Abstract—In health care services, achieving high performance is at utmost importance as it relates to human life. In lieu to this, performance of the health care practices has to be measured. Measuring the performance of a health care practice has existed since 250 years ago. Until now, it is still significant; however the names and faces of the measures have changed. In Malaysia, the private medical clinics operate on profit bases, therefore it is important for the providers to monitor patients’ satisfactions, loyalty and foremost is to establish image as the reputable service providers.  On this ground, this paper aims to construct a conceptual framework that describes the relationship between service attributes that contribute patients’ satisfaction, loyalty and their judgment on reputation. The relationship is mediate by a mediator (patients’ health consciousness) and moderate by patients’ category, i.e. type of payment. The subject of this paper focuses on the Private Medical Clinics that provide primary care services to the outpatients in eight districts of Johor State. The selection of the private medical clinics will use quota sampling from each district. The potential respondents are among the outpatients who visited the clinic to get primary care services from the resident physician. They have to answer a set a questionnaire and the data will be analyzed using SPSS and Structural Equation Modeling (SEM) - Smart- PLS. The expected finding from this paper is there are positive significant relationship between both, the independent and dependent variables, and the relationships are significantly mediated by the mediator, and moderated by type of the payment category.

Keywords-Performance Measurement; Healthcare Services; Patient Satisfaction; Health Consciousness, Healthcare Service Reputation

                                                                                                                                                                 I.          Introduction

In health care services regardless of whether in public or private sector, achieving high performance is at utmost importance as it relates to human life. Previous researchers suggested that a healthcare service provider to monitor their practices and one of the appropriate methods is by measuring the performance of the health care practices.

Measuring the performance of a health care practice is not a new agenda at all. The health care quality measurement has existed since 250 years ago [46]. Until today it is still significant. While the names and faces of the measures have changed. Nonetheless, the intent of such measurement, i.e. obtaining data and information upholding medical outcomes, has not changed over the years, and nor have the challenges associated with the measurement of quality in health care. The reason behind is that, the health care itself is a complex system [11]. Past researcher [79] claimed that service quality in health care is very complex as compared to other services because this sector highly involves risk. It is due to high integration between departments and units; large number of parties involves and engages with many process and procedures, which are all linked from one to another. Another factor is the target of the health care exercises, i.e. human, and each and every one of human being has a different body system and anatomy.  Even though there is a global standard treatment for many kinds of illness, but the result may vary from one patient to another. Differences in outcome may be due to case mix, setting differences, data collection method, chance or quality of care [48][80].

Past researchers have investigated the performance measurement subject in the health care industry [80][18][30]. The performance in health care services was viewed from several perspectives and been categorized into three main aspects, i.e. the structure, process and outcome. An outcome measures are an indicator of health and valid performance indicators [48]. Process measures are a direct measure of the quality of health care. It relates to outcome measure too, provided there is a link is demonstrated between a given process and outcome [80]. Nonetheless, it is more sensitive to differences in quality of care [30]. The third element is the structure measures.  The measurement of structure quality includes the examine of overall health care organization, the types of the services offered, category and quantity of the staff that involve in the service delivery, equipments that consists of medical and non-medical as well as medicines. On the other hand, process measures examine the process quality that includes the process of delivering the treatment services, which includes both, the technical and non-technical processes.

This research focuses on the outcome measures, that examines the outcome quality that consists of the changes of the health status of a patient due to the health care services been delivered, patients’ satisfaction [30] and economic performance Health status and economic performance are unassessable due to privacy regulation, therefore this research focuses on the patient satisfaction. Patients’ satisfaction specifically had been used as a way to include patients’ perceptions and preferences when evaluating the success of both medical treatments and systems of healthcare delivery [42][81][124].

                                                                                                                                                        II.         Literature Review

Past researches on health care performance were mostly focused on the hospital setting [67][63][17][3][77] in the public sector and private sector [2]. Primary health care setting has been investigated as well, but limited to public sector’s primary care or general practitioners’ services.  The private medical clinic has been ignored for a while. Even though there were several researches been carried out on private medical clinic, the focus of the research was on the demographic, establishment and structure of the practices [1]. Few other researchers investigated the quality issues of the private primary medical practices [68], however the focuses were shallow, just concentrating on the satisfaction issue but do not exactly examining the performance of the practices.

            Performance measurement (PM) attained a high profile in the 1980s. There were two primary reasons for this being first, the pressure from the government and the auditing purposes and second, due to a greater public expectation and consumerism movements [43]. At that time, public worldwide were increasingly expects the government and related agencies to demonstrate accountability to justify the efficient use of public funds. Consumer on the other hand, demands for the value of the money they have paid. The value they received indicates the satisfaction level, which will promote loyalty and the aspect of consumers’ judgment on reputation of one’s company. Therefore, in this research these three aspects are treated as the indicators of the performance of a business entity. 

            In reviewing the literature, this research is specifically made a reference of performance measurement on the date of the references in which researcher refers to references of post-1980’s literature. It is because of the change in perspective of performance measurement in business took place in the 1980s, by which performance measurement moved away from having a pure financial focus to include more comprehensive business characteristics [57][58][59]. Moreover, the performance measurement researches in this era have gone beyond the technical measurement of performances and include the managerial dimension of performance measurement system. It incorporates all the company systems and supports the decision-making, control, learning and communication [52].

            To define a concept, it is crucial to identify the necessary and sufficient conditions for its existence [14]. The purpose is to get greater clarity on the concept and to formulate the comprised substances of business performance measurement for this research. Besides, comparability and generalizability of the research conducted in the field of PM could be achieved. In addition to the identification of sufficient conditions, three elements are necessary to be included [39] specifically in defining the concept of business performance measurement. The three elements are: the features (properties or elements), roles of performance measurement and processes of performance measurement. Thus, this review considers previous definitions on the fulfillment of the above-mentioned three requirements.

            Follows are the review of several definitions of performance measurement system expounded by the past researchers. The element of feature(s) includes multi-dimensional, multi-level, leading/ lagging, efficiency/ effectiveness, internal/ external, and vertically and horizontally integrated. The definition constructed by Moullin [55] fits the first constraint. It stated that PM as the evaluation of how well a business organization is managed and deliver the value for customers and other stakeholders. In this definition, the phrase ‘value the business entity deliver for customers and other stakeholders’ clearly stated the property that the performance measurement system is working upon. Correspondingly, the definition by Maisel[47] perceptibly expressed the elements of performance measurement, i.e. the sales and marketing initiatives; operating practices; information technology resources; business decision; and people’s activities are aligned with business strategies to achieve desired business results and create shareholder value. Likewise, definition by Jirapan[38] mentioned clearly the properties of the performance measurement, i.e. the performance of people (the producer of the service, such as the physician), the activities (for instance diagnosing, dressing, prescribing, etc), processes (for instance, registration process, payment process etc.), products (the services that customer consumes such as advices and recommendation from the physician, the prescription that the patients have to take, the treatment that patients went through, etc.) and the business units (sub section of pharmacy, surgical and examination room for instance).  Noticeably, earlier definition that was forwarded by Neely[58] stated that a business performance system is mainly perceived as a set of metrics used to quantify both the efficiency and effectiveness of actions. In this definition, ‘set of metrics’ is the element of the system. McGee[51] specifically highlighted the components of performance metrics by outlining the evaluation criteria and corresponding measures that will operate as leading indicators of performance against strategic goals and initiatives. The definitions discussed above are all produced prior to the analyses on the performance measurement [39].  Despite of the above-conformity on the definitions, John[39] made a claim by stating that there seem to be lacking of agreement on a definition, which, creates confusion and clearly limits the potential for generalizability and comparability of research in performance measurement area. This study aims to define performance measurement on the private medical services specifically.

The performance measurement in this research is multi-dimensional, single-level, lagging, efficiency, internal and vertically integrated by features.  The performance measurement will determine how well the private medical clinics deliver the services that are valued to the patients. Value in this context refers to services that meet patients’ requirement, make patients understand the symptom of the illness, know how to take care of the illness, know what to do next etc.  The elements and properties of the performance measurement in this research context are the operation practices, people’s activities and marketing initiatives.  They include; the performance of the physician in diagnosing, taking the history of illness, dressing, prescribing, communicating, advising, explaining, etc.; the process involve would be the registration, medicine disbursement and payment process. The role of performance measurement in this research context is as the information provider and translator to the owner (or manager) of the private medical clinic about how well are their services been delivered to the patients.  The measurement will tell the provider whether patients are satisfied with their services, whether they will come back to get the treatment should they have health problem in future, whether they will recommend others to come for treatment at the specific clinic and whether they have good judgment on the reputation of the clinic based on their experience of consuming the health care services. In the process perspective, as this research is focusing on the function of the performance measurement, therefore the process that this research will go through is; collecting, processing and delivering information from the patients on the performance of the private medical clinic services that involve several aspects. First is the people, that consists of patients, the physicians and other clinic staff; second, the activities that consist of delivery of the ‘medical services’; third is processes which, includes all the procedures that patients will go through from the registration until the dispensing of the medicine and payment; and lastly is the product, that includes all the service that patients consume during their visit to the clinic and business units that consist of the whole private medical clinic itself, including the reputation, name, security, safety, guarantee etc.  

                                                                                                                                   III.        A Proposed  Conceptual Model

The most researched aspects of satisfaction are its association with service quality.  Based on the concept of service quality, the most prominent is SERQUAL [64]. Despites of several controversial issues regarding the validity and reliability of SERQUAL [75], the model existed in several researches in health care. The model however has gone through some modifications, additions as well as Kraft[48] and Tomes[77]. The model have produced constructs of customer satisfaction, that were heavily utilized in 1990s, which were ‘empathy’, ‘understanding of illness’, ‘relationship of mutual respect’, ‘dignity’, ‘food’, ‘physical environment’ and ‘religious needs’, ‘accessibility/affordability’, ‘caring’ and ‘outcomes’.

Several past researchers on service quality attributes of the health care have resulted into quite a number of health care service quality constructs. The definition, operationalization and description of the constructs show some redundancies. It due to multi-dimensional perspectives, differences in health care setting, different target audiences, different countries and other aspects of practices. In this study, researcher decides to adopt constructs [49] as they have been tested at different setting and circumstances.

Figure 1: A Proposed Conceptual Framework - The Relationship between the Private Medical Clinic Service Quality Attributes and the Private Medical Clinic’s Performance with Effect of Patient’s health Consciousness as the Mediating Factor.

A.     Healthcare Service Attributes

There were quite a number of researchers that actively investigated the element of service attributes. There were five relevant elements that are: ‘communication’, ‘responsiveness’, ‘courtesy’, ‘cost’ and ‘cleanliness’. Earlier, Camilleri et al. [12] considered seven dimensions as appropriate for health care service environment: “Professional and technical care’, ‘service personalization’, ‘price’, ‘environment’, ‘patient amenities’, ‘accessibility’ and ‘catering’. Another author found five element; ‘communication’, ‘cost’, ‘facility’, ‘competence’, and ‘demeanor’ (conduct / manner / appearance). Potter et al. (1994) came out with the classifications of the attributes, which are ‘technical’, ‘interpersonal’ and ‘amenities and environment’ as an addition to dimensions that have emerged i.e. access / waiting time, cost, outcomes and religious needs.  Much earlier year, Berry et al. [8] stressed on reliability and claimed it as the most important attributes in services industry. The author believed that unreliability would lead to dissatisfaction and reliability would lead to satisfaction.

Several other authors, on consensus agreed that communication skills are the most important determinant of patient satisfaction with care [16], and satisfaction with care is the primary determinant of personal decisions to use health plans and hospitals [59].

B.     Customer Satisfaction

Delivering poor quality service and having dissatisfied customers are antecedents to a number of critical behaviour. These may be in the form of switching service providers and influencing others in their perception of quality [7]. For patients, switching providers could be detrimental to health, as the cost of disruption or non-compliance of treatment could directly impact on healthcaare outcomes [29], and create psychological trauma due to dealing with the uncertainty of adjusting to new service providers [20]. Serious deficiencies are likely to occur if there is any attempt to achieve quality without a full understanding of the requirements and expectations of customers [70]. Therefore businesses have to remain customer-focused by reviewing the approach of how business is managed, begins with customer problem, needs and priorities and find ways to meet them. In Malaysia specifically, there are no statistics available and, as per now, no study has been conducted to quantify the cost of health service failure in Malaysia. Most of the complaints were on long waiting time, high costs, and unfriendly, apathetic and uncaring attitudes of staff. These dissatisfactory attributed may looks simple and did not cause terminal damage, but it has to be addressed accordingly, as these factors may be the causes of service provider switching.

Measurement of Patient Satisfaction fulfills three distinct functions: Understanding patients’ experiences of healthcare, identifying problems in healthcare and evaluation of healthcare [71][49][14]. Evaluation is regarded as the most important dimension. Last few years, researches have shown that service satisfaction can significantly enhance patients’ quality of life [19] and enable service providers to determine specific problems of customers, on which corrective action can then be taken [61]. Determining the factors associated with patient satisfaction is a significant issue for health care providers. It is also important to understand what patients to know where and how service changes can be made value.  Patient satisfaction models, which are supported by patient satisfaction theory, suggest that patients’ evaluations of access, communication, outcomes, and quality, significantly predict patients’ satisfaction. Additionally, social identity theory [78] posits that attitudes are altered and affected by demographic, situational, environmental, and psychosocial factors as well as health status. Patient satisfaction theory distinguished patient satisfaction as an attitude [45]. Due to its evaluative or affective nature, an attitude is distinct from other concepts, such as perceptions. Additionally, as attitudes are distinct individual states that are affected by upbringing, environment, and beliefs, individuals are expected to differ on their evaluations, therefore patient satisfaction should be measured by the totaling of the subjective assessments of the multi-dimensional attributes associated with the care experience. Numerous studies on patient satisfaction with health care support depiction as an attitude that can be measured on multidimensional attributes of care scale [15][32][39][44][52][54].

C.    Customer Loyalty as a Performance Measure

            Good quality service results in long-term customer loyalty [84], poor service quality experiences on the other hand will more likely result in customer defections. Long-term loyalty usually showed by relationship. Quality of the relationship between service provider and customer is a significant indicator of performance, as strong relationship affects customer’s expectations of future interactions over the long term [18]. Quality of the relationship is shown through both, the behavioral and attitudinal loyalty, which both are related to customer’s commitment.  Bloemer and Kasper[9] and Fullerton[29] attempted to integrate the concept of attitudinal commitment in an effort to distinguish between true and spurious loyalty. There are two types of customer commitment conceptualizations exist; that are affective and calculative or continuance commitment [86].

Affective commitment reflects a consumer's sense of belonging and involvement with a service provider parallel to emotional bonding [29]. This loyalty explains customer’s strong belief and consistent behaviour towards single service provider. Simillarly, de Ruyter and Wetzels, [20] stated preference and price indifference explain customer’s attitudinal loyalty. Calculative commitment on the other hand is the way that the customer is forced to remain loyal against his/her desire [20]. In calculative commitment customers can be committed to a selling organization because they feel that ending the relationship involves an economic or social sacrifice [29].

Both, affective and calculative commitments are suitable for performance measurement exercises. Therefore firms should be explicitly link the affective and calculative as well as continuance commitments to the dimensions of quality. Then the dimension of quality should be translated clearly in measurable terms.

Service provider has to give attention on spurious loyalty as it will not build the desired level of commitment, that could be used as genuine performance measure. At the same time, encouraging the dissatisfaction response will give benefit to service prodicer as it helps in determining the faults in the services delivery system. Dissatisfaction response is also regarded as loyalty construct [20].

D.    Reputation as a Performance Measure

Performance was identified to be important drivers in influencing corporate reputation and also in driving customer loyalty [85].  Contrary, in this research, reputation is hypothesized as the contributor to performance. In several empirical examples of reputation indicate that reputation and performances come together, because it emerges at the end of the evaluation. Nonetheless, the evaluation of reputation or image is continuous. At Fujitsu, the top three characteristics that customer associate most closely with Fujitsu’s reputation are honest in what they say and do; realistic in their promises and strongly focus on customer needs [65]. Align with Pollitt[65], Parasuraman[64] mentioned about credibility, which entails trustworthiness, believability, and honesty. A case of reputation in China’s health care environment associates reputation with trust. Therefore trust is one of the measures of reputation besides honesty, trustworthy and believability.

The notion of trust, honesty, trustworthiness and believability are all intangible and very subjective in nature. They are associated with feelings one’s has for the company, therefore measuring it would be rather complex.  However these attribute are measureable and has strong relationship with perceptions. Pettijohn et al. (2001) claimed that organization’s reputation could be improved if perceptions are raised across all levels of stakeholders (whether directly or indirectly) involved with the service processes. In this scenario, perception is strongly associated with experience and knowledge of the appraiser him or herself. In different perspective, Desai[22] came out with a metric that able to measure the return on reputation (ROR). The metric consists of consideration (likelihood of purchasing company products over competitors); brand loyalty (self-reported share of wallet); sales; price premium (willingness to pay a higher price for company products over competitors).

            In the health care service scenario, image and reputation are always be associated with quality. If the patients perceive, belief and trust that the specific service provider are delivering quality services, then the reputaiton of the service provider is high [38]. An evidenced is found in a study on the private and public village clinics in China [66] that stated, most of the outpatients choose to visit the closest health care provider. However, they are willing to go further away if the specific provider has a better reputation or skills. In health care services, the reputation aspect is associated with skills in treating the disease; which in the mentioned case, patients have strong trust on the reputable service provider. Trust is an indispensable part of reputation [82], the fact is that, it is an outcome of reputation and is also an important prerequisite for the formation of customer loyalty [82]. Moreover, Caruana[13] suggested for reputation to be added as a construct that related to satisfaction and loyalty [13] which, this research consider reputation as one of the performance traits.

            Since the last two decades, pyhsicians were competing to get a place in the consumers’ mind on a non-price basis; such as based on location, colleagues’ referrals and foremost was the reputation [21].

Reputation is a great concern among the health care practitioners, especially in the eyes of their colleagues and competitors. Physicians may compete for patients who are able to pay for services and do not have health insurance, or for patients who have their expenditures paid for by third-party insurers – for these, physicians compete on a non-price basis, based on location, colleagues’ referrals and reputation [21].

D. The Linkages between Customer Satisfaction and Loyalty and Reputation

1)           Relationship Between Satisfaction and Loyalty &

Satisfaction and Reputation

Since few decades ago, customer satisfaction has been a major goal of business organizations, since it has been deemed to affect customer retention and companies’ market share. There are many cases that indicate a strong realtionship between two of performance constructs, i.e. satisfaction and loyalty. One of it is as what Fecikova[27] mentioned. The contemporary global and highly competitive economy it is fatal for a business organization to be non-customer-oriented. Indeed, to survive organizations need to produce products and services of very good quality that yield highly satisfied and loyal customers. 

Second, customer satisfaction has been found as an immediate antecedent to quality judgment and loyalty that, in turn, is directly related to. Satisfaction however, traditionally been regarded as submissive, wherein satisfied customers have been thought of as less price sensitive, less influenced by competitors, buying additional products and/or services and staying loyal longer [124]. Nevertheless, in today’s dynamic business environment, customers have vast of alternatives solution to their needs and requirements. Therefore, the concept of satisfaction has to be revised and investigated further to find how it relates to loyalty and reputation. 

Another instances of the relationship between satisfaction and loyalty is presented in the finding of a research at Xerox. McCarthy[50] discovered that satisfied customers were not behaving the way they were expected. According to the author, “Merely satisfying customers, who have the freedom to make choices, is not enough to make them loyal” (p. 13). It means that customers may not coming back to to repurchase. In earlier study at Xerox, Jones[41] stated that the truly loyal customers are totally satisfied customers. These three instances show some links between customer satisfaction and customer loyalty.

Customer satisfaction towards a company should not be interpreted as a conceptually distinct construct from cutomer loyalty. In fact, reputation [13] aspects do relevant in the whole relationship ties, as recommended by several authors on image.  An image building is looked upon as being essential for attracting and retaining clients, that is, important drivers of loyalty [32][73].

2)       The relationship between Reputation and Loyalty

In customer settings, investigations of reputation as a determinant of loyalty have led to inconsistent results and remained a matter of debate [10]. Fombrun is convinced that ‘reputation breeds customer loyalty’ (1996: 78) and also,               Nguyen and LeBlanc[60] regarded  reputation as an important determinant of loyalty. Another two researchers found a positive relationship between corporate reputation and the intention to buy a firm’s products, and Martensen et al. (2000) report that corporate image is a main driver of customer satisfaction and loyalty.

Andreassen [5] do not support the hypothesized direct impact of corporate image (interpreted synonymously to reputation) on loyalty, and also the study results discussed by Bloemer and Kasper [10]. Initially they did not support the hypothesized direct impact on satisfaction and loyalty but the direct impact showed due to mediation factors, i.e. perceived quality. In addition, the authors also pointed out that (as an input for customer evaluations), image perceptions should precede satisfaction and loyalty.

E.     Health Consciousness

            Almost everyday health caretakers and mass media broadcasted message about health to remind people to live healthy. Many health problems are related with unhealthy lifestyle, such as lack of exercise, improper dieting, smoking and drinking habits. Necessarily there is an exploding number of people with cardiovascular complaints, obesity, cancer and alcohol-related illnesses, a part of which could be prevented if people led more healthy lives (Lányi Katalin, 2008). Does health consciousness has any relationship with the said scenario, the answer is positive. According to Furtherer and Bryant (2000), individuals with high health consciousness are more likely to be ready to undertake health preventive behaviors, which promise a better chance to achieve desirable outcomes (easily recover from the illness and stay healthy).

Health consciousness is a particularly psychographic variable [35], suitable to be used in designing health interventions and segmenting target publics because it determines one’s responses to health information and sources of health information [34]. Health consciousness refers to an individual’s comprehensive mental orientation toward his or her health, and being comprises of personal responsibility [43] and health motivation and self-health awareness [53][37].  

Closer look into routine of one’s care on own self health, it was found that individuals with high level of health consciousness are likely to be aware of their health condition by paying attention to and reflecting on their health, as well as being responsible for their health and motivated to improve or maintain their health as well as given the high level of health value [53][37][74][30]. Besides health matters, individual with high level of health conscious too reflects the consciousness on daily life style. They concern about ‘quality of life’, usually adopt a ‘wellness-oriented’ lifestyle, overt action on health-related activities such as eating nutritious foods, read the ingredients on food labels and exercising regularly [24][43]. Likewise, health conscious individuals are more prone to undertake preventive health care behaviour [35] and more health-information oriented [23]. Preventive health care refers to behaviour that will prolong one’s healthy life or practice that otherwise lessen the effects on infectious disease, chronic illness, or weaken ailments [6][26][23][25]. 

            Although there is any number of attributes or dimensions of services, customers usually use only a few to infer the quality. It so much depends on the nature of the services and the environment where the service is delivered, as stated by Cherghi-Sohi et al. [87], different ways of organizing consultations may lead to different patient experiences. Thus, this research hypothesizes the relationship in private primary medical clinic services environment.

            Numbers of previous researchers have acknowledged that in general, service quality attributes and satisfaction as two separate concept, yet related constructs [13][64]. It is empirically supported by several researchers [36][28][70][72][77][4] that service quality is an antecedent for satisfaction.  Nonetheless, satisfaction will not remain constant and likely to decrease or be negatively related unless continual improvements are made in the quality of the service performance. Service quality is too found to be significant to the purchase intention and recommend others [83]. Other researches found that there was a direct [11]; both, direct and indirect [17] effect of service quality on behavioral intentions.

Satisfying customers is an important agenda in all businesses. This is due to the consequences of not satisfying customers can be severe, as customers can decided to: discontinue purchase; making a complaint to the company as well to the third party; return the items or ask for the money back; and in worse scenario customer would engage in word of mouth communication. Customer satisfaction is largely influenced by the value and the quality of services delivered to customers.

            The term ‘customer loyalty’ signifies a deeply held commitment to re-buy or repatronize a preferred product or service consistently in the future [62] and this term applies in health care service environment [69]. [124] stated that a commitment to continue to do business or exchange with a particular company on an ongoing basis is a definition of retention, which is one of the objectives of the businesses (to retain good customers). Retention and commitment are two correlated conceptions.  The notion ‘commitment to re-buy’ is demonstrated in loyal patients commitment in which, they decide to consult the same physician for majority of his or her health needs even if occasionally they do consults another professional. Should a patient needs his or her physician’s approval for anything that has to do with their health, he or she would only want to interact with a specific doctor. This behaviour confirmed the notion of consistent that mentioned above. Disloyal patient on the other hand, does not seek to establish a continuous link with physician and will consult physicians and clinics indiscriminately regardless of the nature of health problems [69][76]. This behaviour is considered as shoppers [69]. The indicators of loyalty behaviours that were found in past researchers are: commitment of patient and physician, patients participation in the decision making process [56], the climate of trust between patient and the physician [69] [76] the quality of the interpersonal relationship [69][76], consistent use of a regular source of care [69] as stated by [29] loyal customer returns despite offers by the competition.

Corporate image influences customers satisfaction and loyalty [88]. Likewise, MacGregor et al.[89] affirmed that reputation and an affective evaluation provide the basis for customers’ buying decisions. In health care services, the reputation aspect is associated with skills in treating the disease; which in the mentioned case, patients have strong trust on the reputable service provider. Trust is an indispensable part of reputation [82], the fact is that, it is an outcome of reputation and is also an important prerequisite for the formation of customer loyalty. If the patients perceive, belief and trust that the specific service provider are delivering quality services, then the reputation of the service provider is high  [38].

                                                                                                                                                                  IV.        Conclusion

            Previous studies on service quality in health care setting reported that accessibility, convenience and continuity of care, doctor’s explanation, doctor’s attitude, and waiting time has been shown to be an important service quality attributes to patient satisfaction. Likewise, time attributes is an influence in loyalty assessment. Nevertheless does not affect loyal patients as they willing to wait for consultation no matter how long the time takes.

            From different measures perspective, functional quality was found significantly and positively affected satisfaction whereas technical quality, on the other hand, was found to affect customer loyalty in the high contact service. Health care is an instance of high contact service, by which the notion of technical quality might include the quality and effectiveness of diagnoses and medical procedures. The functional quality on health care service environment comprises the care and manners of the personnel involved in the delivery of service products.

            Parallel to above-mentioned views, some prominent researchers highlighted that customers tend to rely primarily on functional-based dimensions of service quality, as they may not have the knowledge and skill to evaluate more technical-based dimensions. Others  reported that although clients evaluated both functional and technical dimensions of service quality, the functional dimensions seemed to carry the most weight. Conversely some researchers found evidence that patient satisfaction was a bi-dimensional construct with an emphasis on interpersonal relationships and organization characteristics. In a different perspective, some found that both technical and functional dimensions explained more of the variation in customer choice behavior than functional measures alone.

Acknowledgment

The authors would like to thank Faculty of Management, Universiti Teknologi Malaysia (UTM) for its support in this project.

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Biography

Ms. Norzaidahwati is a Lecturer in Universiti Teknologi Malaysia. She obtained her first degree in BBA from Universiti Utara Malaysia, MSc in Business Information Technology System and MSc in International Marketing from University of Strathclyde, Glasgow, Scotland and currently pursuing her PhD in Management (Performance Measurement) from Universiti Teknologi Malaysia. She has several years industrial experience before joining universities as the faculty member.