Analysis of Healthcare Services Quality Using Servqual-Fuzzy Method

One of the important concepts in management and business is service quality. Service quality is a very important concepts that companies must understand if they want to remain competitive and evolving. Service quality becomes increasingly important for today’s business, particularly in high-customer involvement industries such as healthcare services [1]. Health care service providers should disseminate correct information from time to time as more quality information leads to patient awareness and satisfaction [2]. Service quality in hospitals should be directed towards the satisfaction of patients [3]. Service quality and customer satisfaction have been recognized as the main preserve of curtomer loyalty [4].


Introduction
One of the important concepts in management and business is service quality. Service quality is a very important concepts that companies must understand if they want to remain competitive and evolving. Service quality becomes increasingly important for today's business, particularly in high-customer involvement industries such as healthcare services [1]. Health care service providers should disseminate correct information from time to time as more quality information leads to patient awareness and satisfaction [2]. Service quality in hospitals should be directed towards the satisfaction of patients [3]. Service quality and customer satisfaction have been recognized as the main preserve of curtomer loyalty [4].
With the development of business competition, it is important to make health care providers improving their service qualities. This research is to analyze how the quality of health service in inpatient unit of Dr. Ramelan Surabaya hospital. Based on the results of this study, it could be conclude that it can assist the management of the hospital in determining the policy setrategy by prioritizing attributes that have a big gap to improve the quality of its services.
The purpose of this paper was to identify the gaps between customer expectations of a service and their perceptions of service at Dr. Ramelan hospital, particularly in inpatient units. This paper used a Servqual approach that was integrated with the fuzzy method to gain a gap between the perceptions and expectations of consumers. This approach had been used extensively to assess the quality of private sector services, but there was little application to public services [5].
This paper had many literature to support the research, for example paper titled "A Conceptual Model of Service Quality and Its Implications for Future Research" [6] and other research such as SERVQUAL: A Multiple-Item Scale for Measuring Consumer Perseptions of Service Quality [7]. Five Imperatives for Improving Service Quality [8]. Health Care Service Quality: Case Example of a Hospital with Lean Implementation. A study on Service quality and customer satisfaction of selected Private hospitals of Vadodara City. Service Quality and Determinants Of Customer Satisfaction In Hospitals: Turkish Experience [9]. A Comparative Study of Service Quality on Patient Satisfaction Between Public Hospital in Johor Bahru. Impact of Service Quality on Customers' Satisfaction [10]. Essentials for improving service quality in cancer care [11]. A Review on Dimensions of Service Quality Models [12]. Service Quality in the Public Service.
The other literature supporting this paper was Measuring Consumer Satisfaction in Healthcare Sectore: The Applicability of Servqual [13]. The Dimensions of Service Quality for Hospital [14]. Factors influencing healthcare service quality [15]. Hospital Service Quality and its Effect on Patient Satisfaction and Behavioural Intention [16]. The Assessment of Perceived Service Quality of Public Health Care Services in Romania Using the SERVQUAL Scale [17]. SERVQUAL: Measuring higher education service quality in Thailand [18]. Service quality assessment in health care sector: the case of Durres public hospital [19]. Assessing Obstetrics Perceived Service Quality at a Public Hospital [20,21].
The results of this study can be used by the management of the hospital as a material consideration in determining the policy strategy to improve the quality of service.

Service quality
The first is that customers are the sole judge of service quality. Customers assess service by comparing the service they receive (perceptions) with the service they desire (expectations). Majority of research pertaining to service quality has focused on the measurement of service quality based on the functional dimension [22]. The techniques of measuring service quality and service quality dimensions have become a major area in marketing literature during the past few decades.

Fuzzy
Generally, the fuzzy set is an extension of the crisp set, the set that divides a group of individuals into two categories, namely members and non-members. Fuzzy number is a special fuzzy set F={(x,µ F (x)), x€R} where x where x is the values that lie on the line of real numbers. R 1 ; -∞< x<+∞ R:1 and is a continuous mapping of R 1 into the closed interval [0, 1]. Fuzzy number is used to describe non-precise numerical concepts. A triangular fuzzy number (TFN), expressed by M=(a,b,c), where a<b<c, is a special fuzzy number and has the following type triangular membership function [23]:

Methodology of Research
The methodology of this research is described as follows: The stages of this research were data collection, validity and reliability test, fuzzyfication, calculation of mean value, defuzzyfication, calculation of servqual value without weight, calculation of weight of each variable, calculation of weighted servqual value. The stage of data collection in this study was performed to identify the attributes of health services, preparation of questionnaire, and then distributed the questionnaire to the respondents ( Figure 2). Respondents used in this research were patient or family of patient in Dr. Ramelan hospital, especially in inpatient units. In this research, a total amount of 25 attributes of health services had been identified to be assessed by the respondents, such attributes were shown in Table 1.

Result
In this study, Likert scale was used as measuring tools in the questionnaire. Questionnaires were distributed to 98 respondents randomly at the inpatient unit of the Dr. Ramelan hospital. The test validity and reliability from the results of the questionnaire were performed with SPSS 17.0 software.
Fuzzification of respondent's data (perception and expectation) was done by changing the result of respondent appraisal (in likert scale) to form fuzzy number with formation TFN s (Triangular Fuzzy Number) ( Table 2).
After all the fuzzification results obtained in each attribute, then the average (perceptions and expectations of respondents) from each attribute was calculated, and the defuzzification stage was subsequently performed (Tables 3 and 4).
Source: Parasuraman et al. [6].   The next stage was the calculation of servqual value (gap) without weight (Table 5). Servqual Value (gap score)=Mean of perception -Mean of expectation. The next step after the obtained of servqual value without weight performed was the weighting of each attribute. In this study, the weighing of the attribute was performed by calculating the value average of each service quality attribute given by the respondent. Weighted questionnaires were distributed to experts in the health sector, in this case the staff of Dr. Ramelan hospital as many as 10 respondents. Based on the distributed questionnaire data, the results of weighting each attribute were obtained as shown in Table 6.
After the result of weighting each attribute were obtained, servqual weighted value was subsequently counted by multiplying servqual value without weight with weight value of each attribute (Table 7).

Discussion
The respondent's perception value indicated the level of service quality received by the patient during the use of health services at Dr. Ramelan hospital. Based on the average value of respondent perception, attribute X 5 (Cleanliness of the bathroom and availability of clean water) had the lowest value, while the attribute X 8 (Neatness and cleanliness of the appearance of doctors and nurses) had the highest value. The expectation value of the respondent showed the respondent's willingness to the quality of service that should be given by Dr. Ramelan hospital. The highest expectation value was the attribute of doctors'      ability to analyze the disease (X 19 ). While the smallest expectation value was attribute X 1 (Convenient to inpatient unit location).
The analysis of servqual without weight was performed to find out how big the gap between perception and expectation of respondent to health service in Dr. Ramelan hospital. Based on the results of this calculation, the attribute X 5 (Cleanliness of the bathroom and availability of clean water) had the largest gap , this showed the biggest gap between the perception and expectations of respondents to this attribute. While the smallest gap value was the attribute of Neatness and cleanliness of the appearance of doctors and nurses (X 8 ).
From the weighting of each attribute by the hospital management, the highest value of weight on attribute X 19 (The ability of doctors to analyze the disease) was obtained. While the lowest weight value was in the Convenient to Inpatient unit location (X 1 ) attributes. In the final result, a weighted servqual value with the highest gap was obtained in the attribute of Cleanliness of the bathroom and availability of clean water (X 5 ) with a score of -0.0433, The availability of doctors and nurses at the time of patient need (X 18 ) with a score of -0.0364, and attribute of Fast, accurate examination, treatment and treatment services (X 10 ) with a score of -0.0354. This indicated that these attributes should be a prioritized to improve service quality.

Conclusion
Based on the results and discussion above, the policy strategy that can be taken by hospital management to improve the quality of service was prioritizing service quality improvement on attribute X 5 (Cleanliness of the bathroom and availability of clean water), X 18 (The availability of doctors and nurses at the time of patient need) and attribute X 10 (Fast, accurate examination, treatment and treatment services). Attributes these services assessed by customers were the least quality.