Challenges of measuring dental service quality

Content

Introduction

Part 1: Overview and Definitions

Part 2: Challenges of Measuring Service Quality

Part 3: Methods to Measure Service Quality

Conclusion

References

Introduction

The aim of this report is to show typical difficulties to measure service quality in healthcare services and to discuss potential approaches offered by science to meet these challenges.

The area of “General Dentistry” is chosen as an example for the complexity of services.

Dentistry includes several fields with different specifications.

Main divisions are:

- Prophylaxis and Preventive Dentistry
- Dental examinations
- Orthodontics
- Restorative Dentistry
- Endodontics
- Periodontics
- Prosthetics
- Oral Surgery
- Implantology

A general practitioner may offer all or just selected specifications. As might be expected every division demands completely different strategies to evaluate service and its quality.

As distinguished from human medicine dentistry is not separated into countless specialisations, after finishing studies in general dentistry only 3 academic specialisations are offered by universities:

- Orthodontics
- Oral Surgery
- Periodontics

Scientific dental societies provide continuing education on all other fields for general dentists, who perform most of all treatments. This must be kept in mind, because the number of different treatments complicates evaluation of quality.

The first part of this report gives an overview about service, quality, service quality and their definitions.

Then the second part looks at different challenges of measuring the quality from two sides:

- from the perspective of the service provider, the dentist and the team
- from the perspective of the service recipient, the patient and -in any sense- the healthcare insurance company.

To get a better understanding of this distinction differences between quality and performance are explained.

Different requirements and patient expectations on treatments in various subdivisions are outlined.

The third part contains a discussion of methods to measure quality, paying special attention to SERVQUAL:

- Performance targets
- Surveys
- SERVQUAL

As a conclusion the outcomes of those methods may be used as a foundation to get some practical advice to assist a dental office to determine its position in the local market and to identify areas of potential improvements.

Part 1: Overview and Definitions

Service

Before starting to think about measuring “service quality” this should be defined.

What does “service” mean? What is hidden behind “quality”?

Current literature offers several definitions for “service”. It is obvious there is no generally accepted one.

A wide definition is given by the BusinessDictionary (businessdictionary.com): “A valuable action, deed, or effort performed to satisfy a need or fulfill a demand.”

Translated into dentistry it may look like this: The dental treatment performed by a dental team to satisfy the patient’s need for pain-free and healthy teeth or fulfil the demand for aesthetic and cosmetic improvements of a smile.

Primarily that is an explanation of the goal of a service, but no characteristics which distinguish services from goods are included. In 2007 Gronroos introduced a comprehensive definition. Additional key points are:

- Service is a process (may be interpreted as perishability)
- It consists of “more or less intangible activities” (intangibility)
- There may be interactions between customer and employees (inseparability, heterogeneity)
- Service provides solutions to customer problems

The choice of words gives a hint to apply the mentioned additions to a continuum.

They are the most commonly accepted characteristics of a service (Bateson, 1995), known as the IHIP model.

IHIP Model

IHIP is an abbreviation for:

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These service characteristics are applied to the dental treatment to explain the weight and need to consider continuums.

- Intangibility

It is obvious that the dental treatment itself is intangible, but the patient’s perception is influenced by tangible elements like the look of equipment and the environment of the practice.

Moreover, dentistry often produces tangible outcomes like fillings and dentures.

Taking all these points into account dental treatment may be rated at just 75 % on an intangibility continuum.

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- Heterogeneity

As patients are humans and no industrial workpieces everyone is different. They have different time frames, different pain thresholds, sometimes additional medical problems, and different expectations. They may be (positive or negative) influenced by family and friends or by internet research.

For everyone an individual care approach must be found, especially because dentistry appears as a high-contact service (Gronroos, 2007).

Furthermore, the dentist, assistants, and receptionists are humans, too. The knowledge and mood of every single member, who is involved, may have an important impact on the treatment and its outcome.

To minimise these effects on the side of the providers there are movements to standardise typical treatments. A routine workflow may be captured as a step-by-step chart.

But this can only be seen as a kind of technical help with limitations in consideration of different types of patients.

Therefore, 90 % on a heterogeneity continuum seem to be appropriate.

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- Inseparability

For a dental examination or treatment the patient and the dentist have to be at the same place, normally in a treatment room. To work on teeth it must be possible to see and touch them.

But again, there may appear some exceptions in dentistry:

- A lot of work is done in laboratories. Here plaster models of the patient’s teeth are basis for the making of crowns, bridgeworks, and prostheses.
- After taking x-rays the patient’s presence is not necessary to analyse them.
- Prescriptions may be written and sent to the patient by mail.

Even inseparability doesn’t reach 100 % on its continuum, 80 % is a reasonable

choice.

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- Perishability

Parallels with intangibility may be detected.

Each treatment is consumed directly, storage isn’t possible, but the outcomes should last for a longer time. Fillings and lab work have to stay in mouth for several years. In Germany a practice has to give a 2-year-guarantee on every work, replacements within this time aren’t paid by insurance companies.

That’s why 75 % on the perishability continuum are a good fit.

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After this integration of dentistry into the context of “service” the second term “quality” is evaluated.

Quality

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(youtube.com, Sood, M., 2013)

“Even though quality cannot be defined, you know what it is.” (Pirsig, R., 1976)

That transcendent approach makes it difficult to know how to satisfy as it refers to an innate quality of excellence (Shirley, D., 2011). Unfortunately, in dentistry most patients act in that way. As there is no universal idea of quality, everyone has an own one. This leads to challenges, which are discussed later.

There are several other approaches (Garvin, 1983), which are applied by different stakeholders.

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Table 1a - d

German insurance companies use this approach as a questionable way to reduce their costs. With assistance of the government rules for guarantees on dental work were legislated.

It was set that renewable fillings and prostheses aren’t chargeable again within two years. In this way dental treatment is reduced to a measurable product, which has to last at least for two years, without taking any special features or patients’ medical problems into account.

Though this report concentrates on the stakeholder patient and dentist, the different approaches to quality demonstrate, that there are more interested parties with different ideas involved to be considered.

Service Quality

The different approaches to quality require various definitions of service quality, too. As expressed above every stakeholder uses an own view belonging to their personal interests. In addition, especially patients are no homogeneous group. Therefore, it is nearly not possible to find a universal definition. A broad one by Kotler and Armstrong (1996) sees

service quality as “the totality of features and characteristics of a product or service that bear on its ability to satisfy stated or implied needs”. It is usable for the service “dentistry”, but the value of offered features and characteristics is in the eye of the beholder.

With other words: Service quality is everything a patient individually expects.

Though it is possible to work dentistry out as a service, there is no way to give a definition of dental quality, which is universally applicable.

Thus, before evaluation of service quality the investigator and her/his intentions as well as the recipients must be known. It is important for all participants to have a clear and equal understanding of service quality.

Misunderstandings and problems will occur, if different stakeholders with different ideas of quality have to negotiate without an agreement on their definitions in advance.

One already mentioned example for such a misunderstanding are negotiations about the dental remuneration of statutory insurance companies. With a little more interest in all stakeholders’ views and a focus on the patient’s needs the product-based approach to quality wouldn’t be legally defined.

Similar problems even occur on a lower level when the number of stakeholders is reduced from 5 (politics, insurance companies, industry, dentists, patients) to 2 (dentist – patient).

Every patient (and dentist) has her/his own vision of service quality.

The heterogeneity of patients induces various individual assumptions to reach satisfaction, but service quality should be consistent through most of the interactions.

Dentists may follow a guideline given by their professional organisations. The STEEEP model by the Dental Quality Alliance (DQA), part of the American Dental Association (ADA) is a good example (DQA, 2016):

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ADA.org)

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Table 2

Patients don’t have a professional guideline. They follow individual expectations, influenced by several factors mentioned later.

It’s a challenge to match the guided perspective of a dentist with the unguided expectation of a patient.

Part 2: Challenges of Measuring Service Quality

View from the Perspective of the Service Provider

A big challenge for the dentist is to decide why and what to measure.

Several reasons could be possible for the need of a deeper look at service quality:

- Benchmarking of the practice
- Looking for fields to grow or improve
- Searching for a reason of patient loss
- Information to support decisions about investments in new equipment

These are examples from different fields to demonstrate the necessity of a well-chosen subject to measure.

Benchmarking

If benchmarking is the main goal, only published data could be compared with own collected data. A look at the statistical yearbook 2017 of the professional body “KZBV (Kassenzahnärztliche Bundesvereinigung)” leads the way to the best choice.

Typically, a well- educated and -trained dentist wants to achieve best state-of-the -art outcomes due to several reasons:

- Professional behaviour
- Meeting patients’ expectations
- Marketing and competition
- Target of insurance companies

Thus, one option is the measurement of outcomes.

Several objective data are conceivable:

- Marginal leakage of crowns and bridgework
- Stability of fillings and prostheses
- Repetition rate of fillings
- Number of repeated visits
- Number of patients treated per day or month

Own results may easily be compared with published overall data and a personal classification is possible.

Taking only such external factors into consideration may be helpful to create a foundation of minimal requirements to be met, but leaves out the wide field of subjective factors, both in patients and providers.

As these factors aren’t comparable or released, benchmarking has to be confined to performance data.

This is the right place to introduce the conceptual pair:

Performance – Service Quality

“How well a person, machine, etc, does a piece of work or an activity”, the Cambridge Dictionary defines “performance”. It is an easy to measure, objective factor, which may vary from day to day, patient to patient. It is the outcome, that is paid by insurance companies.

As this is the only objective part there are trends to use it as the only value to determine service quality in health care.

Such a concept may work well in an industrial environment to rate production.

- Building 10 products A each day is a better performance than 9 products A. The first worker or machine is the better choice.
- Performing 10 Composite-fillings each day is a better performance than 9 fillings?

This question cannot be answered easily, because a lot of information - primarily about the patient - is missing. “Soft” elements on both sides, like attitude, building relationships, and behaviour of the dentist and assistants as well as fear, expectations, and possible medical problems of the patient are hidden.

Reducing service quality to performance leaves at least interaction, physical environment, and patients’ expectations aside.

Improvement

If the practice looks for fields to improve, performance data may be helpful, but there are several other “soft” factors to grow, which may establish a competitive advantage over many dental offices.

As performance data can easily be collected and analysed, it is a challenge to choose and measure a suitable “soft” factor.

Some of them are:

- To take enough time for every patient
- To listen to the patient’s needs
- To work as painless as possible
- To build personal relationships with long-term patients

After a decision for one or more factors to improve in, an appropriate way to measure has to be chosen. As there are no objective numbers to count a patient’s perception must be taken into account, too. Guidance comes from Baldwin and Sohal (2003), who identified fear and anxiety, appreciation of punctuality, and involvement in the development of treatment plans as significant impacts upon service quality perception.

Patient loss

Today the dental market changes from a demand-driven one to a supplier market. Many practices with similar offers compete for a limited number of patients.

It may happen that some patients leave and choose another practice. If the number of leavers becomes bigger than the number of new patients the dentist has to wonder about some modifications of the concept.

In the majority of cases any shortcomings relate to “soft” service, which are difficult to see from the perspective of the provider. Usually a lost patient doesn’t leave any message explaining reasons for choosing a competitor. Riley et al. found that “there was a substantial subset of cases in which dentists were not aware of dissatisfaction” (2014). Thus, ways must be found to get information about the grade of satisfaction from current patients.

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