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Healthcare
Healthcare service quality service quality
perception in Japan perception
Amira ep Koubaa Eleuch
Osaka University of Economics, Osaka, Japan 417
Received 7 April 2008
Abstract Revised 28 August 2008
Purpose This study aims to assess Japanese patients healthcare service quality perceptions and to Accepted 13 September
shed light on the most meaningful service features. It follows-up a study published in IJHCQA Vol. 21 2008
No. 7.
Design/methodology/approach Through a non-linear approach, the study relied on the scatter
model to detect healthcare service features importance in forming overall quality judgment.
Findings Japanese patients perceive healthcare services through a linear compensatory process.
Features related to technical quality and staff behavior compensate for each other to decide service
quality.
Research limitations/implications A limitation of the study is the limited sample size.
Non-linear approaches could help researchers to better understand patients healthcare service quality
perceptions. The study highlights a need to adopt an evolution that enhances technical quality and
medical practices in Japanese healthcare settings.
Originality/value The study relies on a non-linear approach to assess patient overall quality
perceptions in order to enrich knowledge. Furthermore, the research is conducted in Japan where
healthcare marketing studies are scarce owing to cultural and language barriers. Japanese culture and
healthcare system characteristics are used to explain and interpret the results.
Keywords Overall quality judgement, Cognitive structure, Scatter model, Technical features,
Health care, Perception, Japan
Paper type Research paper

Introduction
Interest in healthcare service quality is remarkable. Practitioners and academics are
struggling to find healthcare systems that satisfy different stakeholders (patients,
providers, practitioners, and insurers). Healthcare organisations are under pressure.
Laws emphasising patients rights to good care interfere with cutting costs and
insurance system pressures. Therefore, the emerging question i.e. how to satisfy
patients, provide service quality and maximise profit under limited resources in a
competitive environment? is still waiting to be answered in many countries. Japan is
no exception. The pressures from powerful insurance institutions and the politics of
minimising costs lead Japanese healthcare services providers to valorise quantity
(examined patients) to service qualitys detriment. Such situations seem to deeply
affect medical practices and perceived quality.
In this article, we follow-up a study published in IJHCA Vol. 21 No. 7 (Elleuch, 2008)
and explore Japanese patients healthcare service quality perceptions using a
non-linear approach (Otani et al., 2003; Cronin, 2003; Brannick and Brannick, 1989). International Journal of Health Care
Using a non-linear model offers the opportunity to point out the most salient service Quality Assurance
Vol. 24 No. 6, 2011
features that affect service quality perceptions. As the Japanese context is relatively pp. 417-429
q Emerald Group Publishing Limited
scarcely investigated (in contrast with the USA and Europe), our work aims to enrich 0952-6862
the current knowledge on healthcare service quality perceptions and to reveal Japanese DOI 10.1108/09526861111150680
IJHCQA healthcare practice characteristics. Furthermore, by adopting a quality model that
considers both functional and technical features (Kang and James, 2004; Gronroos,
24,6 2001) through a non-linear approach, we try to go deeper by investigating patients
reactions and behaviours in order to better assess their needs.

Theoretical background
418 Technical and functional quality
Perceived quality is the consumers evaluative judgment regarding the superiority of
service performance (Zeithaml, 2000). Medical service quality perception is a judgment
of whether the service performed for a patient was the most appropriate to produce the
best result that could be reasonably expected by the patient, and whether that service
or those services were delivered with due attention to the doctor/patient relationship
(Martinez Fuentes, 1999). Traditionally, functional/interaction quality how the
service is delivered, i.e. physical environment quality; where the service is delivered;
and technical quality, i.e. what is delivered are believed to shape service quality
perceptions (Gronroos, 2001; Donabedian, 1988). The service experience is formed by
the joint and inter-related effects of three quality dimensions (Brady et al., 2006; Orava
and Tuominen, 2002). Some healthcare research disregards the importance of technical
features, since it was believed that customers would not be able to discern a services
technical aspects and therefore would therefore rely on processes. Works by Zifko
Baliga and Krampf (1997), Winsted (2000), Beattie et al. (2002) and Marley et al. (2004)
support the positive effect of doctors and nurses perceived skills on patients quality
perception. The patient is able to infer an evaluation of his/her care through the skills
shown by the doctor and nurses when dealing with him/her (Trumble et al., 2006).
Further, the patients ability to understand disease description and treatment
procedures is developed owing to easily accessed scientific knowledge. Technical
feature perception complements and integrates with the process quality dimensions of
a successful medical service (Orava and Tuominen, 2002). Patients perceptions of
successful healthcare outcomes in physical and emotional amelioration terms
(Zineldin, 2006; Zifko Baliga and Krampf, 1997) could positively affect the overall
evaluation of their experience (Marley et al., 2004; Lytle and Mokwa, 1992). In this
respect, it seems unfair to neglect the effects of technical attributes on patients
reactions to the healthcare service experience. Furthermore, holistic comprehension of
the service judgment implies consideration of all features on which patients may rely to
evaluate the service. Our conceptual model, therefore, is based on the frame where both
technical and functional aspects are equally evoked (Brady et al., 2006; Gronroos, 2001;
Brady and Cronin, 2001; Donabedian, 1988) when the service is subject to customers
evaluation. We propose that both technical features and processes affect patients
healthcare service quality perceptions:
H1. Overall healthcare service quality perceptions depend on functional and
technical attributes.

Non-linear approach
In confronting the enormous complexity of human behavior, the investigator has two
choices. He can severely simplify the phenomena under study and base all his
conclusions on this simplified model. Or he can attempt to grapple with all the
complexities simultaneously, hoping for an inspired solution (Kotler, 1973, p. 1).
Likewise, attempting to simplify our comprehension of patient reaction to healthcare Healthcare
service experience, researchers have largely studied and depicted perceived service service quality
quality antecedents (service attributes) and consequences (intentional behaviours) in
linear models. Many works considered that patients mathematically average their perception
reactions to different healthcare service attributes to come out with an overall quality
judgment about their experience. However, psychological theory weakens and
contrasts the linearity presumptions validity stipulating that in reality, evaluation 419
does not follow a linear judgment processing (Cronin, 2003; Green and Wind, 1973). In
the same vein, marketing researchers posit that some attitudes have a strong impact on
consumer behaviour, whereas others do not influence a persons action (Van Doorn
et al., 2007; Agarwal and Malhotra, 2005). Our interpretation is neither linear nor
objective. Human subjectivity and selection shape evaluation (Einhorn, 1971). People
may be inductive selecting one element and basing their overall evaluation on it
(Kardes et al., 2004). Evaluation processes are often not additive (Brannick and
Brannick, 1989). Positively evaluated attributes cannot compensate for negative
perceptions. Consequently, just one missed performance can lead to an overall negative
perception (Otani et al., 2003; Cronin, 2003; Brady et al., 2006). Suggestions that word-of
mouth from poor performance exceed those resulting from positive performance
represent a possible non-linear effect (Cronin, 2003; Watkins and Liu, 1996). Using
non-additive models to approximate processes underlying evaluation can lead to
greater accuracy in quantifying the cognitive processes that underpin decision making
and evaluative judgment (Cronin, 2003; OConnor and Shewchuk, 2003; Einhorn, 1971).
Thus, non-linear models are likely to come closer to describing and predicting
judgment processes (Brannick and Brannick, 1989). Among several non-linear models,
Ganzach and Czaczkes (1995) concluded that the non-linear scatter model fits the data
best. The scatter model, developed by Brannick and Brannick in, 1989, has the strength
to indicate whether evaluation follows a compensatory/non-compensatory process and
to describe the nature of an attributes addition (conjunctive/disjunctive). In a
compensatory model, the patient linearly adds his or her experiences. A low value
attributed to one feature can be compensated by a high value accorded to another. In a
non-compensatory model, one or some attributes perception may overcome other
attributes, and hence patients end up with an overall positive or negative evaluation
with reference to one or few attributes. There is no trade-off between attributes (Otani
and Harris, 2004). Two configurable rules govern non-compensatory performance
evaluation, i.e. disjunctive and conjunctive rules (Ganzach, 1995). In the disjunctive
model, the rating is fundamentally based on positively evaluated attributes. In the
conjunctive model, negatively appraised attributes have more impact on devaluing the
overall rating (Brannick and Brannick, 1989). Brady et al. (2006) stressed the necessity
to examine thoroughly the compensatory effect between attribute reactions. Therefore,
it seems wise to examine whether a smart, smiling nurse or a pleasant care setting
could compensate for a negative outcome or unskilful doctor struggling to diagnose the
patients disease, i.e. understanding compensatory effects between attributes could
enhance our grasp of patient quality perceptions. Psychologists stipulate that relying
on conjunctive/disjunctive processes depends on the situation. If people are risk-averse
and they avoid making mistakes then negative attributes often prevail and the
conjunctive model is more likely to depict the evaluation process (Otani and Harris,
2004). As medical service consumption seems to be a risky experience, where the
IJHCQA patient is highly involved and mistakes should be avoided, it is therefore likely that
patients rely on a conjunctive process when assessing the medical service quality:
24,6
H2. Overall quality perception is inferred according to a conjunctive process.

Japanese healthcare
420 At the macro level, Japan appears to have an excellent healthcare system, as services
are mostly available to all people at relatively cheap prices. The Japanese have a long
life expectancy (75 years for female and 71 years for males) and low maternal (7.1 per
thousand) and infant (three per thousand) mortality rates. However, recently,
discussion has arisen about poor micro economic efficiency (Ogata, 2001). Likewise,
research conducted in Japan regarding healthcare quality and patient satisfaction
revealed many problems that affect the relationship between provider and patient,
which may jeopardise patient health (Elleuch, 2008; Yutaka, 2002; Ovretveit, 2001;
Kurata et al., 1994). Furthermore, the scarcity of research attests a reluctance to adopt a
marketing perspective in Japanese healthcare organisations owing to a tendency to cut
costs while maximising profit.
The fee payment system and the service price fixed by the government means that
most Japanese healthcare settings are offering standard services that lack
specialisation and deprive medical institutions of competitive advantages.
Additionally, medical and administrative tasks overlap as physicians are managing
the setting without having management skill and knowledge (Levin et al., 1987).
Medical services are becoming high-volume, where the lack of restrictions on
frequency and duration appears to be responsible for the high number of visits and
short consultation times. In 1999, a survey conducted by the Japanese Ministry of
Health, Labour and Welfare (1999) showed that 47 per cent of outpatients wait less
than 30 minutes in small hospitals, while 30 per cent wait less than 30 minutes in large
hospitals. Those waiting more than one hour were 15 per cent in small hospitals and 29
per cent in larger hospitals. Two-thirds experienced a consultation of less than ten
minutes in duration, of which 18 per cent were less than three minutes.
Quality seems to be sacrificed by Japanese doctors as they pursue quantity to
maintain their incomes. Doctors try to see the maximum number of patients without
caring about how they see patients or about what they do to patients. Onda et al. (2004)
remarked that the ability to communicate with patients and show him/her enough
interest, to hear his/her story and complaints is not a skill of Japanese doctors.
Nevertheless, communication was found to affect Japanese consumers evaluation of
maternal and child health services (Hisako and Ritsuyo, 2006). Japanese outpatients
evaluate pharmacists better than physicians and nurses based on medical consultation
experiences and the ability to explain instructions and treatment (Onda et al., 2004).
Poor communication between patients, physicians and nurses in Japanese medical
settings appears to be a strong barrier to establishing deep and long-lasting
relationships with healthcare organisations. Friction between patients and providers is
a heavily debated phenomenon after many medical scandals were revealed recently.
Medical practices and healthcare systems need revising before they can adapt to
Japanese societys needs. Hence, our interest is focused on Japanese medical service
consumers and their evaluation of healthcare service delivery. Through this focus, we
try to enrich existing knowledge and to detect potential problems that could affect
healthcare service experiences before illuminating ways to enhance services.
Method Healthcare
Questionnaire and sample service quality
We carried out an empirical investigation among Japanese patients to test our
hypotheses. Originally the investigation is a part of an earlier study that aimed to perception
assess the link between quality perception and patient satisfaction in Japanese
hospitals (Elleuch, 2008). We took into consideration functional and technical medical
service facets (Gronroos, 2001). The functional features are depicted by 21 items 421
extracted from the SERVQUAL instrument (Parasuraman et al., 1988). The
instruments five dimensions were included in our questionnaire:
(1) reliability the ability to perform services dependably and accurately;
(2) assurance employees knowledge and courtesy and their ability to convey
trust and confidence;
(3) responsiveness willingness to help customers and provide prompt services;
(4) empathy caring, individualized attention firms provide to its customers; and
(5) tangibles physical facilities, equipment and staff appearance.
Clinical aspects include the providers qualifications, using the proper diagnostic
equipment, and selecting, timing and sequencing medical diagnosis and treatment (Li
and Collier, 2000; Donabedian, 1988). Patients can infer technical quality through
diagnostic procedures and the physicians ability to explain. The patient could judge
his/her treatment if illness is ameliorated (Marley et al., 2004; Zifko Baliga and Krampf,
1997). Hence, depicting technical quality means using sentences like The doctors
service (explanation, listening, ability and knowledge, etc.) was good, Diagnostic tests
were performed according to the explanation and Treatment was appropriate, which
any patient would be able to understand. We asked participants to recall their visits to
the doctor before answering questions. Overall, perceived quality is captured by asking
the patient to evaluate services (Martinez Fuentes, 1999). For all propositions, a
five-point Likert-type scale was used to capture answers ranging from 1 (disagree) to 5
(agree). Respondents were asked at the end of the questionnaire to provide personal
information such as age, gender and education level. The questionnaire was originally in
English, so translation into Japanese was performed by the researcher and then checked
and corrected by two Japanese professors. A back-translation was performed to verify
that the meaning of sentences was preserved during the translation process.
We did a pilot study with 12 outpatients experiencing services three months earlier.
Respondents confirmed the clarity and understandability of the questionnaire and
suggested adding items about the doctors examination. When discussing experiences
of public and private hospital admission processes, respondents felt that admission
processes can be quicker and discussion with physicians easier if the patient has a
recommendation letter from another physician or another medical organisation. Some
respondents indicated that they were obliged to offer a gift to famous doctors in order
to be accepted into the facility for treatment. Hence we added the item You needed a
recommendation or offer gifts to be admitted in our questionnaire. The
self-administered questionnaire was then distributed to 200 outpatients visiting
medical institutions in Kansai (West Japan). All respondents were at least 18 years and
had directly consumed medical services. Offering almost similar medical consultations
and treatments, institutions were different regarding appearance and material
innovation. Staff (receptionists, nurses and physicians) working in these clinics were
IJHCQA all Japanese. In total, 160 questionnaires (79 males and 80 females) were completed a
79 per cent response rate. The average age of respondents was 43.8 years (SD 12:7)
24,6 and 84 per cent were educated to university level.

Data analysis
The initial step was to verify instrument reliability. Cronbachs alpha values for
422 quality dimensions and intentional behaviour scales were 0.89 and 0.84, respectively.
The scales reliability therefore satisfies Nunnallys (1987) . 0.7 criterion. Using SPSS
14, we employed exploratory factor analysis (EFA) using principal component analysis
with Varimax rotation to assess service attributes. Validity was verified through a
confirmatory factor analysis (CFA) using AMOS 5. Confirmatory factor analysis
revealed three main constructs. The service attributes perceived overall quality and
service attributes intentional behaviour were estimated using Brannick and
Brannicks (1989) scatter model:
2 s2 3
X n
Y a b1 X 1 b2 X 2 . . . bn X n 4 Bk1 X i 2 X
5;
1

where Y is the patients overall quality perception, a is an intercept, Xi is the ith attribute
evaluation, X
is the average of attribute evaluations in one profile, bi are coefficients, and
Bk1 is a coefficient to estimate whether consumer is influenced by negative or positive
values when evaluating services. The scatter model includes two parts:
(1) a linear additive model; and
(2) a sum of negative or positive values occurring when evaluating each attribute.
If the estimated relation was linear then the scatter terms coefficient will be
insignificant and we return to the traditional linear model. However, if non-linear then
the coefficient will be significant and subject to a positive or negative value. Negative
value indicates that the consumer evaluation is more influenced by negative
alternatives than positive. Positive value means that consumer evaluation is influenced
more by positive alternatives than negative.

Results and discussion

Health services attribute structure
The exploratory factor analysis revealed three main factors that explain 55.6 per cent
of the total variance. The goodness of fit indexes given by the confirmatory factor
analysis is presented in Table I.

Goodness of fit indexes RMR GFI AGFI NFI RFI CFI RMSEA

Value 0.024 0.961 0.918 0.963 0.94 0.985 0.063

Notes: RMR, root mean square residual; GFI, goodness of fit statistic; AGFI, adjusted goodness of fit
Table I. statistic; NFI, normed fit index; RFI, relative fit index; CFI, comparative fit index; RMSEA, root mean
Goodness of fit square error of approximation
The structure depicts three factors: Healthcare
(1) staff behaviour when delivering services; service quality
(2) technical quality; and perception
(3) physical appearance.
The first factor groups three items:
423
(1) service was quick;
(2) staff are willing to help; and
(3) staff behaviour transmits trust and confidence.
This factor represents the services functional features how the service is performed
by medical staff. The second factor is formed by three items:
(1) doctors service (explanation, listening, ability and knowledge, etc.);
(2) diagnostic tests were performed according to the explanation given; and
(3) treatment was appropriate.
As discussed earlier, these items depict the medical services technical facets or the what
as perceived by patients. The third factor draws out the services tangible dimension. Two
items (i.e. setting was visually attractive and beautifully decorated; and medical staff in
the setting have neat appearance (smart, clean uniform, etc.)) are related to this factor.
Medical service features perceived by Japanese patients seem to fit the quality structure
presented by Gronroos (2001) based on the how and what. Functional quality is not
enough to draw out medical service delivery assessments and it seems necessary to refer
technical attributes to understand how patients judge service quality. (See Appendix for
items measured.)

Compensatory/non compensatory process

The composite index (CI) was computed for each attribute (independent variable) as the
arithmetic mean of all items measuring that attribute (Bagozzi and Heatherton, 1994).
Three independent variables are described in Table II.
Scatter model results show that only staff behavior and technical quality are
statistically significant (p , 0:00) and positively related to the overall quality
judgment. The scatter term and physical appearance were not significant. Patient
satisfaction depends on technical quality and staff behaviour. Our first hypotheses was
confirmed, as patients addressed both functional (staff behaviour) and technical
features to evaluate service quality (see Table III).
The non-significant scatter term indicates that Japanese patients are following a
compensatory judgment process while assessing overall medical service quality.
Positively evaluating one attribute can compensate for a negative reaction to another.
Our second hypothesis is confirmed the technical dimension seems more important

Quality attributes Physical appearance (appear) Staff behaviour (behav) Technical quality (tech) Table II.
Service attributes and
CI mean 4 3.9 3.1 composite indexes (CI)
CI SD 0.75 0.78 0.67 description
IJHCQA (coefficient 0.67) than staff behaviour (0.23). In fact, Japanese healthcare settings use
standard admission and discharge procedures. Such a routine does not contribute
24,6 much to quality judgment, and patients focus more on human and interactive
relationships, characterised by staffs willingness to help and serve quickly while
transmitting confidence and trust. An interactive service process, where the physician
carefully listens to the patient in a friendly way in order to prescribe the appropriate
424 treatment, seems to be a necessary ingredient to ameliorate perceived service quality.
Nonetheless, most Japanese physicians working under the duty to allocate equal time
to every patient (Kurata et al., 1994) often use diagnostic and prescriptions without
even touching patients. More patients and doctor shortages lead Japanese physicians to
work three times harder than the OECD country average; that is, a Japanese doctor
examines 8,400 patients per year, seeing the patient for only three minutes after he or
she had waited more than one hour (Honda, 2007). This strategy, which attempts to
maximise revenue by increasing patient numbers, may be an unrealisable target and
quality may suffer. Therefore, despite technical importance, patients seem to trade off
technical quality with trustworthy staff. Such results may be explained by Japanese
thinking despite patients ability to assess the service critically, they seem to
consider that no solution exists to the problem and are content with the actual situation
(shikata ga nai ) (Kurata et al., 1994). Patients seem to trade-off certain service
attributes: for example, staff behaviour can compensate for inappropriate technical
quality, and good technical quality can compensate for unacceptable staff behaviour.
Additionally, technical features salience may illustrate Japanese societys evolution
generally and the patient/provider relationship specifically (Elleuch, 2008). In fact, the
old Japanese Confucian culture placed physicians in the top of the hierarchy, whereas
patients were classified in the bottom as they are presumed to lack scientific
knowledge and power. Hence, Japanese healthcares traditional approach emphasised
doctors authority (Westmore, 2005), where patients have to listen and follow the
doctors orders without discussing or complaining. However, it seems that such
asymmetry is an assumption and should not be the rule as patients become more aware
about their rights (Ogata, 2001). Japanese societys evolution and its adoption of many
liberal and individualist norms (Gjerde and Onishi, 2000) encouraged patients to view
care services critically. Poor communication with doctors, a shortage of physicians,
inappropriate staff behaviour and the care settings appearance may lead patients to
mistrust doctors and medical technology especially, and to report medical errors
(Yutaka, 2002). If patients complaints are not taken seriously then patients
experiencing bad service often react by changing providers the insurance system
allows access to any provider at the same price. Further, they abstain from
recommending providers as they fear from losing face inside their group (family or
friends) (Triandis, 2004; Duffin, 1994).
It is worth noting that such fragile relationships between patients and their
healthcare providers are probably leading them to say that the settings closeness to

Terms
Intercept appear behav tech Scatter
Table III.
Scatter model estimation Coefficient 0.31 0.0047 0.23 * 0.67 * 2 0.046
for overall quality
perception Note: *Significant at p , 0:00
home or work is a first motivation beyond provider choice (50.9 per cent of patients in Healthcare
our sample). In extreme cases, on the other hand, angry patients may react violently. In
2006, there were 430 cases where doctors and nurses were physically harassed and 990
service quality
incidents where they were verbally abused by patients or families (Tokita, 2007). perception

Implications
Taking into account both medical service technical and functional facets and using the 425
scatter model, we depict patient reaction to healthcare service experience. Our findings
contribute to understanding how patients judge healthcare services and decide about
re-using and recommending the provider of those services. The scatter model offers the
opportunity to detect service features that are more susceptible to the patients service
quality perception. Hence, researchers should be more aware about the ability of
non-linear models to better depict judgment and decision processes. Researchers in
healthcare service marketing are invited to rely more on such compelling models in
order to grasp the patients reaction and predict his or her future behaviour. Equally,
the services technical facet, as perceived by the patient, should figure among those
healthcare service attributes believed to drive quality perception and intentional
behaviour. Researchers should invest more time in defining and measuring this
dimension. Further, reactions toward attributes should be assessed within the patients
cultural context. The results show how Japanese cultural characteristics and medical
practices could provide a better understanding of Japanese patients. Health service
researchers ought to use cultural context as a foothold to understand results and
predict phenomena (Terpstra et al., 2006; Elleuch, 2008).
Our findings indicate that Japanese patients overall quality judgments and their
loyalty follow a linear compensatory process. Perceived overall quality depends on the
appraisals of staff behaviour and technical features, while loyalty is affected by
technical attributes and patients first impression of staff and service setting.
Managers who are also physicians in Japanese healthcare settings should pay more
attention to the service how and what as both influence patient satisfaction and
intentional behaviour. Enhancing service features through developing customer
orientation among different employees could positively affect patient/provider
relationship and then ensure patient loyalty. As the services technical dimension
seems by far to affect patients overall quality perception, Japanese healthcare
providers should focus on that feature. Providers should define patient needs and try to
adopt medical practices that enhance functional specialisation rather than
under-developed standardisation (Yutaka, 2002). Long waiting times and expensive
gifts offered by patients to some doctors reputed to be skilful suggest that a physicians
technical ability is important. Physicians ought to develop communication, diagnostic
and treatment skills to improve their service quality. Such an evolution could
ameliorate technical weaknesses and enhance patient health. Nonetheless, as a rule,
Japanese doctors receive training only in their speciality, and then they are often
unable to understand exactly the patients whole health situation. The Japanese
healthcare system should encourage a medical education that emphasises clinical
training in different medical treatments to incite knowledge diversification. Further,
more than routine words and a courteous manner, staff should be able to demonstrate
their willingness to help patients, transmit trust and confidence, and perform services
quickly. Patients seem tired of long waiting times (88.7 per cent in our study believe
they waited too long) and the staffs busyness with routine tasks. Incentives to medical
IJHCQA providers should encourage an effective appointment system in order to save patients
time and better organize staffs work.
24,6
Conclusion
Relying on a non-linear approach to assess how patients cognitively process healthcare
service delivery, we explored a scarcely investigated context, i.e. Japan. Furthermore,
426 our study was designed to investigate a service framework that considers both
functional and technical healthcare delivery. Although the results could illuminate our
understanding of patients reaction to the healthcare experience generally and within
the Japanese context specifically, this study seems to be limited by the relatively small
sample. Because Japanese patients and healthcare settings are reluctant to answer
questionnaires and cooperate with such research owing to their unfamiliarity with
studies of this nature, researchers should rely on official organisations such as the
health ministry to run larger investigations. Generally, our study demonstrates that
Japanese healthcare providers ought to take patient needs into account. Providers are
encouraged to build long-term relationships with patients if they want to maintain
their viability. Evolution at the micro and macro levels seems necessary to avoid an
unsolvable breakdown of Japanese medical services.

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Appendix. Items measured: perceived service quality

The functional features
.
Setting was approachable (easy to contact, easy telephone access, etc.).
.
The service is available when needed.
 .
You did not need a recommendation or offered a gift to be admitted. Healthcare
.
The facilities were updated and high technology is used. service quality
.
The physical facilities were visually attractive (reception area, corridors, car park, etc.).
perception
.
The environment is attractive and comfortable.
.
The staff have a professional appearance (smart, clean uniform, etc.).
.
The services were provided at the time promised (time of operation, medicine, food, etc.). 429
.
The services were carried out right first time.
.
When a patient has a problem, there was a sincere interest to solve it.
.
Patients documents were managed correctly.
. Hospital staff told patients exactly when services would be performed (date of operation,
laboratory results, etc.).
.
The service is performed quickly.
.
The staff are willing to help patients.
.
The staff try to respond to patient requests.
.
The staff behaviours transmit trust and confidence.
. Patients feel secure in receiving medical care at this facility.
.
The staff are courteous when dealing with patients (good communication manner,
consideration).
.
Hospital staff have the knowledge to answer patients questions (knowledge and skill
regarding medical and health information).
.
The staff give patients individual attention (learning a patients specific medical history,
flexibility and accommodating the individual patients requirements, etc.).
. The staff listen to patients and keep them informed.
.
Hospital staff could understand patients specific needs.

The technical features

.
The diagnostic was performed according to the explanation given by the patient.
.
The doctors service was good (given explanation, careful listening, ability and
knowledge).
.
The treatment was appropriate.

Overall service perceived quality

.
In general, how do you evaluate the overall quality of the received services?

Corresponding author
Amira ep Koubaa Eleuch can be contacted at: amira.elleuch@laposte.net

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