International Journal of Health Care Quality Assurance Quantitative comparisons of urgent care service providers Hong Qin Gayle L. Prybutok Victor R. Prybutok Bin Wang

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To cite this document: Hong Qin Gayle L. Prybutok Victor R. Prybutok Bin Wang , (2015),"Quantitative comparisons of urgent care service providers", International Journal of Health Care Quality Assurance, Vol. 28 Iss 6 pp. 574 - 594 Permanent link to this document: http://dx.doi.org/10.1108/IJHCQA-01-2014-0009 Downloaded on: 31 January 2016, At: 14:59 (PT) References: this document contains references to 51 other documents. To copy this document: [email protected] The fulltext of this document has been downloaded 163 times since 2015*

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IJHCQA 28,6

Quantitative comparisons of urgent care service providers Hong Qin

574

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Received 5 March 2013 Revised 22 January 2014 21 May 2014 1 July 2014 1 October 2014 14 March 2015 Accepted 30 March 2015

Department of Computer Information Systems and Quantitative Methods, University of Texas – Pan American, Edinburg, Texas, USA

Gayle L. Prybutok Department of Library and Information Science, University of North Texas, Denton, Texas, USA

Victor R. Prybutok Department of Information Technology and Decision Sciences, University of North Texas, Denton, Texas, USA, and

Bin Wang Department of Computer Information Systems and Quantitative Methods, University of Texas – Pan American, Edinburg, Texas, USA Abstract Purpose – The purpose of this paper is to develop, validate, and use a survey instrument to measure and compare the perceived quality of three types of US urgent care (UC) service providers: hospital emergency rooms, urgent care centres (UCC), and primary care physician offices. Design/methodology/approach – This study develops, validates, and uses a survey instrument to measure/compare differences in perceived service quality among three types of UC service providers. Six dimensions measured the components of service quality: tangibles, professionalism, interaction, accessibility, efficiency, and technical quality. Findings – Primary care physicians’ offices scored higher for service quality and perceived value, followed by UCC. Hospital emergency rooms scored lower in both quality and perceived value. No significant difference was identified between UCC and primary care physicians across all the perspectives, except for interactions. Research limitations/implications – The homogenous nature of the sample population (college students), and the fact that the respondents were recruited from a single university limits the generalizability of the findings. Practical implications – The patient’s choice of a health care provider influences not only the continuity of the care that he or she receives, but compliance with a medical regime, and the evolution of the health care landscape. Social implications – This work contributes to the understanding of how to provide cost effective and efficient UC services. Originality/value – This study developed and validated a survey instrument to measure/compare six dimensions of service quality for three types of UC service providers. The authors provide valuable data for UC service providers seeking to improve patient perceptions of service quality. Keywords Survey, Perceived value, Service quality, Quantitative measure, Urgent care, Patient perceptions Paper type Research paper

International Journal of Health Care Quality Assurance Vol. 28 No. 6, 2015 pp. 574-594 © Emerald Group Publishing Limited 0952-6862 DOI 10.1108/IJHCQA-01-2014-0009

The authors would like to acknowledge the University of North Texas for the support provided during the conduct of the study and the students at the University of North Texas for their participation.

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Introduction The Urgent Care Association of America (UCAOA) defines urgent care (UC) as the delivery of ambulatory medical care that is provided outside of an emergency department on a walk-in basis (Urgent Care Association of America (UCAOA), 2011a, b). Urgent care centres (UCC) are unique health care providers, filling the gap in the USA between the hospital emergency department and the primary care physician (Pemberton, 2007; Weinick and Betancourt, 2007). In spite of the high costs, overutilization of hospital emergency rooms is a continuing issue. A significant percentage of urgent but non-emergent care visits are made at emergency rooms. With the increasing use of emergency rooms to treat urgent but not emergent cases, it is critical to divert lower acuity patients to other health care providers such as UCC, both to improve efficiency and to reduce health care costs. Primary care physicians manage basic diagnosis and non-surgical treatment of illnesses and medical conditions, including chronic physical and mental health issues. To meet patient demand for accessible, quick, convenient, and affordable care, primary care physicians are extending office hours, providing UC, or collaborating with community-based UC facilities (Steelman, 2010). Each type of UC service provider offers advantages and disadvantages to the patients that it serves. It is essential to understand the differences in patient perception of value as related to service quality among these three types of UC service providers. Ultimately, the patient’s choice of an UC provider influences not only the continuity of the care that he receives, but also affects his compliance with a medical regime, and the evolution of the US health care landscape (Howard et al., 2007). Numerous studies have investigated health care quality and patient satisfaction in the USA (McDermott et al., 2011). However, few studies (e.g. Qin and Prybutok, 2013) have examined UC quality, because the US UC industry has only recently emerged. In 2013, Qin and Prybutok investigated the underlying dimensions of UC quality and the potential factors associated with patient satisfaction. The essential role played by UCC in the US health care continuum mandates research that improves the understanding of how patients perceive the service quality and value of UCC in comparison to care received from other UC providers. Improving our understanding of perceived service quality and value of UC is the goal and contribution of this work, and study results help providers to identify how they can improve both the quality and value of UC services to the patients that they serve. This study compares the quality of care and perceived value provided by UCC, hospital emergency departments, and primary care physicians, all of which can be considered UC service providers. The structure of this paper is as follows. “Background” section presents existing theories and formulates the research hypotheses. “Methodology” describes scale development, data collection, data analysis, and research hypothesis testing. “Results” section presents the study outcome and the theoretical and managerial implications of the findings. “Limitations and future research” section presents the contribution of the work, a discussion of study limitations, and plans for future research. Background UC in the USA The UCAOA defines UC as the delivery of ambulatory medical care that is provided outside of an emergency department on a walk-in basis (UCAOA, 2011a, b). The first UCC in the USA opened in the 1970s. According to Weinick and Betancourt (2007), the

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UC industry declined in the 1980s, and expanded again in the mid-1990s. Since then, UC has grown exponentially, expanding to more than 17,000 centres nationwide. Estimates suggest that an average of six new UCC have opened in the USA each week for the last three years (UCAOA, 2011a, b). The UCAOA, created in 2004, established national criteria for UCC, and worked closely with the Joint Commission, an important accrediting body for US health care organizations, to establish standards for the accreditation of UCC. UCC provide care that is more extensive than the care that can be provided in a primary care physician’s office. UCC’s must meet five criteria established by the UCAOA. First, UCC’s must offer acute care for common medical conditions. Second, they must operate on a walk-in basis without the need for a scheduled appointment, and must offer extended evening and weekend hours. Operating on a walk-in basis relieves patients of the burden of scheduling appointments, and of encountering unanticipated service delays on arrival at their primary physician’s office. Third, patients can be seen as soon as they identify the need for medical care, rather than potentially being forced to wait for several days for an appointment to see their primary care physicians, or to negotiate prior approval to see a particular physician that may not be a covered provider in their managed care plans. During a speech to the Emergence of Urgent Care Conference in 2008, Gollogly (2008) reported that UCC typically offer services until 8 p.m. every day, with some providing services 24 hours per day. Pemberton (2007) pointed out that extended service hours are a very important reason for patients to choose UCC over primary care physicians. Fourth, UCC’s must also provide X-rays onsite. Finally, they must provide advanced procedures such as suturing and casting. While UCC’s treat some medical conditions that are also treatable by a primary care physician, they often treat illnesses not critical enough to require a hospital emergency department visit, yet which must be treated immediately without waiting for a scheduled appointment with a primary care physician (Stern, 2005). A UCC is a unique health care provider, filling the gap in the USA between the hospital emergency department and the primary care physician (Pemberton, 2007; Weinick and Betancourt, 2007). UCC also offer complementary services that are usually not available from a primary care physician, such as treatment of minor traumatic injuries (UCAOA, 2008). Many UCCs in the USA also provide occupational medicine services, travel medicine services, and perform school physicals (UCAOA, 2011a, b), thereby serving other niche patient populations. UCCs are distinguished from emergency rooms because treatment of life threatening conditions and pregnant women in labour or with obstetrical emergencies are beyond the scope of UCC practice. Alternatively, in the USA, emergency departments are typically located within acute care hospitals, and specialize in the management of acute and emergency situations. They have become the health care providers of choice for those without a primary care physician, or whose physician is not available (Lang et al., 1997). A study at Emory University School of Medicine in 2010 revealed that “28% of acute care visits take place in emergency rooms, including almost all of the visits made on weekends and after office hours” (Miller and Washington, 2011, p. 183). However, the cost of care in an emergency department is astronomical. Even for minor acute illnesses, the cost of care in an emergency department is traditionally much higher than the cost of a visit to a primary care physician and an UCC (Howard et al., 2007). When compared with UC visits, the cost of emergency department visits are higher by between $228 and $583 for the same diagnosis. This price difference is even higher between primary care physicians and emergency departments (UCAOA, 2011a, b). Miller and Washington (2011)

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also reported that over half of acute care patient visits by the uninsured occur in emergency departments, which are legally required to provide a screening examination to all patients on arrival, regardless of their ability to pay. In spite of the high cost of care in hospital emergency departments, a significant percentage of urgent (but non-emergent) care visits occur here, making emergency departments occasional UC providers. According to a recent analysis by the RAND Corporation, approximately 40 per cent of emergency room visits are Level 1 or 2 in severity, and 13-27 per cent are less severe (Level 3 or 4), and could be treated in UCC (Steelman, 2010). With the increasing use of emergency rooms for urgent (but not emergent) cases, it is critical to divert lower acuity patients to more appropriate health care providers like UCC, both to improve efficiency and to reduce cost. Primary care physicians manage basic diagnosis and non-surgical treatment of illnesses and medical conditions, including chronic physical and mental health issues. The greatest benefits of primary care physicians are continuity of care for all family members, and the ability to develop trusting interpersonal relationships with the primary physician and his staff. Approximately 32 million uninsured individuals are expected to acquire insurance, which will substantially exacerbate the shortage of primary care physicians, and potentially increase pressure on the inappropriate use of hospital emergency rooms (Steelman, 2010). To meet patient demand for accessible, quick, convenient, and affordable care, primary care physicians are extending office hours, providing UC, or collaborating with community-based UC facilities (Steelman, 2010). However, in a primary care physician’s office, appointment scheduling can be complex and difficult to manage due to the uncertainty of each patient’s potential care need (Klassen and Yoogalingam, 2008). They cannot offer the flexibility of other UC providers. It is essential to examine the differences in patient perception of value as related to service quality among these three UC providers. An understanding of patient perceptions fosters both improvement in service quality across all providers, and helps each type of UC provider to improve efforts to educate the public, and to direct consumers to the most appropriate and cost effective UC provider based on their health care needs at the time. Service quality The term “perceived service quality” has been frequently used by practitioners and academicians in the past few decades. The consensus about service quality is that it is a consumer’s evaluative judgment or impression regarding a service provider’s overall performance or excellence (Parasuraman et al., 1985, 1988; Cronin and Taylor, 1992). The theoretical conceptualization of perceived service quality indicates that it is a multidimensional, higher-order construct and cannot be measured in a single dimension (e.g. Parasuraman et al., 1988; Brady and Cronin, 2001). The SERVQUAL instrument created by Parasuraman et al. (1988) is widely used in a variety of industries to measure service quality. SERVQUAL uses the gap between customer perceptions of the service they received and their expectations, which Parasuraman et al. (1988) developed as a measure of service quality. Their work identified five dimensions of service quality including tangibles, assurance, empathy, responsiveness, and reliability. These constructs are widely accepted by both academics and practitioners as appropriate dimensions for numerous service quality applications (Parasuraman et al., 1988). Cronin and Taylor (1992) modified the SERVQUAL instrument by using customer perceptions only, and empirically tested

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the new instrument named SERVPERF. The authors found that SERVPERF demonstrated improved measurement properties, and was useful for relating to constructs in more complex models. Others demonstrated that SERVPERF used a number of dimensions more consistent with the predicted five dimensions, and exhibited a greater capacity to assess the fit of the constructs within complex models (Van Dyke et al., 1997, 1999; Landrum and Prybutok, 2004). Qin and Prybutok (2013) recently identified six dimensions of UC quality, including tangibles, professionalism, interactions, accessibility, efficiency, and technical quality. In this study, we posit that customer perceptions can provide a better measurement of perceived service quality, and use those six dimensions to measure UC service quality. In their 2013 study, Qin and Prybutok developed an UC patient satisfaction model using behavioural intention as the dependent variable, and modelled the relationships among perceived service quality, patient satisfaction, and behavioural intentions in the UC industry. The current work conducts multivariate analyzes of variance to compare the service quality among UCC, emergency rooms, and primary care physicians, making an important contribution to research in health care service quality for several reasons. First, it is the relative quality of the providers that is important to patients with the ability to make a choice. Second, it is important to providers within a specific provider category, such as UCC’s, to understand how they are perceived as compared to providers in other categories. Such information allows providers to better understand the challenges that they face in delivering high quality service to patients and in competing in the marketplace. Health maintenance organizations have proliferated explosively in the USA over the past few decades (Mitchell, 1998). Patients now have more options than ever for sources of UC services, including primary care physicians, hospital emergency departments, and UCC (Weinick and Betancourt, 2007). UCC treat a broader spectrum of medical conditions and age groups (UCAOA, 2011a, b). According to Weinick and Betancourt (2007), primary care physicians, hospital emergency departments, and UCC are health care providers of choice for college students seeking medical care, and consumers typically compare them based on convenience, cost, and scope of services. The range of available services has a distinct impact on the selection of an UC service provider. UCC’s provide a wider range of medical services than primary care physicians, and offer a selection of point-of-care (onsite) medical tests. This means that patients do not have to wait for results (Weinick and Betancourt, 2007) as they do in a primary care physician’s office. Emergency departments provide the broadest range of services, and are staffed by skilled clinical professionals who are specially trained in the management of catastrophic illnesses and injuries (Sparrow Emergency Services, 2008). Since emergency departments are often hospital based, they offer the added advantages of specialty medical equipment, clinical specialists available or on call, and a seamless transition to inpatient care. Building upon the above discussion, we propose the following hypothesis: H1. There are significant differences among primary care physicians, hospital emergency departments, and UCC in terms of perceived service quality. Perceived value Perceived value measures the utility of a service based on customer perceptions of its benefits and costs (Zeithaml, 1988). Benefits in health care are primarily the process and outcomes of good quality service, whereas costs include both the price that patients

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have to pay and other non-monetary costs such as wait time (Choi et al., 2004). Delivering a better trade-off between benefits and costs of a service can contribute to a company’s sustainable competitive advantage (Eggert and Ulaga, 2002). Customers with higher evaluations of perceived value also experience higher satisfaction, meaning that perceived value has a direct impact on satisfaction (Anderson et al., 1994; Lemmink et al., 1998). In the health care industry, patient perceived value has been fundamentally neglected for decision making (Choi et al., 2004). Given the significant influence of perceived value on medical outcomes and patient loyalty, it is necessary to better understand how patients perceive value of the medical care they received and compare their perceptions across distinct health care providers. To our knowledge, there are few studies discussing perceived value in the UC industry. Qin and Prybutok (2013) proposed the contextual relationships between perceived value with satisfaction and intentions, and both relationships are supported empirically. Their findings substantiate the need to examine the differences in perceived value across a variety of UC providers. This research fills this gap and the findings will be beneficial to all UC providers who seek to position themselves in today’s market, and to increase their market share. Among the three UC providers examined in this research, hospital emergency departments are available 24/7. However, long wait times and high costs for service prevent them from being a convenient UC option. In addition, inappropriate use of emergency departments for non-emergent care increases health care costs and delays treatment for true emergency cases. While most UCC accept insurance, the cost of health care is a significant concern for most people, particularly for the uninsured, who must pay out of pocket. A visit to an UCC is less expensive than a visit to an emergency department. Miller and Washington (2011) reported that emergency department visits cost an average of $1,500 per visit, a cost that is ten times the cost of a primary care physician visit. Clearly, a primary care physician can provide more efficient and cost effective treatment for many medical conditions. As a result, patients evaluate their UC options, and see that the three types of providers differ significantly in monetary costs and wait times. Therefore, this study proposes the following hypothesis: H2. There are significant differences among primary care physicians, hospital emergency departments, and UCC in terms of perceived value. In summary, UCC are popular because of their convenient locations, extended hours, walk-in policy, short wait times, and accessibility (Salisbury and Munro, 2002; Van Remortel and Miceli, 2003; Pemberton, 2007). The main differences between UCC and emergency departments are that UCC are designed to address acute but not life threatening illnesses and injuries, and typically are not located in hospitals. Comparatively, UCC provide medical care at a lower price. UCC offer a clear advantage over primary care physicians: no appointment necessary. The research objective of this study is to quantify the differences in patient perceptions of quality and value among the three UC service providers. Methodology Measurement Our study measured UC quality, cost, and patient satisfaction, and also measured the underlying dimensions of these variables. However, this paper focuses only on

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differences in perceived service quality and perceived value among three UC providers, and uses six dimensions to measure the components of service quality. The focus on service quality was one of the original hypotheses in a comprehensive study that measured numerous constructs and categorical variables when surveying respondents about their health care choices (Qin and Prybutok, 2013). The focus on service quality by provider is an important research question that can also be answered using this comprehensive study data. The six dimensions previously identified as significant to measure UC service quality include: tangibles, professionalism, interaction, accessibility, efficiency, and technical quality (Qin and Prybutok, 2013). Each construct is listed and defined in Table I, and are discussed in detail. The items used to measure each dimension are based on the findings of Qin and Prybutok (2013), which employed both exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) to obtain and refine observable items. Tangibles This construct refers to the physical facilities and care environment offered by UC providers. The following items are used to measure tangibles: •

Tang 1 – physical facilities visually comfortable and attractive (e.g. waiting rooms, chairs, tables, etc.);

•

Tang 2 – the smell in the facility is pleasant; and

•

Tang 3 – the design of the facility is patient friendly (e.g. comfortable to sit in, television provided, privacy maintained, etc.).

Professionalism The professionalism construct reflects the patient’s perception of the knowledge and expertise of the centre’s professional staff and the patient’s assessment of their clinical competence. Three items are used to measure professionalism: (1) Prf1 – well-trained physicians and nurses; (2) Prf2 – highly experienced professionals; and (3) Prf3 – knowledgeable and skilled professionals. Dimension (abbreviation)

Sources

Tangibles Parasuraman et al. (1988) and (Tang) Ramsaran-Fowdar (2005) Interaction (Int) Dagger et al. (2007)

Table I. Six dimension of urgent care quality

Definition Physical facilities and environment

Service encounters between patients and providers Professionalism Ramsaran-Fowdar (2005) and Knowledge and expertise of professionals and (Prf) Dagger et al. (2007) their professional competence Accessibility Otani et al. (2005) and Patients’ ability to obtain urgent care in a timely (Access) Wicks (2004) manner Technical Zifko-Baliga and Krampf (1997) Results of urgent care treatment including both quality (TQ) and Dagger et al. (2007) physical and emotional recovery Efficiency (Eff) Sofaer and Firminger (2005) and Collaboration and corporation between multiple Schoen et al. (2006) medical care providers

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Interaction The construct interaction measures the quality of the interaction between patients and providers during service encounters. Previous studies have pointed out that patients do not have sufficient knowledge to evaluate the technical quality of the medical care that they receive (Donabedian, 1982). Therefore, their perceptions of UC service quality largely depend on communication and interaction with UC employees, from support staff to physicians. The following items are used to measure interaction in this study: •

Int1 – offering the flexibility to change doctors at your request;

•

Int2 – showing concern for your family; and

•

Int3 – effective communication with your family.

Accessibility This construct is concerned with patients’ ability to obtain UC services, including appointment scheduling, available centre hours, transportation barriers, etc. This dimension has been targeted for improvement in order to meet patients’ expectations of high quality care (Lifvergren et al., 2010). Three items measure accessibility, including: (1) Accss1 – easy to schedule an appointment; (2) Accss2 – accessible by phone; and (3) Accss3 – easy to schedule an appointment at a convenient time. Efficiency This construct refers to the collaboration and cooperation among multiple medical care providers both within the UCC and between the UCC and external providers. For instance, if patients need a referral to a specialist, the efficiency of the referral process is used to measure the efficiency of UC service delivery. The following items are used to measure efficiency: •

Eff1 – uninterrupted medical care;

•

Eff2 – consistent medical care; and

•

Eff3 – internal and external medical care collaborating well.

Technical quality The construct technical quality refers to the outcome of medical treatment, including both physical and emotional recovery. Technical quality is the ultimate objective of all types of health care service delivery. The data collected in our survey show that technical quality is an important dimension of UC service quality, and it is measured using four items: (1) TQ1 – you leave the clinic feeling encouraged about your treatment; (2) TQ2 – you believe that the results of your treatments are the best that they can be; (3) TQ3 – the quality of the UC you received was excellent; and (4) TQ4 – you are impressed by the care provided.

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Perceived value Perceived value is a function of service costs and the patient’s perception of the value that he or she received for the money spent. UC costs include both the time it takes to receive the service and the price. Typically hospital emergency room costs are higher in both time and price than primary care physician costs for the same service, while UCC service costs are more competitive with costs incurred in a primary care physician’s office. In addition to actual costs, it is generally true that patients wait longer in emergency rooms than they do either in a primary care physician’s office or in an UCC, so the cost of customer inconvenience is a factor here. Three items measure perceived value: (1) PV1 – the price was reasonable;

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(2) PV2 – the UC provider offered the medical service at an appropriate cost; and (3) PV3 – the UC you received was good for the price. Survey development and validation In developing the survey instrument, the 22 performance items segment of Parasuraman et al.’s (1988) five dimension service quality instrument were included based on the contextualization of Cronin and Taylor’s (1992) SERPERF version of the instrument to UC. The items were retained as appropriate to the UC model based on their loadings in an EFA conducted on the survey data to appropriately contextualize the survey items to the current research’s health care application. After a set of preliminary survey questions were developed for all constructs based on the extant literature (e.g. Parasuraman et al., 1985, 1988; Cronin and Taylor, 1992; Qin and Prybutok, 2013), three specialists, including university professors with extensive teaching experience in service quality and health care management, reviewed the questions. Each specialist was asked to comment on the clarity of questions and on the content of the instrument, including an assessment of all constructs and associated items to assess face, construct, and content validity. Data collection A pilot study was conducted at the University of North Texas with ten doctoral students and 20 master’s degree students pursuing degrees in marketing, management, and management science. The pilot study was conducted to confirm that items were not ambiguous and that they adequately captured the claimed domain (Churchill, 1979). As a result of the pilot study, some questions were modified to better fit the UC context. The final 22 survey items (19 measuring perceived service quality and three measuring perceived value) were rated on a seven-point Likert scale with the verbal anchors of strongly disagree to strongly agree. In addition, several demographic variables were included in the questionnaire such as gender, age, and family income. College students were asked to evaluate their perceptions of UC service since they are frequent customers of UC service providers (Weinick and Betancourt, 2007). The usable respondents in this study had visited at least one of these types of providers within the specified period, making them qualified to evaluate UC service providers. Most college students are taking 12-15 credit hours each semester and according to a new US Census Report, 71 per cent of the college undergraduates were working in 2011, and 20 per cent of these undergrads were working more than 35 hours a week (US Census Report, 2013). Their inflexible schedules limit their access to health care

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services to those that are available after working hours and without any appointment, which is exactly what UC providers can offer at a reasonable price. Moreover, many UCCs target college students as an important market segment and maintain franchises near campuses. According to the industry strategic plan created by UCAOA (2012), college students’ health care utilization is episodic and many college students are intimidated to use the student health centre. Therefore, college students are open to using UC service providers. The study sample consisted of undergraduate students enrolled in a variety of business courses in a major south-western university in the USA, and 95 per cent of these students were between the ages of 18 and 30. All participants were qualified by asking them if they had used these services within the past 12 months. Those that had not were removed before analyzing the data. An online survey hosted by Websurveyor was used to collect the data. The online survey link was posted on various class sites and was announced in class by instructors who decided whether any extra credit would be given to participants. Potential respondents could access this survey at their convenience during a specific time frame. This online survey link was given to approximately 918 college students and the survey was administered over a 30-day period. The respondents were asked to evaluate the most recent UC service that they received during the preceding 12 months. We obtained 485 surveys but only 462 of those were usable for further analysis, giving us a response rate of 52.8 per cent. Respondent profiles Among the 462 respondents, most were from the College of Business; a small percentage of students were from other colleges including science, arts, etc. Approximately 39 per cent of the respondents visited primary care physicians, 29.2 per cent visited hospital emergency rooms, and 31.8 per cent visited UCCs. Men constituted almost 55 per cent of the respondents and women were just over 45 per cent of these respondents. In this sample, close to 87.0 per cent of the respondents were aged between 18 and 25 years old, which is comparatively high, but consistent with our use of college students as a sampling frame. Among the 462 usable responses, about 24 per cent had an annual family income less than $30,000, approximately 19 per cent between $30,000 and $60,000, 19.5 per cent between $60,000 and $90,000, 16.5 per cent between $90,000 and $120,000, and 12.3 per cent more than $120,000. The following section describes the knowledge analysis process applied in the study. The knowledge analysis process The research hypotheses propose differences among several types of UC service providers (i.e. primary physicians, hospital emergency rooms, and UCC), in terms of patient perceptions of UC service quality and perceived value. Six dimensions/ nineteen items measured UC service quality, and three items measured perceived value. Both EFA and CFA were used to assess the reliability and validity of the instrument. EFA was first used to determine the number of factors and which observed items were indicators of each latent variable. CFA was used on the results of the EFA to validate that the selected set of items fit the constructs on which they loaded. Given the validity of individual latent variables, EFA was conducted for all of the items measuring the dimensions of UC service quality. EFA was performed using SPSS for Windows (version 15.0, SPSS Inc.). The result of principal axis factor analysis with varimax rotation for UC service quality is presented in Table II.

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Table II. EFA of UC service quality

Items

Factors Technical quality Tangibles Interaction Professionalism Efficiency Accessibility

TQ2 0.791 0.154 0.226 TQ1 0.791 0.208 0.193 TQ4 0.790 0.161 0.215 TQ3 0.766 0.161 0.199 Tang1 0.183 0.804 0.163 Tang3 0.165 0.779 0.097 Tang2 0.120 0.779 0.130 Intrct3 0.201 0.119 0.850 Intrct2 0.242 0.125 0.824 Intrct1 0.149 0.159 0.648 Prf3 0.294 0.233 0.180 Prf1 0.305 0.280 0.152 Prf2 0.293 0.226 0.201 Eff1 0.277 0.125 0.241 Eff2 0.196 0.170 0.183 Eff3 0.342 0.162 0.272 Accss3 0.224 0.170 0.223 Accss1 0.174 0.241 0.106 Accss2 0.275 0.210 0.131 Factor mean 5.601 5.311 5.146 Factor SD 1.516 1.451 1.849 Cum. % var 17.437 30.170 42.735 Eigenvalue 3.313 2.419 2.387 Note: Rotation method, varimax with Kaiser normalization

0.228 0.225 0.221 0.226 0.156 0.196 0.158 0.146 0.147 0.101 0.790 0.748 0.738 0.143 0.168 0.190 0.197 0.224 0.267 5.758 1.523 54.921 2.315

0.230 0.247 0.226 0.196 0.118 0.165 0.093 0.224 0.149 0.181 0.174 0.205 0.180 0.828 0.764 0.664 0.181 0.228 0.163 5.385 1.730 66.937 2.283

0.185 0.212 0.161 0.234 0.164 0.169 0.162 0.071 0.119 0.211 0.238 0.263 0.287 0.205 0.217 0.151 0.794 0.730 0.626 5.608 1.570 78.421 2.182

Based on the results, the 19 items measuring UC service quality loaded into six factors. They are technical quality, tangibles, interaction, professionalism, efficiency, and accessibility. All of the main loadings are higher than 0.60, and cross loadings are less than 0.40, which indicates the validity of the measurement instruments (Hair et al., 2010). We present factor mean, factor standard deviation, cumulative percentage of variance and the eigenvalue for each dimension identified in EFA in Table II. Eigenvalues range from 2.182 to 3.313. The average variance explained is approximately 78 per cent, higher than 60 per cent, which also indicates the validity of the measurement instruments. The reliability of the measurement instrument was assessed using Cronbach’s α values. These values appear as the diagonal elements in Table III. These values range Technical quality

Table III. Correlation matrix of UC service quality

Technical quality Tangibles Interaction Professionalism Efficiency Accessibility Notes: aThe diagonal

Tangibles Interaction Professionalism Efficiency Accessibility

a

0.951 0.453* 0.891a 0.519* 0.374* 0.650* 0.532* 0.617* 0.415* 0.570* 0.490* elements are Cronbach’s

0.883a 0.464* 0.948a 0.528* 0.543* 0.912a 0.435* 0.633* 0.539* α values. *Significance at p o 0.01 level

0.882a

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from 0.882 to 0.951, much higher than the cut-off value 0.80 (Nunnally and Bernstein, 1994). This indicates the reliability of the measurement instrument for patient perception of UC service quality. Convergent validity was measured by the high correlations between the dimensions of service quality. All of the correlation coefficients in Table III are significant. This supports the convergent validity of the measurement instruments. Discriminant validity was evaluated by comparing the correlation coefficients and Cronbach’s α values. The off-diagonal elements in Table III are the correlation coefficients between dimensions of UC service quality. All of the correlation coefficients are less than the Cronbach’s α values on the diagonal. Furthermore, the 95 per cent confidence interval of all correlation coefficients was evaluated. None included the absolute value of 1.0. This confirms the discriminant validity of the instruments. Given the reliability and validity of all constructs, MANOVA was then used to compare the differences between the UC providers under investigation: primary care physicians, hospital emergency rooms, and UCC. The independent variables include technical quality, tangibles, interaction, professionalism, efficiency, accessibility, and perceived value. The means of all of these latent variables are listed in Table IV. Interestingly, primary care physicians performed better for all of these measures, followed by UCC, and then hospital emergency rooms. This pattern held true with the exception of perceptions of interaction, since hospital emergency rooms performed better than UCC on this dimension. For instance, patients’ evaluations of technical quality in primary care physicians’ offices were approximately 5.810 on a 1-7 Likert Scale, 5.667 for UCC, and only 5.305 for hospital emergency rooms. To examine whether the differences among the means were significant or not, MANOVA was conducted.

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Results MANOVA analysis From the output of MANOVA (shown in Table V), all of the selected statistical tests were significant. Pillai’s trace, Wilks’ λ, Hotelling’s trace, and Roy’s largest root have a significance level of less than 0.01. This indicates that accessibility and perceived value are significantly different among providers. However, no significant differences were Provider

TQ

TANG

INT

PRF

a

PCP(1) 5.810 5.491 5.506 5.948 HER(2)b 5.305 5.179 4.926 5.606 UCC(3)c 5.667 5.435 4.764 5.884 Total 5.633 5.389 5.186 5.835 Notes: aPrimary care physician offices; bhospital emergency rooms;

Model Pillai’s trace Wilks’ λ Hotelling’s trace Roy’s largest root Notes: aPrimary care physician offices; bhospital

EFF

ACC

5.661 5.961 5.199 4.968 5.389 5.810 5.471 5.640 c urgent care centres

Value 0.134 0.869 0.147 0.114 emergency rooms; curgent care centres

PV 5.472 4.865 5.435 5.287

Table IV. Means of perceived value and dimensions of UC

p-valuea,b,c 0.000 0.000 0.000 0.000

Table V. MANOVA results three urgent care providers

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found for tangibles, efficiency, or professionalism at the 0.05 significance level when comparing the perceptions of all three providers together. In detail, technical quality, interaction, accessibility, and perceived value are significantly different among providers. However, no significant differences were found for tangibles, efficiency, or professionalism at the 0.05 significance level. Primary care physicians perform better than UCC, followed by hospital emergency rooms. To further test the significance of the differences among these three providers, several more MANOVA tests were conducted. The results are presented in Table VI. For instance, the three providers performed significantly differently in terms of technical quality. However, this difference is presented only between Provider 1 (primary care physicians) and Provider 2 (hospital emergency rooms). This would be expected based on the acuity of the conditions treated in each setting. These results are discussed further in the next section. Technical quality Technical quality measures the physical and mental outcome of medical treatment. Results showed that these three types of UC service providers differed in technical quality. Each pair of providers was further compared using MANOVA. Table IV demonstrates that primary care physicians had the best performance while hospital emergency rooms were evaluated the lowest in technical quality. This might be explained by the patient population treated by each provider. In a primary care physician’s office, patients generally seek care for more minor and routine illnesses, and they are able to interact with familiar providers with whom they have typically developed a personal relationship. In contrast, most patients that seek care in an emergency department are cared for by unfamiliar providers, and have more critical and urgent conditions that often are frightening, and that can have less than desirable treatment outcomes. The difference between these two UC service providers was statistically significant. However, the difference between primary care physicians and UCC was not significant, nor was there a difference between hospital emergency rooms and UCC. This indicates that patients were more confident in and satisfied by the physical and emotional outcomes of UC received from primary physicians than they were by the same outcomes of care received from emergency departments. Practically speaking, the care needs of patients seen in a physician’s office can be far less complex than the care provided by emergency departments. In addition, patients gain confidence and emotional satisfaction by having a long-term relationship with a single physician in the physician’s office. Emergency departments are unable to provide the same relationshipbased benefits. In addition, patients are generally unable to evaluate the technical Dependent variable

Table VI. MANOVA results comparisons of providers

p-valuea,b,c

p-valuea,b

p-valuea,c

TQ – technical quality 0.020 0.006 0.457 TANG – tangibles 0.152 0.057 0.760 INT – interaction 0.003 0.005 0.003 PRF – professionalism 0.132 0.051 0.733 EFF – efficiency 0.065 0.021 0.227 ACC – accessibility 0.000 0.000 0.365 PV 0.001 0.001 0.838 Notes: aPrimary care physician offices; bhospital emergency rooms; curgent care centres

p-valueb,c 0.133 0.214 0.589 0.207 0.463 0.001 0.009

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quality of care received in an emergency department. However, both UCC and emergency departments can improve their patients’ perceptions of technical quality by focusing on improving communication with patients throughout their visits to these providers. From the point of entry, staff should introduce themselves to patients, and make a point of explaining the tests being done, the treatment provided, the sources of treatment delays, and should provide clear and specific discharge instructions. Such communication reduces anxiety and inspires confidence and an emotional connection. In addition, it appears that as customers receive care from two different providers that are closely aligned on the health care continuum, their perception of differences is more limited than when they receive care from providers at opposite ends of the urgency spectrum. Tangibles The difference among these three providers in terms of tangibles was not supported even though primary care physicians had slightly better performance. This result implies that the physical appearances of the three providers were not significantly different. The designs of these facilities were patient friendly and patients felt comfortable, and felt that their privacy was a priority. A closer look at the results also reveals that primary care physicians perform marginally better than hospital emergency rooms. To improve patients’ perceptions of tangibles, all three providers should focus on the design of patient friendly facilities that protect patient privacy while being comfortable and functional for patients/caregivers. Interaction A significant difference among the three UC service providers was identified on this item. Specifically, primary care physicians performed better than the other two providers did, and the differences were both significant. This is expected because the patient sees the same medical doctor in the physician’s office but sees different providers at each visit to the other two types of UC facilities. No difference, however, was identified between UCC and emergency rooms. Interaction is less personal at these two types of facilities and the patient cannot develop an ongoing relationship because the patient does not see the same provider each visit. Positive patient perceptions result when any UC service provider maintains a strong customer service culture. This includes frequent, personal, and meaningful communication with the patient/significant others during the visit, timely and efficient service delivery, and the provision of a broad spectrum of services, reasonably priced. Professionalism No significant differences were identified among these three providers. Professionalism measures how patients perceive the expertise of professionals and how they assess their clinical competence. One reason for the lack of significance might be that patients do not have sufficient knowledge to evaluate professional expertise (Donabedian, 1982). Another possibility might be the nature of the care that they received. The majority of the respondents went to their facilities for minor medical condition such as flu, a shot, and minor injuries, which usually do not require complicated or painful medical treatments. Professionalism is essential in order for UC service providers to retain market share. In order to improve UC service quality and increase positive word-ofmouth, UC service providers can provide their physicians and support staff with systematic training to enhance customer service.

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Efficiency While primary care physicians’ offices performed significantly better than hospital emergency rooms, results did not show a significant difference between the efficiency of UCC and hospital emergency rooms. Even though elderly and uninsured patients may use emergency departments for primary or UC, hospital emergency rooms are also capable of handling patients whose conditions are immediately life threatening. Due to the prioritization of medical needs, patients seen in the emergency department might be interrupted or delayed by the need to treat more critically ill patients immediately, which affects the efficiency of care provided in an emergency room setting. The implication is that UCC and emergency rooms should continuously work to improve efficiency and the timeliness of service delivery. Since patient satisfaction and perceptions related to the efficiency of care delivery frequently focus on wait times (Handley, 2011), Shiver (2007) pointed to the need to redesign processes in emergency departments and UC settings so that wait times can be reduced. To this end, Shiver recommended a shift to bedside patient registration, cross-training of staff to prevent delays, the use of a dedicated X-ray technician to a limited number of patients, and the establishment of a fast track room for the care of patients with low urgency care needs. Accessibility Primary care physicians and UCC performed significantly better than emergency rooms in terms of accessibility. In comparing primary care physicians and UCC, primary care physicians performed slightly better, though the difference was not significant. Emergency rooms can be perceived to have the best performance on accessibility, because they provide medical service on a 24/7 basis, and no appointment is necessary. However, results show that the other two providers received higher evaluations. This result is not surprising considering the three items used to measure accessibility: easy to set up an appointment, available by phone, and easy to get a time convenient to patients. These three items were valid measures of accessibility across all types of UC providers, but are not always realistic scales for the evaluation of hospital emergency rooms. First, there is no appointment necessary for an emergency room visit. In addition, the majority of patients do not contact emergency rooms for medical advice or to schedule an appointment by phone. For these reasons, patients evaluate accessibility in emergency rooms based on the time that they wait to be seen. According to Soremekun et al. (2011), emergency room wait times are important measures in predicting patient satisfaction with the care that they receive during an emergency room visit. A better instrument for accessibility of emergency rooms is recommended for future studies. This result does not suggest that emergency rooms are inaccessible, but does imply that patients may perceive that service delivery is delayed in the emergency department. The result indicates that the difficulty of scheduling an appointment is very important for patients, Therefore, to extend office hours to nights and weekends might contribute to improvement of patients’ perceptions of accessibility of UC providers. Another recommendation for future research is to take accessibility (waiting time) of medical care into consideration. The lower evaluation of emergency rooms might be caused by a lack of this perspective in the measurement scale. Perceived value The three items related to perceived value are reasonable price, value worthy of price, and competitive price. This construct was designed to measure the trade-off between prices and benefits, or the patient’s perception of whether the service merits the costs.

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Actual costs include not only money but also time and other sacrifices patients make for the medical visit. However, these three items focus on only financial cost. The result demonstrates that primary care physicians and UCC offer better prices for the services that they provide than emergency departments. Hospital emergency rooms offer higher prices comparatively, but of course, have higher overheads to maintain the expertise, equipment and supplies needed to care for emergent conditions. Patients have also realized that emergency rooms are not the most efficient UC providers. This helps primary care physicians and UCC to differentiate themselves from emergency rooms as preferred UC providers. In addition, patients’ recognition of higher price of emergency rooms might reduce misuse of emergency rooms for non-emergency medical visits, unless the patient is uninsured and has no other option. Review of research hypotheses In summary, in addition to developing and testing a structural model, this study tests two research hypotheses about UC providers: H1. There are significant differences among primary care physicians, hospital emergency departments, and UCC in terms of perceived service quality. H2. There are significant differences among primary care physicians, hospital emergency departments, and UCC in terms of perceived value. The MANOVA results in Table V show a statistically significant difference among the three types of UC providers, with a p value of 0.000. In sum, Table VI shows the following significant differences between the groups: first, primary care physicians’ offices and hospital emergency departments differed in terms of technical quality, interaction, efficiency, accessibility, and perceived value; second, primary care physicians’ offices and UCC varied in terms of interaction; and third, hospital emergency departments and UCC differed in accessibility and perceived value. Overall, the results in these two tables show that both H1 and H2 were supported in this study. Theoretical implications This work developed and tested a SERVQUAL model within the UC setting and demonstrated that the number of dimensions in a health care setting is different than the number of dimensions in other industries. This reinforces the need for further study of the application of SERVQUAL to health care environments and makes a valuable contribution to current theory because it supported a structural difference in the SERVQUAL model in this application. Managerial implications For each of the UC settings discussed, the managerial implications are remarkably similar. While UC services are best delivered in physicians’ offices and UCC to be most cost effective and most appropriately delivered in the continuum of care, people will still select their service provider of choice among the three provider types. However, in all three settings, the patients’ care experiences and the quality of the services delivered can all be improved by a managerial emphasis on communicating with patients and families throughout the care episode. Providers in all three settings should communicate with the patient and family about many aspects of the care being delivered. Wait times should be explained and shortened whenever possible, diagnoses, and treatment steps should be explained in plain language, and discharge instructions should be provided verbally and

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in writing. The purpose of medications should be explained, and patients should be told whether a generic form of the medication can be substituted for the brand name version, and how the medication should be administered. Patients should be informed of the circumstances under which a call to the physician for instructions or a return visit might be necessary, and the patient should be thanked for choosing the provider, and asked what would make their care experience better. Customer satisfaction should be as much the goal of each care episode as the desired clinical outcome, and a managerial emphasis on communication and customer service is essential. Limitations and future research Some limitations should be acknowledged in this study. Most notable are the limitations associated with our sample. College students were used to evaluate patient perceptions of UC service delivery. The homogenous nature of this sample and the use of a non-probability sampling plan limit the generalizability of the findings. However, college students were selected because they are frequent customers of UC providers, particularly UCC. College students do not have flexible schedules, and UCC offer no-appointment medical care at a reasonable price. A second limitation associated with the sample is that the respondents were recruited at a single university. Their perceptions might not be as diverse as those collected from universities across several regions of the country. A random selection of patients from nationally recognized UC providers in multiple regions would provide more reliable and valid results (Taylor and Cronin, 1994). The final limitation of this study is that the respondents were asked to evaluate their most recent UC visit in the last 12 months. The assumption is that the respondents could remember clearly their perceptions about their UC visits. The time frame, however, may be too long for them to adequately remember what happened during their visit, and their perceptions may have been affected by events after their visit. Therefore, an onsite survey of patients immediately after their visit is recommended for future studies. The value of the findings in this work suggest that it would be valuable to compare results of this study to results obtained when the same research strategy is applied to populations of different ages. In addition, findings suggest that another productive area for future research would be the application of the survey instrument developed in this work to patients who have been treated for illnesses at different levels of acuity. Overall, significant differences were identified among these three types of UC service providers. Primary care physicians were evaluated higher by patients in terms of the UC service quality and perceived value, followed by UCC. UCC’s provide high quality UC with reasonable prices. Hospital emergency rooms, however, are evaluated lower in both quality and perceived value. No significant difference was identified between UCC and primary care physicians across all the perspectives examined in this study except for the quality of patient and provider interaction. Although established only in recent years, UCC offer convenient medical care at reasonable prices. To earn patient loyalty and positive word-of-mouth, UCC can improve in the areas of communication and efficiency, and managers of such centres would be well served by examining how they perform on the dimensions identified in this research. Study contributions This work developed and tested a SERVQUAL model within the UC setting and demonstrated that the number of dimensions in a health care setting is different than the number of dimensions in other industries. In addition, the results of this study

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provide important findings about patient perceptions, and suggest that patients may appropriately prefer different UC providers based on the complexity of care that they seek. It is not surprising that primary care physicians perform better than UCC on the interaction dimension because of the likely difference in the strength of the personal relationship between patient and provider available in the primary care physician’s office. The differences among construct means for interaction, efficiency, accessibility, and price/value when comparing the emergency department and the primary physician’s office are also potentially based on the severity of the illness or injury and the subsequent complexity of the treatment that the patient is seeking. For example, the significant difference in technical quality between primary care physicians and hospital emergency rooms might be the result of the acuity of the conditions treated in each setting. In another example, the differences in the means of accessibility and price/value between the emergency department and UCC may indicate that consumers perceive that UCC offer better accessibility and price/value than emergency departments only when they can afford to wait for medical treatment because their need is less emergent. These findings provide unique insights for UC providers and highlight important considerations for managers who seek to increase market share and improve customer satisfaction. References Anderson, E.W., Fornell, C. and Lehmann, D.R. (1994), “Customer satisfaction, market share, and profitability: findings from Sweden”, Journal of Marketing, Vol. 58 No. 3, pp. 53-66. Brady, M.K. and Cronin, J.J. Jr (2001), “Some new thoughts on conceptualizing perceived service quality: a hierarchical approach”, Journal of Marketing Research, Vol. 65 No. 3, pp. 34-50. Choi, K.-S., Cho, W.-H., Lee, S., Lee, H. and Kim, C. (2004), “The relationship among quality, value, satisfaction and behavioural intention in health care provider choice: a South Korean study”, Journal of Business Research, Vol. 57 No. 8, pp. 913-921. Churchill, G.A. Jr (1979), “A paradigm for developing better measures of marketing constructs”, Journal of Marketing Research, Vol. 16 No. 1, pp. 64-73. Cronin, J.J. and Taylor, S.A. (1992), “Measuring service quality: a reexamination and extension”, Journal of Marketing, Vol. 56 No. 3, pp. 55-68. Dagger, T., Sweeney, J. and Johnson, L. (2007), “A hierarchical model of health service quality: scale development and investigation of an integrated model”, Journal of Service Research, Vol. 10 No. 2, pp. 123-142. Donabedian, A. (1982), Explorations in Quality Assessment and Monitoring, in the Definition of Quality and Approaches to its Assessment, Health Administration Press, Ann Arbor, MI. Eggert, A. and Ulaga W. (2002), “Customer-perceived value: a substitute for satisfaction in business markets?”, Journal of Business and Industrial Marketing, Vol. 17 Nos 2/3, pp. 107-118. Gollogly, D. (2008), “Speech to the emergence of urgent care conferences”, Speech made at the Emergency of Urgent Care Conference, March 7-9, Auckland, available at: www.docstoc.com/ docs/70381608/David-Gollogly—Speech-to-the-Emergence-of-Urgent-Care-Conference (accessed July 2, 2008). Hair, J. Jr, Black, W., Babin, B. and Anderson, R. (2010), Multivariate Data Analysis, 6th ed., Pearson Prentice Hall, Upper Saddle River, NJ. Handley, A. (2011), “Fast-track to efficiency”, Nursing Standard, Vol. 25 No. 20, pp. 18-19. Howard, M., Goertzen, J., Hutchison, B., Kaczorowski, J. and Morris, K. (2007), “Patient satisfaction with care for urgent health problems: a survey of family practice patient”, Annals of Family Practice, Vol. 5 No. 5, pp. 419-424.

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Steelman, A. (2010), “Health care reform: bridging the gap between emergency care and primary care via urgent care”, Strategies and Solutions, A Publication of Health Strategies & Solutions, Inc., available at: www.hss-inc.com/healthcare-report/health-care-reformbridging-the-gap-between-emergency-care-and-primary-care-via-urgent-care.pdf (accessed December 22, 2013). Stern, D. (2005), “Status of Urgent Care in the US – 2005”, Business Briefing: Emergency Medicine Review, pp. 15-18, available at: www.touchbriefings.com/pdf/1334/Stern.pdf Taylor, S.A. and Cronin, J.J. Jr (1994), “Modeling patient satisfaction and service quality”, Journal of Health Care Marketing, Vol. 14 No. 1, pp. 34-44. Urgent Care Association of America (UCAOA) (2008), “Urgent care news”, UCAOA, Naperville, IL, available at: www.ucaoa.org/Newsletter/Urgent_Care_ news_11-05.html (accessed June 20, 2008). Urgent Care Association of America (UCAOA) (2011a), “Urgent care industry information kit”, UCAOA, Naperville, IL, available at: www.ucaoa.org/docs/UrgentCareMediaKit.pdf (accessed January 9, 2012). Urgent Care Association of America (UCAOA) (2011b), “The case for urgent care”, UCAOA, Naperville, IL, available at: www.ucaoa.org/docs/WhitePaperTheCaseforUrgentCare.pdf (accessed May 10, 2012). Urgent Care Association of America (UCAOA) (2012), “Urgent care industry awareness campaign marketing ideas – details”, UCAOA, Naperville, IL, available at: www.ucaoa.org/docs/ IndustryCampaignCalendar_WINTER.pdf (accessed January 9, 2014). US Census Report (2013), “School enrolment and work status: 2011”, United States Census Bureau, available at: census.gov (accessed January 4, 2014). Van Dyke, T.P., Kappelman, L.A. and Prybutok, V. (1997), “Measuring information systems service quality: concerns on the use of the SERVQUAL questionnaire”, MIS Quarterly, Vol. 21 No. 2, pp. 195-208. Van Dyke, T.P., Prybutok, V.R. and Kappelman, L.A. (1999), “Cautions on the use of the SERVQUAL measure to assess the quality of information systems services”, Decision Sciences, Vol. 30 No. 3, pp. 877-891. Van Remortel, D. and Miceli, P.J. (2003), “Fostering patient loyalty in urgent care settings”, AAACN Viewpoint, Vol. 25 No. 6, pp. 1-20. Weinick, R.M. and Betancourt, R.M. (2007), No Appointment Needed: The Resurgence of Urgent Care Centres in the United States, California Healthcare Foundation, Oakland, CA, ISBN 1-933795-39-5. Wicks, A.M. (2004), “The development and evaluation of a patient satisfaction model for health service organizations”, No. 3131268, University of Houston, ProQuest Database, UMI Dissertation Information Service. Zeithaml, V.A. (1988), “Consumer perceptions of price, quality, and value: a means-end model and synthesis of evidence”, Journal of Marketing, Vol. 52 No. 3, pp. 2-22. Zifko-Baliga, G.M. and Krampf, R.F. (1997), “Managing perceptions of hospital quality”, Marketing Health Services, Vol. 17 No. 1, pp. 28-35. Further reading Hair, J.F., Black, W.C., Babin, B.J., Anderson, R. and Tatham, R.L. (2006), Multivariate Data Analysis, 6th ed., Pearson Education, Upper Saddle River, NJ. National Association of Community Health Centers (2009), “A sketch of community health centres”, National Association of Community Health Centers, available at: www.nachc. com/client/documents/Chartbook%20FINAL%202009.pdf (accessed January 8, 2012). SPSS Inc. Released (2007), ”SPSS for Windows, Version 15.0”, SPSS Inc., Chicago, IL.

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About the authors Dr Hong Qin is an Assistant Professor at the University of Texas – Pan American. She received her Doctoral Degree from the University of North Texas. Her teaching areas include business statistics, multivariate statistics, and management science. Some of her more recent publications can be found in the International Journal of Quality and Service Sciences, International Journal of Services and Standards, Quality Management Journal and Socio-Economic Planning Sciences. Dr Qin is also a Board Council Member of the Decision Sciences Institute – Southwest Region. Dr Gayle L. Prybutok, BSN, MBA, and PhD, is a Student at the University of North Texas, has over 30 years of experience as a Nurse and Health Care Executive in a variety of ambulatory care and hospital settings. She has been the Executive Director of the National Disease Research Interchange; a programme funded by a grant from the National Institutes of Health to procure human tissue for research and has extensive experience and an ongoing interest in community health education. Her research interests include the use of social media to communicate important health information to target populations, and the information-seeking behaviours of specific populations in their quest for health information. Dr Gayle L. Prybutok is the corresponding author and can be contacted at: [email protected] Dr Victor R. Prybutok is a Regents Professor of Decision Sciences in the Information Technology and Decision Sciences Department and Associate Dean of the Toulouse Graduate School at the University of North Texas. He received, from the Drexel University, his BS with High Honors in 1974, an MS in Bio-Mathematics in 1976, an MS in Environmental Health in 1980, and a PhD in Environmental Analysis and Applied Statistics in 1984. Dr Prybutok is an American Society for Quality Certified Quality Engineer, Certified Quality Auditor, Certified Manager of Quality/Organizational Excellence, and an Accredited Professional Statistician (PSTAT®) by the American Statistical Association. Dr Prybutok has authored over 120 journal articles, several book chapters, and more than 135 conference presentations in information systems measurement, quality control, risk assessment, and applied statistics. Dr Bin Wang is an Associate Professor of Computer Information Systems at the University of Texas – Pan American. Her research focuses on IT adoption, the performance of IT firms, electronic commerce, mobile commerce, and social commerce. Her research has appeared in the Journal of Management Information Systems, Information Systems Journal, Industrial Management & Data Systems, Information Technology and Management, Electronic Commerce Research and Applications, Computers in Human Behavior, and Electronic Markets – The International Journal.

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