berdasarkan

andaian perhubungan lelurus. Hasilnya, model kepuasan servis yang dibangunkan juga

menyumbang kepada ketidaktepatan pada pemahaman kelakuan pesakit terhadap servis

kesihatan. Satu andaian ketaklelurusan perlu dipertimbangkan bagi ketepatan terbaik

kerana ketaklelurusan kehendak pesakit masih belum ditentukan. Tesis ini bertujuan

untuk membangunkan model kepuasan servis ketaklelurusan yang mengandaikan para

pesakit tidak semestinya berpuashati atau tidakberpuashati dengan kebagusan atau

ketakbagusan servis kesihatan. Oleh yang demikian, aduan dan pujian perlu disekalikan

dalam pembangunan model. Satu pengalatan kepuasan ketaklelurusan servis dinamakan

Kano-Q dan Kano-SS telah dibangunkan berasaskan model Kano dan Teori Sifat

Kualiti bagi mengenalpasti kepuasan dan ketakpuasan pesakit yang tak terjangka,

tersembunyi dan tak dinyatakan kepada sifat kualiti servis. Instrumen tersebut telah

digunakan untuk mengukur sepuluh pembolehubah aduan terbanyak dalam servis

kesihatan. Satu algoritma Kano-Q dan Kano-SS bagi penilaian sifat kualiti telah

dibangunkan berdasarkan teori impak kepuasan dan instrumen didapati mematuhi ujian

kebolehpercayaan dan kesahan. Keputusan juga disahkan berasaskan prosedur piawai

model Kano sebelum model Kano dan Quality Function Deployment (QFD)

diintegrasikan untuk sifat bagi pesakit dan keutamaan servis. Satu algoritma bagi

operasi matrix Kano-QFD dibangunkan bagi terbitan keutamaan indeks aduan dan

pujian. Walaupun metodologi baru membentuk kaedah untuk integrasi Kano-QFD,

metodologi tersebut terhad kepada industri perkhidmatan yang selalu mengalami

ketidapuashatian yang tinggi yang mana darjah sifat kualiti adalah Mesti, Menarik and

Satu-Dimensi. Kesimpulannya, satu ketaklurusan model Kano-QFD telah dibangunkan,

diuji dan disahkan untuk menyokong pembuatan keputusan bagi penambahbaikan

penghantaran servis. Perbandingan dengan model-model lain daripada literasi

menunjukkan ciri-ciri persamaan dalam bentuk sifar kualiti Kano. Sebagai cadangan

kajian pada masa hadapan, perbandingan kajian antara lelurus dan ketidak lelurusan

berdasarkan integrasi Kano-QFD perlulah dibangunkan.