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A fuzzy framework to evaluate service quality in

the healthcare industry: An empirical case of
public hospital service evaluation in Sicily

ARTICLE in APPLIED SOFT COMPUTING · DECEMBER 2015

Impact Factor: 2.81 · DOI: 10.1016/j.asoc.2015.12.010

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Toni Lupo
Università degli Studi di Palermo
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Please cite this article in press as: T. Lupo, A fuzzy framework to evaluate service quality in
the healthcare industry: An empirical case of public hospital service evaluation in Sicily,
Appl. Soft Comput. J. (2015), http://dx.doi.org/10.1016/j.asoc.2015.12.010. (IN PRESS)

A fuzzy framework to evaluate service quality in the healthcare industry: an empirical case of
public hospital service evaluation in Sicily

Toni Lupo*
Dipartimento di Ingegneria Chimica, Gestionale, Informatica, Meccanica (DICGIM),
Università degli Studi di Palermo,
Viale delle Scienze, 90128, Palermo, Italy

*Corresponding author. Tel.: +39 91 23861879

Email: toni.lupo@unipa.it

Abstract
A novel fuzzy evaluation framework is applied in this study to evaluate service quality in the public
healthcare sector. In particular, the proposed framework is based on the ServQual disconfirmation
paradigm and incorporates the Analytic Hierarchy Process (AHP) method to elicit reliable
estimations of service quality expectations. Moreover, degrees of uncertainty, subjectivity and
vagueness on the part of stakeholders are addressed via linguistic evaluation scales parameterized
by triangular fuzzy numbers. With reference to nine relevant public hospitals in the Sicilian Region
(Italy), a detailed case study evaluating four core service criteria and 15 fundamental service items
is conducted so as to discern dissatisfying aspects regarding the public healthcare service in the
Region. Dissatisfaction reasons with the provided service are identified in the analysis as well,
further demonstrating the effectiveness of the proposed approach.

Keywords: healthcare service quality; patient satisfaction; ServQual; AHP; fuzzy sets theory;
stakeholders’ uncertainty.

1. Introduction
Healthcare is a fundamental and relevant issue whose importance pervades all aspects of society.
In fact, it has medical, social, political, ethical, business, and also financial implications.
Although the recent restructuring of the Italian healthcare system, following the model of the
business enterprise, has produced new opportunities, it calls for yet more rigorous constraints.
Perhaps, the most significant opportunity for healthcare organizations is a new autonomy in
pursuing targeted service outcomes, whereas economic and budget issues unmistakably represent
1
Please cite this article in press as: T. Lupo, A fuzzy framework to evaluate service quality in
the healthcare industry: An empirical case of public hospital service evaluation in Sicily,
Appl. Soft Comput. J. (2015), http://dx.doi.org/10.1016/j.asoc.2015.12.010. (IN PRESS)

the stringent constraints. However, the gap between these two often conflicting aspects may be
bridged by an element, i.e. quality, able to compensate for the distorting potential inherent in an
unwary or ill-advised overemphasis merely on costs and budgets [1, 2, 3, 4].
Healthcare quality has been defined as “the ability to achieve desirable objectives using legitimate
means” whereby the desirable objective implied is “an achievable state of health” [5]. Similarly,
healthcare quality may be conceived as an approach to achieve improved health outcomes for
consumers [6]. Nevertheless, necessary prerequisites of quality healthcare also include appropriate
technology, timely treatment, adequacy of the offer of services with regard to the demand, as well
as guaranteeing acceptable standards of medical practice [7]. All the more, from a corporate
viewpoint, healthcare quality constitutes a reliable means for extending the client base, so as to gain
a competitive edge, thus assuring economic viability and long-term profitability [8, 9, 10].
To all intents and purposes, public healthcare quality can be viewed as a multi-dimensional entity
affected by various interacting aspects and actors: institutions which organize and finance
healthcare, healthcare providers and professionals in the front line of service tending to patients’
needs in terms of diagnosis, treatment and, in recent years, rehabilitation as well. Last but not least,
there are the citizens experiencing the clinical outcomes, but whose bottom line also comprises a
keen eye for certain aspects of the services provided, such as human relationships, hospitality and
the regard for their dignity and privacy. Fig. 1 shows the three main dimensions of healthcare service
quality [11].

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Please cite this article in press as: T. Lupo, A fuzzy framework to evaluate service quality in
the healthcare industry: An empirical case of public hospital service evaluation in Sicily,
Appl. Soft Comput. J. (2015), http://dx.doi.org/10.1016/j.asoc.2015.12.010. (IN PRESS)

Management quality

Procedures
and methods

Social Provided
quality quality
HEALTHCARE
SERVICE

Service relational Medical equipment

and facility aspects Perceived quality and skills

Stakeholder Professional quality

perceived quality

Fig. 1: Multi-dimensionality of healthcare quality.

In detail:
• management quality, concerns efficient and effective resource utilization and management
to deliver services able to satisfy stakeholders’ needs. The evaluation of this quality
dimension takes into consideration the managerial measures and methods adopted.
• professional quality, includes perspectives of healthcare experts and professionals regarding
medical aspects of healthcare. This quality dimension is directly characterized by in-house
medical skills and hospital facilities.
• Stakeholder perceived quality, consists of citizens/patients perceptions with reference to
healthcare aspects involving accessibility, responsiveness, human relationships, hospitality
and other service features.
This latter quality dimension is considered the most significant one since it exerts a direct influence
on the perceived value of the hospital and its image and, as such, it is regarded as a key measure of
the service effectiveness, as well as of the patient satisfaction [12, 13, 14]. Additionally, this quality
dimension also indirectly impacts on patients’ behavior in the sense that, satisfied patients do not
tend to seek healthcare services elsewhere and, moreover, they more likely recommend the same

3
Please cite this article in press as: T. Lupo, A fuzzy framework to evaluate service quality in
the healthcare industry: An empirical case of public hospital service evaluation in Sicily,
Appl. Soft Comput. J. (2015), http://dx.doi.org/10.1016/j.asoc.2015.12.010. (IN PRESS)

hospital to other potential patients [15, 16]. For such reasons, the systematic implementation of
procedures and approaches to evaluate stakeholder satisfaction represents a fundamental aspect
in today’s healthcare context [17].
In the literature, a number of methods have been proposed to assess stakeholder satisfaction in the
healthcare field. Basically, they can be classified into three fundamental groups: Stated Importance
Methods (SIMs), Derived Importance Methods (DIMs) and the Multi-Criteria Decision-Making
(MCDM)-based approaches. As regards SIMs [18, 19, 20], stakeholders are asked to fill out a detailed
questionnaire related to both expectations and perceptions on fundamental service quality aspects.
On the contrary, DIMs [21, 22] require a significantly simplified questionnaire given that
stakeholders are asked to assess only perceptions on service quality aspects and to provide their
overall satisfaction degree as synthesis of the perceived service quality. Quality expectations are
statistically derived in a second phase, after the survey, on the basis of relations among the collected
perceptions and the overall satisfaction degree. Finally, MCDM approaches are based on the general
principle that the attitude of customers towards a given service is based on their assessment of
service aspects on the basis of the importance assigned to them [23]. With this recognition, MCDM
methodologies such as the Analytic Hierarchy Process (AHP) method [24], the VIsekriterijumska
optimizacija I KOmpromisno Resenje (VIKOR) method [25], the Technique for Order Preference by
Similarity to Ideal Solution (TOPSIS) method [26] and so on, constitute a solid underpinning on which
to draw so as to favor the development of approaches able to comparatively evaluate and/or select
service alternatives. Several recent applications of such approaches in the healthcare sector are
described in [27, 28, 29].
Nevertheless, results obtained by the above mentioned methods can be imprecise or even
unreliable for various reasons. For example, lengthy questionnaires typical of SIMs often bore
respondents, consequently lessening the reliability of the data collected [30]. In addition, since users
tend to attribute a greater importance to all service aspects especially when they are asked upon to
directly rate them, quality expectations may be overestimated and also characterized by a lower
discriminatory power. Moreover, quality preferences garnered by such methods can be flawed by
uncertainty, subjectivity and vagueness inherent in the use of linguistic variables to assess service
quality aspects [31, 32].
In the light of the previous considerations, a novel evaluation framework is herein developed to
overcome the known weaknesses of the aforementioned methods, with the aim of assessing the

4
Please cite this article in press as: T. Lupo, A fuzzy framework to evaluate service quality in
the healthcare industry: An empirical case of public hospital service evaluation in Sicily,
Appl. Soft Comput. J. (2015), http://dx.doi.org/10.1016/j.asoc.2015.12.010. (IN PRESS)

healthcare service quality. Specifically, such a framework is based on the ServQual disconfirmation
paradigm [33] and incorporates the AHP method to point out reliable estimates of quality
expectations [34, 35].
ServQual is the most commonly used conceptual model for studying and analyzing the quality of
services [36]. The large employment of its paradigm is widely witnessed by the large amount of
scientific literature produced over the years in different service fields, such as car rental industry
[37], financial services [38], transportation [39], higher education [40], quality certification [41],
hotel services [42, 43], online business [44, 45, 46]. On the contrary, AHP is one of the most
established MCDM methods for facing a wide variety of decision situations, in fields such as
government, business, industry, healthcare, shipbuilding and education [47]. This fact is probably
due to some aspects characterizing such method, such as: possibility to integrate both quantitative
and qualitative and also conflicting criteria, opportunity to conduct sensitivity analysis on obtained
results and, moreover, it is well supported by user-friendly computer software. Furthermore, the
advantageous mathematical structure characterizing AHP and its easiness in acquiring the required
data allow to overcome many critical issues, namely the well-documented respondents tendency to
select the central category of the evaluation scale to express their judgments [48], the influence in
the evaluation process of the categories number of the evaluation scale, the form and the type of
related linguistic variables [49, 50].
Finally, a fuzzy evaluation environment is considered to deal with the inherent uncertainty,
subjectivity and vagueness characterizing stakeholders in expressing their own judgments on service
quality [51, 52, 53]. The fuzzy set theory has been successfully applied in many fields of the
management science as decision-making [54], service performance evaluation [55, 56], information
retrieval [57, 58], and so on. In the field of healthcare service quality evaluation, several recent
applications are described in [59, 60, 61]. Fig. 2 summarizes the architecture of the evaluation
framework developed.

5
Please cite this article in press as: T. Lupo, A fuzzy framework to evaluate service quality in
the healthcare industry: An empirical case of public hospital service evaluation in Sicily,
Appl. Soft Comput. J. (2015), http://dx.doi.org/10.1016/j.asoc.2015.12.010. (IN PRESS)

Fuzzy service quality evaluation

module

Fuzzy service quality Service quality

perceptions analysis module

ServQual
Fuzzy service quality
paradigm
expectations
Fuzzy
AHP

Fig. 2: Architecture of the framework adopted, including fuzzy service quality evaluation and analysis modules.

The framework herein proposed seeks to support healthcare-decision makers and managers in their
choice of effective and efficient strategies aimed at service quality improvements. For example, it
can facilitate the rational prioritization of interventions, such as allotting additional resources for
those service aspects that prove to be inadequate, in order to achieve improved levels of
performance.
The remainder of the present paper is organized as follows. Section 2 contains a detailed description
of the framework. Section 3 illustrates the strategic service quality analysis focusing on the public
healthcare service of Sicily (Italy). Finally, conclusions Section comprises a summary, suggestions for
service quality improvements and directions for future research.

2. The novel fuzzy evaluation framework

As mentioned before, the devised evaluation framework includes fuzzy service quality evaluation
and analysis modules. In Sections below, such modules are in detail described.

2.1 Fuzzy service-quality evaluation module

Service quality perceptions and expectations are assessed under a fuzzy evaluation environment,
taking into account the service aspects of the service quality structure (Fig. 3).

6
Please cite this article in press as: T. Lupo, A fuzzy framework to evaluate service quality in
the healthcare industry: An empirical case of public hospital service evaluation in Sicily,
Appl. Soft Comput. J. (2015), http://dx.doi.org/10.1016/j.asoc.2015.12.010. (IN PRESS)

Overall Customer
Satisfaction

Criterion 1 Criterion 2 Criterion n

Service Criteria (C1) (C2) (Cn)

SI1,1

SI1,2
Service Items …
…
…

SI1,m
Fig. 3: Service quality structure

In order to compute linguistic variables used to represent stakeholders’ perceptions and

expectations, several methods are available in the literature. The method hereafter described is
commonly adopted in the service quality evaluation field for its ease of use and effectiveness [62,
63, 64] and, thus, is employed in this study. In particular, quality perceptions are assessed using a
five-point linguistic scale parameterized by Triangular Fuzzy Numbers (TFNs) [65, 66]. In detail, the

membership function of a TFN B is µ B~ ( x ) : R → [0, 1] and it can be represented by the set of Eqs.
~

(1), where lB < mB < uB. The parameter mB corresponds to the maximum value of µ B~ ( x ) , whereas lB

and uB are the lower and upper limits of the definition interval, respectively [67].

 x − lB
 for lB ≤ x ≤ mB
 mB − lB
 u −x
µ B~ ( x) =  B for mB ≤ x ≤ u B
 uB − mB
(1)


 0 otherwise

Fig. 4 shows the five-point fuzzy-linguistic scale utilized herein to assess perceptions.

7
Please cite this article in press as: T. Lupo, A fuzzy framework to evaluate service quality in
the healthcare industry: An empirical case of public hospital service evaluation in Sicily,
Appl. Soft Comput. J. (2015), http://dx.doi.org/10.1016/j.asoc.2015.12.010. (IN PRESS)

0.8

Very Poor
0.6
Poor

Medium
0.4
Good

Very Good
0.2

0
1 2 3 4 5

Fig. 4: Five-point fuzzy perceptions scale

Quality perceptions of stakeholders are evaluated by the procedure reported below.

~
(
Considering the generic kth service criterion (k = 1, 2, …, n), let Pi ,k = l Pi , k , mPi , k , u Pi ,k denote the TFN )
which measures the aggregate perception characterizing its ith service item (i = 1, 2,…, Ck) obtained
via the arithmetic mean, as reported below:

lPi ,k =
1 J
∑ P l( )
J j =1 i ,k , j
; mPi ,k =
1 J
J j =1
m (
; u ) =
1 J
∑ Pi ,k , j Pi ,k J ∑j =1
uPi ,k , j ( ) (2)

(
where lPi ,k , j , mPi ,k , j , u Pi ,k , j ) denotes the TFN measuring the perception of the j th evaluator (j = 1, 2,

…, J).
Finally, the relative crisp perception can be obtained with reference to the confidence level α (α-
cut) [66], which includes evaluators’ uncertainty over their judgments, and the optimism degree ρ
on fuzzy results [68], by the following relationship:
Piα,k = ρ ⋅ u αP + (1 − ρ ) ⋅ l αP
i ,k i ,k

∀ρ ∈ [0,1]
(3)
k = 1, 2, ..., n
i = 1, 2, ..., C k

in which,

8
Please cite this article in press as: T. Lupo, A fuzzy framework to evaluate service quality in
the healthcare industry: An empirical case of public hospital service evaluation in Sicily,
Appl. Soft Comput. J. (2015), http://dx.doi.org/10.1016/j.asoc.2015.12.010. (IN PRESS)

 Pi ,k i ,k
(
u α = u P − u P − m ⋅ α
i ,k Pi , k
)

 Pi ,k
(
 lα = m − l ⋅α + l
Pi , k Pi , k
) Pi , k
(4)

α ∈ [0,1]

A larger α value is considered when evaluators are confident in choosing a crisp value to represent
their judgments, whereas ρ: R → [0, 1] reflects evaluators’ attitudes towards risk on fuzzy
assessment results [69]. Evaluators are inclined to prefer higher or lower crisp values, derived from
fuzzy assessments, according to whether they are optimistic or pessimistic, respectively.
Conversely, AHP is considered to assess expectations of stakeholders on the healthcare service
quality. The employed procedure is composed by the following fundamental steps: i) pairwise
comparisons of service aspects, ii) structuring of the fuzzy comparison matrix, iii) computing of fuzzy
expectations and, finally, iv) calculating crisp expectations. Such steps are described below.
i) Terms used to express the relative importance of each pair of service aspects, at the
same level of the service quality structure (Fig. 3), are quantified by TFNs. Fig. 5 shows
the fuzzy-linguistic importance scale adopted comprising TFNs (Fig. 5a) and their
reciprocal values (Fig. 5b)

a)
1

0.8

0.6

0.4

0.2

0
1 2 3 4 5 6 7 8 9
Equally important Moderately more important
Strongly more important Very strongly more important
Extremely more important

b)

9
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the healthcare industry: An empirical case of public hospital service evaluation in Sicily,
Appl. Soft Comput. J. (2015), http://dx.doi.org/10.1016/j.asoc.2015.12.010. (IN PRESS)

0.8

0.6

0.4

0.2

0
0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

Fig. 5: Fuzzy importance scale (a) and relative reciprocal values (b)

ii) Considering the service criteria 1, 2, …, n, of the service quality structure, the fuzzy
~
comparison matrix A is defined as:

 1 a~1, 2 ... a~1,n 

 
~  a~2,1 1 ... a~2,n 
A = (5)
 ... ... ... ... 
~ 
an ,1 ... ... 1 

( )
where the generic term a~k ,w = lak , w , mak ,w , u ak , w denotes the TFN measuring the relative importance

of the kth vs the wth service criterion. Particularly, lak ,w , mak ,w , uak ,w are the minimum value, most

plausible value and maximum value, respectively, obtained by aggregating evaluators’ assessments
via the geometric mean [70]:

1 1 1
 J  J  J  J  J  J
lak ,w =  ∏ lak ,w , j  , mak ,w =  ∏ mak ,w , j  , uak ,w =  ∏ uak ,w , j  (6)
 j =1   j =1   j =1 

(
where lak ,w, j , mak ,w , j , uak ,w , j ) indicates the TFN measuring the assessment expressed by the jth

evaluator (j = 1, 2, …, J).

10
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the healthcare industry: An empirical case of public hospital service evaluation in Sicily,
Appl. Soft Comput. J. (2015), http://dx.doi.org/10.1016/j.asoc.2015.12.010. (IN PRESS)

~
iii) From the fuzzy comparison matrix A , fuzzy expectations are computed via the

logarithm least-squares method [71], which is selected herein for its effectiveness. In
~
particular, the expectation level expressed in fuzzy form for the kth service criterion Ek ,

can be obtained as follows:

~
(
E k = l E k , m Ek , u Ek ) k = 1,2,.., n (7)

in which:

1
 n n
 ∏ sak , w 
s EK =  i =1 
1
s ∈ {l , m, u} (8)
n
 n n
∑  ∏ s ak , w 
k =1  i = w 

iv) The related crisp expectation can be obtained with referring to the confidence level α
and the optimism degree ρ by the following relationship:

E kα = ρ ⋅ u αEk + (1 − ρ ) ⋅ l Eαk
k = 1, 2, .., n (9)
∀ρ ∈ [0,1]

in which,

 k k k
(
u αE = u E − u E − m ⋅ α
Ek
)

 Ek
(
 lα = m − l ⋅ α + l
Ek Ek Ek
) (10)

α ∈ [0,1]

Also in this case, the α index reflects the degree of uncertainty in choosing a crisp value, on the part
of the evaluators, to represent their judgments and the ρ index is considered to reflect evaluators’
attitudes towards risk on fuzzy assessment results.

11
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the healthcare industry: An empirical case of public hospital service evaluation in Sicily,
Appl. Soft Comput. J. (2015), http://dx.doi.org/10.1016/j.asoc.2015.12.010. (IN PRESS)

Finally, by following such a procedure, expectations of service items are obtained by multiplying
their importance weights, which can be obtained via the above described procedure, by the
expectation level of the related service criterion.

2.2 Service quality analysis module

As before said, the healthcare service quality is herein analyzed by means of the ServQual paradigm.
The latter is based on the expectations disconfirmation approach, also defined as disconfirmation
paradigm, to identify dissatisfying service aspects and reasons of such dissatisfactions. In particular,
with reference to the generic ith service aspect, seven fundamental service discrepancies (i.e. gaps)
are defined:

Gapi 1: represents the discrepancy between what customers actually want and
what managers perceive customers to want;
Gapi 2: denotes the discrepancy occurring when managers fail to design service
standards that meet customers’ expectations;
Gapi 3: occurs when the service delivery system, that is employees, technology and
processes, fails to deliver according to specified standards;
Gapi 4: occurs when the communication to customers is misleading, promising
service quality levels unfulfilled by employees, technology and processes;
Gapi 5: represents the discrepancy between customers’ perception (Pi) and their
expectation (Ei);
Gapi 6: indicates the difference between what customers actually want and what
employees assume customers to want;
Gapi 7: expresses the divergence between what employees assume customers to
want and what managers think they want.

According to the ServQual paradigm, the Gapi 5 value represents a direct measure of customers’
satisfaction (CSi), that is:

CS i = Pi − E i (11)

12
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the healthcare industry: An empirical case of public hospital service evaluation in Sicily,
Appl. Soft Comput. J. (2015), http://dx.doi.org/10.1016/j.asoc.2015.12.010. (IN PRESS)

Thus, a positive CSi value indicates satisfaction with the ith service aspect, whereas customers’
dissatisfaction for this aspect exhibits a negative discrepancy value. Moreover, customers’
satisfaction is related to values assumed by the other six service discrepancies, as expressed below:

CS i = f ( Gapi 1; Gapi 2; Gapi 3; Gapi 4; Gapi 6; Gapi 7 ) (12)

However, as recent literature indicates [72], customers’ satisfaction proves to be tightly correlated
to only two service discrepancies: Gaps 1 and 6, that is:

CS i = f ( Gapi 1; Gapi 6 ) (13)

with only limited effects resulting from the others. Therefore, the relationship (13) is used, as
reported below, to discern reasons underlying stakeholders’ dissatisfaction with regard to
healthcare services, whereas relationship (11) is considered to evaluate stakeholder satisfaction
concerning the established service items, on the basis of the data collected by way of the survey.

3. Preliminary aspects of healthcare quality in Sicily

Healthcare in Sicily, as in the rest of the Country, is overburdened with ever increasing state
expenditures with a consequently expanding deficit. Paradoxically, while spending for healthcare
has been rising, patient satisfaction seems not to have followed suit. In fact, in many cases there
seems to be a negative correlation between total expenditures and the level of satisfaction of
patients and other stakeholders, as well. This situation may, at least in part, be attributable to an
ineffective and inefficient use of resources [73].
Hence, in recent years in Sicily, evaluation, as strategic tool for triggering systems of actions and
reactions aimed at improving efficiency and effectiveness of organizations, has assumed a focal role
in monitoring healthcare effectiveness. This increased importance attributed to evaluation
processes also arises from the following reasons:
- an increased awareness on the part of the citizenry, whose pursuit of elevated health
standards and psychological well-being implies a demand for state-of-the-art healthcare,
reflected in their expectations of personalized, high quality services;
- healthcare federalism policies have raised the issue of guaranteeing equality, while
establishing minimum service standards for all. As a consequence, assessing the healthcare
levels actually offered in Italy has become a virtual necessity.
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the healthcare industry: An empirical case of public hospital service evaluation in Sicily,
Appl. Soft Comput. J. (2015), http://dx.doi.org/10.1016/j.asoc.2015.12.010. (IN PRESS)

In response to the above context, three types of evaluations are currently performed in the Sicilian
healthcare system:
- evaluations of technical and scientific quality, performed by professionals and academics as
dictated by “evidence-based medicine;”
- evaluations of organizational quality, mainly performed by consultants, concerning
voluntary accreditation and certification procedures;
- evaluations of perceived healthcare quality, according to a variety of techniques (customers’
satisfaction, focus groups, civic audits, etc.).
With reference to the latter, nowadays in Sicily stakeholder perspectives on healthcare quality are
considered a necessary and indispensable dimension to evaluate healthcare effectiveness.
Currently, surveys on perceived healthcare quality comprise the most numerous and significant
means of evaluation.
Given the premises above, an empirical evaluation study of service quality in the public healthcare
sector in Sicily has been undertaken. In particular, the investigation has been focused on 9 relevant
public hospitals, covering the entire Sicilian territory and over 30% of the healthcare demand,
namely St. Giovanni di Dio (Agrigento), St. Elia (Caltanissetta), Cannizzaro (Catania), Enna Hospital
(Enna), St. Martino (Messina), Di Cristina e Benfratelli (Palermo), Ragusa Hospital (Ragusa), Umberto
I, (Syracuse) and St. Antonio Abate (Trapani).
These hospitals are comparable and highly specialized structures which, thanks to their set of
advanced technologies and facilities, professional skills, productive capacity and the variety of
services provided, represent reference points not only for Sicilians, but for non-residents from the
other Italian regions as well. The evaluation results obtained may effectively map out stakeholder
needs for hospital managers, thus assisting their endeavour to deliver quality healthcare.

3.1 Structure of healthcare service quality

The quality structure of the healthcare service has been described on the basis of a comprehensive
review of the relevant literature in the field [74, 75, 76, 77], after a wide consultation involving
several healthcare managers and experts, physicians and a representative body of both in-patients
and out-patients. Particularly, the overall healthcare service quality structure is subdivided into six
service criteria and 32 service items as shown in Fig. 6.

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the healthcare industry: An empirical case of public hospital service evaluation in Sicily,
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Parking area for patients and Ability of doctors to Swiftness of registration and
visitors; understand patients’ needs; admission procedures;
Suitability of rooms for Ability of nurses to Administrative quality;
patient; understand patients’ needs;
Waiting time for test results;
Suitability of waiting area for Capacity to work as a team;
family/visitors; Waiting time for medical
Reliability; records;
Restrooms for out-patients
Availability; Outpatient waiting time for
and family;
Appearance of service medical treatment;
personnel;
Communication skills;

Healthcare staff
Tangibles Responsiveness

Stakeholder
satisfaction

Accessibility Relationships

Support services

Quality of food & beverages

Procedures regarding for patients;
medical care;
Security within hospital; Confidentiality between
Hospital accessibility;
Cleanliness of facilities and doctor and patient;
Procedures regarding in- premises; Confidentiality among all
patient services;
Cleanliness of the restrooms; healthcare staff;
Facilities for family/visitors;
Ventilation and hygiene on Cooperation and helpfulness
Hospital website; the ward; of administrative staff;

Available information on Lighting conditions on the Humanization of

facilities; ward; relationships;

Fig. 6: Overall healthcare service quality structure

Subsequently, in order to simplify the questionnaire to be adopted in the survey, this

comprehensive list of service quality aspects has been narrowed down to a set of fundamental
healthcare aspects of services delivered in Sicily. In particular, the latter have been derived by using

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the healthcare industry: An empirical case of public hospital service evaluation in Sicily,
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the Critical Cases method [78] after a consultation involving several healthcare service experts
(healthcare service managers, medical staff and nurses), academics and a limited number of
stakeholders (in-patients, out-patients and their families). The resulting fundamental healthcare
service quality structure is shown in Fig. 7.

Fig. 7: Fundamental structure of healthcare service quality in Sicily

Such a fundamental structure was considered to perform the analysis reported below.

3.2 Healthcare service quality evaluation

The survey was conducted over a five-month period, between January and May of 2014. For each
considered hospital, about 60 respondents between in-patients and out-patients, as well about 20
among managers, doctors and nurses were interviewed via internet by the questionnaire form
reported in Appendix A. Totally, 680 questionnaires were selected for their completeness from
about 730 returned forms. Moreover, for both α and ρ indices a value of 0.5 was assumed. Quality
perceptions and expectations for each established core service item were calculated by
relationships (3) and (9), respectively. Fig. 8 summarizes the obtained results.

16
Please cite this article in press as: T. Lupo, A fuzzy framework to evaluate service quality in
the healthcare industry: An empirical case of public hospital service evaluation in Sicily,
Appl. Soft Comput. J. (2015), http://dx.doi.org/10.1016/j.asoc.2015.12.010. (IN PRESS)

SI1,1
0.150
SI4,3 SI1,2

0.120
: Perception
SI4,2 SI1,3 : Expectation
0.090

0.060
SI4,1 SI1,4
0.030

0.000
SI3,4 SI2,1

SI3,3 SI2,2

SI3,2 SI2,3

SI3,1 SI2,4

Fig. 8: Quality perceptions and expectations of public healthcare in Sicily

(α = 0.5; ρ = 0.5)

More in detail, for all the established service items, quality perceptions varied only slightly within a
narrow range (0.054; 0.083), whereas for quality expectations the degree of variation was
significantly broader (0.036; 0.121), as shown in Fig. 8. In particular, service items with high
expectation levels were SI1,1, SI1,2, SI1,3, SI2,1, and SI2,2. Instead, the service items SI3,2, SI3,3, SI3,4, SI4,1,
SI4,2 and SI4,3 proved to be less important.

3.3 Healthcare service quality analysis

As previously mentioned, the ServQual paradigm was herein adopted to analyze the healthcare
quality. To this aim, stakeholder satisfaction (CSi) for any core service item was evaluated via the
corresponding relationship (11) obtaining the results shown in Fig. 9.

17
Please cite this article in press as: T. Lupo, A fuzzy framework to evaluate service quality in
the healthcare industry: An empirical case of public hospital service evaluation in Sicily,
Appl. Soft Comput. J. (2015), http://dx.doi.org/10.1016/j.asoc.2015.12.010. (IN PRESS)

SI1,1
0.06
SI4,3 SI1,2
0.04
SI4,2 0.02 SI1,3

SI4,1 -0.02 SI1,4

-0.04

-0.06
SI3,4 SI2,1

SI3,3 SI2,2

SI3,2 SI2,3

SI3,1 SI2,4

Fig. 9: Stakeholder satisfaction indices CSi

(α = 0.5; ρ = 0.5)

As one can observe, service items which points representative of their CSi fall within the red area
represent the dissatisfying service aspects. Thus, SI1,1, SI1,2, SI1,3, and SI2,1 represent those healthcare
aspects with which respondents were strongly dissatisfied. On the contrary SI2,4, SI3,2, SI3,3, SI3,4, SI4,1,
SI4,2, and SI4,3 were considered very satisfying healthcare aspects.
Finally, perceptions of stakeholder needs were also collected from healthcare managers and staff
viewpoints via questionnaire to elicit the reasons underlying stakeholder dissatisfaction and, thus,
the Gapsi 1 and 6 were evaluated. In detail, positive values of such discrepancies indicate an
underestimation of the related service aspects by healthcare managers and staff respectively,
whereas service aspects characterized by negative values of such discrepancies are overestimated.
Fig 10 shows the obtained values.

18
Please cite this article in press as: T. Lupo, A fuzzy framework to evaluate service quality in
the healthcare industry: An empirical case of public hospital service evaluation in Sicily,
Appl. Soft Comput. J. (2015), http://dx.doi.org/10.1016/j.asoc.2015.12.010. (IN PRESS)

SI1,1
0.020 : Gap 1
SI4,3 SI1,2
: Gap 6

0.010
SI4,2 SI1,3

0.000

SI4,1 SI1,4
-0.010

-0.020
SI3,4 SI2,1

SI3,3 SI2,2

SI3,2 SI2,3

SI3,1 SI2,4

Fig. 10: Gapsi 1 and 6 values

(α = 0.5; ρ = 0.5)

The results reveal that managers’ perspectives on healthcare quality tend to overestimate service
aspects of the criterion C2 and underestimate those of the service criteria C1 and C3. On the contrary,
importance of service aspects of the criterion C4 are correctly understood by managers since they
are characterized by almost zero Gapi 1 values. Finally, according to staff viewpoints, very important
service aspects are those relating to the criterion C1, service aspects of the criterion C4 are
underestimated, whereas the criteria C2 and C3 are correctly perceived.

4. Conclusions and suggestions

In the present paper, the public healthcare sector of the Sicily Region (Italy) was analysed via a
suitable framework based on the ServQual paradigm. In particular, a fuzzy environment was
considered to deal with the uncertainty of stakeholders in expressing their own judgments on
service quality, whereas AHP was employed to obtain reliable estimations of service quality
expectations. From the results analysis, key factors for healthcare quality emerge and, thus, a
rational strategy for the service quality improvement can be identified. In particular, in the light of
the obtained CSi values, strategic efforts towards the service quality improvement should concern
the following service criteria: Healthcare staff and Responsiveness and, particularly: Staff capacity

19
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the healthcare industry: An empirical case of public hospital service evaluation in Sicily,
Appl. Soft Comput. J. (2015), http://dx.doi.org/10.1016/j.asoc.2015.12.010. (IN PRESS)

to work as a team, Ability of doctors to understand patient needs, Staff reliability and Swiftness of
registration and admission procedures. Conversely, the obtained discrepancies characterizing
managers’ viewpoints on service quality highlight that the importance of the service criteria
Responsiveness, Healthcare staff and Relationships is not correctly perceived by them. Thus, actions
should be primarily focused on improvements in marketing researches, direct interactions between
managers and stakeholders and bottom-up internal communications to correctly understand what
stakeholders actually want. Furthermore, effective internal communications of achievements in
service quality should reduce the discrepancies between stakeholders’ needs and how staff perceive
those needs. Future research development will regard the improvement of the herein adopted
assessment framework by considering MCDM procedures to comparatively evaluate the quality of
healthcare service alternatives.

Acknowledgments The Author thanks the two anonymous referees for their remarks, which helped
to significantly improve the paper

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the healthcare industry: An empirical case of public hospital service evaluation in Sicily,
Appl. Soft Comput. J. (2015), http://dx.doi.org/10.1016/j.asoc.2015.12.010. (IN PRESS)

References
[1] Dagger, T. S., Sweeney, J. C., & Johnson, L. W. A hierarchical model of health service quality:
Scale development and investigation of an integrated model, Journal of Service Research. 10(2)
(2007) 123-142.

[2] Detogni, C. Progettazione Europea di Qualità nel Sociosanitario, Franco Angelo Editore,
Roma, 2014.

[3] Inghilleri, R., Lupo, T. and Passannanti, G. An effective double scheme, Quality and Reliability
Engineering International. 31(2) (2015) 205-216.

[4] Lupo, T. A Multi-Objective Design Approach Considering Taguchi Loss Function, Quality and
Reliability Engineering International. 30(8) (2014) 1179-1190.

[5] Donabedian, A. Quality assessment and assurance: Unity of purpose, diversity of means,
Inquiry. 25(1) (1988) 175–192.

[6] Marshall, G. N., Ron, D. H., & Rebecca, M. Health status and satisfaction with health care:
Results from the medical outcomes study, Journal of Consulting and Clinical Psychology. 64(2) (1996)
380–390.

[7] Li, L., Benton, W.C. Hospital capacity management decisions: Emphasis on cost control and
quality enhancement, European Journal of Operational Research. 146(3) (2003) 596-614.

[8] Headley, D. E., & Miller, S. J. Measuring service quality and its relationship to future
consumer behaviour, Marketing Health Services. 13(4) (1993) 32–42.

[9] Sgroi, F., Di Trapani, A.M., Testa, R. and Tudisca, S. Strategy to increase the farm
competitiveness, Am. J. Agric. Biol. Sci.. 9 (2014) 394-400.

[10] Squatrito, R., Sgroi, F., Tudisca, S., Di Trapani, A.M. and Testa, R. Post feed-in scheme
photovoltaic system feasibility evaluation in Italy: Sicilian case studies, Energies. 7 (2014): 7147-
7165.

[11] Giarelli G. Il malessere della medicina – Un confronto internazionale, Milano: Franco Angeli
ed., 2003.

21
Please cite this article in press as: T. Lupo, A fuzzy framework to evaluate service quality in
the healthcare industry: An empirical case of public hospital service evaluation in Sicily,
Appl. Soft Comput. J. (2015), http://dx.doi.org/10.1016/j.asoc.2015.12.010. (IN PRESS)

[12] Frimpong, N.O., Nwankwo, S. and Dason, B. Measuring service quality and patient
satisfaction with access to public and private healthcare delivery’, Int. J. Public Sector Management.
23(3) (2010) 203–220.

[13] Goldstein, S.M. and Iossifova, A.R. Ten years after: interference of hospital slack in process
performance benefits of quality practices, Journal of Operations Management. 30(1-2) (2011) 44-
54.

[14] Queenan, C.C., Angst, C.M. and Devaraj, S. Doctors’ orders – If they’re electronic, do they
improve patient satisfaction? A complements/substitutes perspective, Journal of Operations
Management. 29(7–8) (2011) 639–649.

[15] Choi, K.-S., Cho, W.-H., Lee, S., Lee, H., Kim, C. The relationships among quality, value,
satisfaction and behavioral intention in health care provider choice: A South Korean study, Journal
of Business Research. 57(8) (2004) 913-921.

[16] Lee, M. A., & Yom, Y. H. A comparative study of patients’ and nurses’ perceptions of the
quality of nursing services, satisfaction and intent to revisit the hospital: A questionnaire survey,
International Journal of Nursing Studies. 44 (2007) 545–555.

[17] Hulton, L.A., Matthews, Z., Stones, R.W. Applying a framework for assessing the quality of
maternal health services in urban India, Social Science and Medicine. 64(10) (2007) 2083-2095.

[18] Brown, T.J., Churchill, G.A., and Peter, J. Improving the Measurement of Service Quality,
Journal of Retailing. 69(1) (1993) 127–39.

[19] Kaplan, R.S. & Norton, D.P. The balanced scorecard: measures that drive performance,
Harvard Business Review. (1992) 71-9.

[20] Schvaneveldt, S. J., Enkawa, T., Miyakawa, M, Consumer evaluation perspectives of service
quality: Evaluation factors and two-way model of quality, Total Quality Management. 2 (1991) 149-
161.

[21] Kucukarslan, S.N., Nadkarni, A. Evaluating medication-related services in a hospital setting

using the disconfirmation of expectations model of satisfaction, Research in Social and
Administrative Pharmacy. 4(1) (2008) 12-22.

22
Please cite this article in press as: T. Lupo, A fuzzy framework to evaluate service quality in
the healthcare industry: An empirical case of public hospital service evaluation in Sicily,
Appl. Soft Comput. J. (2015), http://dx.doi.org/10.1016/j.asoc.2015.12.010. (IN PRESS)

[22] Laschinger, H.S., Hall, L.M., Pedersen, C., Almost, J. A psychometric analysis of the patient
satisfaction with nursing care quality questionnaire: An actionable approach to measuring patient
satisfaction, Journal of Nursing Care Quality. 20(3) (2005) 220-230.

[23] Fishbein, M., & Ajzen, I. Belief, attitude, intention and behavior: an introduction to theory
and research, Addion-Wesley, Reading, Mass (1975).

[24] Saaty T. L., Decision making with the analytic hierarchy process, Int. J. Services Sciences.
(2008) 1(1) 83-98.

[25] Opricovic, S., & Tzeng, G. H. Compromise solution by MCDM methods: A comparative
analysis of VIKOR and TOPSIS, European Journal of Operational Research. 156(2) (2004) 445–455.

[26] Hwang, C.L.; Yoon, K. Multiple Attribute Decision Making: Methods and Applications, New
York: Springer-Verlag (1981).

[27] Li, Y., Hu, Y., Zhang, X., Deng, Y., Mahadevan, S. An evidential DEMATEL method to identify
critical success factors in emergency management, Applied Soft Computing Journal. 22 (2014) 504-
510

[28] Chang, T.H. Fuzzy VIKOR method: A case study of the hospital service evaluation in Taiwan,
Information Sciences. 271 (2014) 196-212.

[29] Lupo, T. Benchmarking of airports service quality by a new fuzzy MCDM approach, European
Transport-Trasporti Europei. 57 (2015).

[30] Chien-Chang chou, Li-Jen Liu, Sue-Fen Huang, Jeng-Ming Yih, Tzeu-Chen Han. An evaluation
of airline service quality using the fuzzy weighted ServQual method, Applied Soft Computing. 11
(2011) 2117-2128.

[31] De Battisti, F., Nicolini, G., Salini, S. The Rasch model in customer satisfaction survey data,
Quality Technology & Quantitative Management. 7 (1) (2010) 15–34.

[32] Hu, H.-Y., Lee, Y.-C., and Yen, T.-M. Service Quality Gaps Analysis based on Fuzzy Linguistic
SERVQUAL with a Case Study in Hospital Out-Patient Services, TQM Journal. 22(5) (2010) 499–515.

[33] Parasuraman, A., Zeithaml, V. A. and Berry, L. L. A conceptual model of service quality and
its implications for future research, Journal of Marketing. 49 (1985) 41-50.

23
Please cite this article in press as: T. Lupo, A fuzzy framework to evaluate service quality in
the healthcare industry: An empirical case of public hospital service evaluation in Sicily,
Appl. Soft Comput. J. (2015), http://dx.doi.org/10.1016/j.asoc.2015.12.010. (IN PRESS)

[34] Aktas, A, Cebi, S., Temiz, I. A new evaluation model for service quality of health care systems
based on AHP and information axiom, Journal of Intelligent and Fuzzy Systems. 28 (2015) 1009-
1021.

[35] Baki, B., Peker, I. An integrated evaluation model for service quality of hospitals: A case study
from Turkey, Journal of Multiple-Valued Logic and Soft Computing. 24(5-6) (2015) 453-474.

[36] Seth, N., Deshmukh, S.G., Vrat, P. Service quality models: A review, International Journal of
Quality and Reliability Management. 22(9) (2005) 913-949.

[37] Zhang, M., Xie, Y., Huang, L., He, Z. Service quality evaluation of car rental industry in China,
International Journal of Quality and Reliability Management. 31(1) (2014) 82-102.

[38] Athanassopoulos, A.D. Service quality and operating efficiency synergies for management
control in the provision of financial services: Evidence from Greek bank branches, European Journal
of Operational Research. 98 (2) (1997) 300-313.

[39] Lupo, T. Handling stakeholder uncertain judgments in strategic transport service analyses,
Transport Policy. 29 (2013) 54-63.

[40] Lupo, T. A fuzzy ServQual based method for reliable measurements of education quality in
Italian higher education area, Expert systems with applications. 40 (2013) 7096-7110.

[41] Liu, R., Cui, L., Zeng, G., Wu, H., Wang, C., Yan, S., Yan, B. Applying the fuzzy SERVQUAL
method to measure the service quality in certification & inspection industry, Applied Soft
Computing. 26 (2015) 508-512.

[42] Stefano, N.M., Casarotto Filho, N., Barichello, R., Sohn, A.P. A Fuzzy SERVQUAL Based
Method for Evaluated of Service Quality in the Hotel Industry, Procedia CIRP. 30 (2015) 433–438.

[43] Carrasco, R.A., Villar, P., Hornos, M., Herrera-Viedma, E. A Linguistic Multi-Criteria Decision
Making Model Applied to Hotel Service Quality Evaluation from Web Data Sources, International
Journal of Intelligent Systems. 27(7) (2012) 704-731.

[44] Herrera, E. Herrera-Viedma, L. Martínez, L.G. Pérez, A.G., López-Herrera, S., Alonso. A. Multi-
granular Linguistic Hierarchical Model To Evaluate The Quality Of Web site Services. In C. Kahraman
(Ed.): Fuzzy Set Techniques in Industrial Engineering. International Series "Studies in Fuzziness and

24
Please cite this article in press as: T. Lupo, A fuzzy framework to evaluate service quality in
the healthcare industry: An empirical case of public hospital service evaluation in Sicily,
Appl. Soft Comput. J. (2015), http://dx.doi.org/10.1016/j.asoc.2015.12.010. (IN PRESS)

Soft Computing" 201. Springer Verlag, Heidelberg. Germany (2006) 247-274. I.S.B.N.: 3-540-33516-
1.

[45] Carrasco, R.A., Muñoz-Leiva, F., Sánchez-Fernández, J., Liébana-Cabanillas, F. J. A model for
the integration of e-financial services questionnaires with SERVQUAL scales under fuzzy linguistic
modeling, Expert Systems with Applications. 39(14) (2012) 11535-11547.

[46] Lee, G., Lin, H. Customer perceptions of e-service quality in online shopping, International
Journal of Retail and Distribution Management. 33 (2) (2005) 161-176.

[47] Mardani, A., Jusoh, A., Zavadskas, E.K. Fuzzy multiple criteria decision-making techniques
and applications - Two decades review from 1994 to 2014, Expert Systems with Applications. 42(8)
(2015) 4126-4148.

[48] Calabrese, A. Service productivity and service quality: A necessary trade-off?, Production
International Journal of Economics. 135(2) (2012) 800-812.

[49] Babakus, E. and Boller G.W. An Empirical Assessment of the SERVQUAL Scale, Journal of
Business Research. 24(3) (1992) 253-268.

[50] Wasserman, G. S. On how to prioritize design requirements during the QFD planning process,
IIE Transactions. 25(3) (1993) 59-65.

[51] Sgroi, F., Tudisca, S., Di Trapani, A.M. and Testa, R. Economic evaluation of aquaculture
investments under conditions of risk and uncertainty in the Mediterranean Sea, Am. J. Applied Sci..
11 (2014) 1727-1734.

[52] Sgroi, F., Tudisca, S., Di Trapani, A.M., Testa, R. and Squatrito, R. Efficacy and efficiency of
Italian energy policy: The case of PV systems in greenhouse farms, Energies. 7(6) (2014) 3985-4001.

[53] Certa, A., Enea, M., Galante, G. M., & La Fata, C. M. A Multistep Methodology for the
Evaluation of Human Resources Using the Evidence Theory, International Journal of Intelligent
Systems. 28(11) (2013) 1072–1088.

[54] Montes, R., Sánchez, A.M., Villar, P., Herrera. F. A web tool to support decision making in the
housing market using hesitant fuzzy linguistic term sets, Applied Soft Computing. (2015), In press.
doi:10.1016/j.asoc.2015.01.030.

25
Please cite this article in press as: T. Lupo, A fuzzy framework to evaluate service quality in
the healthcare industry: An empirical case of public hospital service evaluation in Sicily,
Appl. Soft Comput. J. (2015), http://dx.doi.org/10.1016/j.asoc.2015.12.010. (IN PRESS)

[55] Heradio, R., Cabrerizo, F.J., Fernandez-Amoros, D., Herrera, M., Herrera-Viedma, E. A Fuzzy
Linguistic Model to Evaluate the Quality of Library 2.0 Functionalities, International Journal of
Information Management, 33(4) (2013) 642-654.

[56] Cabrerizo, F.J., Martínez, M.A., López-Gijón, J., Esteban, B., Herrera-Viedma, E. A New Quality
Evaluation Model Generating Recommendations to Improve the Digital Services Provided by the
Academic Digital Libraries. 2011 International Fuzzy Systems Association World Congress and the
2011 Asian Fuzzy Systems Society (IFSA 2011), Surabaya and Bali Island (Indonesia), pp. RW_202_1-
RW_202_6, June.

[57] López-Herrera, A.G., Herrera-Viedma, E., Herrera, F. Applying Multi-objective Evolutionary

Algorithms to the Automatic Learning of Extended Boolean Queries in Fuzzy Ordinal Linguistic
Information Retrieval Systems, Fuzzy Sets and Systems. 160 (2009) 2192 – 2205.

[58] Herrera-Viedma, E., López-Herrera, A.G. A Model of Information Retrieval System with
Unbalanced Fuzzy Linguistic Information, International Journal Of Intelligent Systems. 22(11) (2007)
1197-1214.

[59] Akdag, H., Kalayci, T, Karagöz, S., Zülfikar, H., Giz, D. The evaluation of hospital service quality
by fuzzy MCDM, Applied Soft Computing. 23 (2014) 239-248.

[60] Büyüközkan, G., Çifçi, G. A combined fuzzy AHP and fuzzy TOPSIS based strategic analysis of
electronic service quality in healthcare industry, Expert Systems with Applications. 39(3) (2012)
2341-2354.

[61] Handayani, P.W., Hidayanto, A.N., Sandhyaduhita, P.I., Kasiyaha, Ayuningtyas, D. Strategic
hospital services quality analysis in Indonesia, Expert Systems with Applications Volume 42(6) (2015)
3067-3078.

[62] Büyüközkan, G., Çifçi, G., & Güleryüz, S. Strategic analysis of healthcare service quality using
fuzzy AHP methodology, Expert Systems with Applications. 38 (2011) 9407–9424.

[63] Lupo, T. Fuzzy ServPerf model combined with ELECTRE III to comparatively evaluate service
quality of international airports in Sicily, Journal of Air Transport Management. 42 (2015) 249-259.

[64] Yeh, C.H. and Kuo, Y.L. Evaluating passenger services of Asia-Pacific international airports,
Transportation Research Part E 39 (2003) 35–48.

26
Please cite this article in press as: T. Lupo, A fuzzy framework to evaluate service quality in
the healthcare industry: An empirical case of public hospital service evaluation in Sicily,
Appl. Soft Comput. J. (2015), http://dx.doi.org/10.1016/j.asoc.2015.12.010. (IN PRESS)

[65] Lupo, T. Strategic Analysis of Transit Service Quality Using Fuzzy AHP Methodology, European
Transport-Trasporti Europei. 53 (2013).

[66] Certa, A., Enea, M, and Hopps, F. A multi-criteria approach for the group assessment of an
academic course: A case study, Studies in Educational Evaluation. 44 (2015) 16–22.

[67] Klir G. J., Yuan B., Fuzzy sets and fuzzy logic, Theory and Applications, Prentice Hall P T R,
Upper Saddle River, New Jersey (1999).

[68] Nguyen, T.-L., Hsu, B.-M., Shu, M.-H. New quantitative approach based on index of optimism
for fuzzy judgment of online manufacturing process, Materials Research Innovations. 18 (SUPPL.1)
(2014): S2-S4.

[69] Chen, J.-F., Hsieh, H.-N., Do, Q.H. Evaluating teaching performance based on fuzzy AHP and
comprehensive evaluation approach, Applied Soft Computing. 28(2015) 100-108.

[70] Chen, M.F., Tzeng, G.H. and Tang, T. Fuzzy MCDM approach for evaluation of expatriate
assignments, Int. J. Information Technology & Decision Making. 4(2) (2005) 277–296.

[71] Vahdani, B., Mousavi, S.M., Ebrahimnejad, S. Soft computing-based preference selection
index method for human resource management, Journal of Intelligent and Fuzzy Systems. 26(1)
(2014) 393-403.

[72] Tsai, W.-H., Hsu, W., Lin, T.W. New financial service development for banks in Taiwan based
on customer needs and expectations, Service Industries Journal. 31(2) (2011) 215-236.

[73] Grigoroudis, E., Orfanoudaki, E., & Zopounidis, C. Strategic performance measurement in a
healthcare organisation: A multiple criteria approach based on balanced scorecard, Omega. 40 (1)
(2012) 104–119.

[74] Bakar, C., Akgün, H. S., & Al Assaf, A. L. The role of expectations in patients’ hospital
assessments: A Turkish university hospital example, International Journal of Health Care Quality
Assurance. 21(5) (2008) 503–516.

[75] Noor Hazilah, A.M. Practice follows structure: QM in Malaysian public hospitals, Measuring
Business Excellence. 13 (1) (2009) 23-33.

27
Please cite this article in press as: T. Lupo, A fuzzy framework to evaluate service quality in
the healthcare industry: An empirical case of public hospital service evaluation in Sicily,
Appl. Soft Comput. J. (2015), http://dx.doi.org/10.1016/j.asoc.2015.12.010. (IN PRESS)

[76] Pakdil, F., & Harwood, T. N. Patient satisfaction in a preoperative assessment clinic: An
analysis using SERVQUAL dimensions, Total Quality Management & Business Excellence. 16(1)
(2005) 15–30.

[77] Ramsaran-Fowdar, R. R. The relative importance of service dimensions in a healthcare

setting, International Journal of Health Care Quality Assurance. 21(1) (2008) 104–124.

[78] Hui, T.K., Wan, D., Ho, A. Tourists' satisfaction, recommendation and revisiting Singapore,
Tourism Management. 28(4) (2007) 965-975.

28
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the healthcare industry: An empirical case of public hospital service evaluation in Sicily,
Appl. Soft Comput. J. (2015), http://dx.doi.org/10.1016/j.asoc.2015.12.010. (IN PRESS)

Appendix A

Healthcare staff (C1) Very poor Poor Fair Good Very good

Ability of Doctors to understand patient needs □ □ □ □ □

Capacity to work as a team □ □ □ □ □
Staff reliability □ □ □ □ □
Staff availability □ □ □ □ □

Responsiveness (C2)

Swiftness of registration and admission procedures □ □ □ □ □

Administrative quality □ □ □ □ □
Waiting time for tests results □ □ □ □ □
Waiting time for medical records □ □ □ □ □

Relationships (C3)

Confidentiality between doctor and patient □ □ □ □ □

Confidentiality between all healthcare staff □ □ □ □ □
Cooperation and helpfulness of administrative staff □ □ □ □ □
Humanization of relationships □ □ □ □ □

Support services (C4)

Quality of food & beverage for patients □ □ □ □ □

Security within hospital □ □ □ □ □
Cleanliness of facilities and premises □ □ □ □ □

Table A.1: Questionnaire form to collect perceptions of healthcare service.

29
Please cite this article in press as: T. Lupo, A fuzzy framework to evaluate service quality in
the healthcare industry: An empirical case of public hospital service evaluation in Sicily,
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Please, mark in the questionnaire form reported below the letters related to your judgments:

How important is:

Healthcare staff Responsiveness Relationships

A B a b A B a b A B a b
Compared with

Support services = = =
C D c d C D c d C D c d
A B a b A B a b
Relationships = =
C D c d C D c d
A B a b
Responsiveness =
C D c d

How important is:

Ability of doctors to
Capacity to work as a team Staff reliability
understand patient needs

A B a b A B a b A B a b
Staff availability = = =
Compared with

C D c d C D c d C D c d
A B a b A B a b
Staff reliability = =
C D c d C D c d
Capacity to work as a A B a b
=
team C D c d

How important is:

Swiftness of registration and

Administrative quality Waiting time for tests results
admission procedures

Waiting time for A B a b A B a b A B a b

= = =
Compared with

medical records C D c d C D c d C D c d
Waiting time for tests A B a b A B a b
= =
results C D c d C D c d
A B a b
Administrative quality =
C D c d

How important is:

Confidentiality between doctor Confidentiality between all Cooperation and helpfulness of

and patient healthcare staff administrative staff

Humanization of A B a b A B a b A B a b
= = =
Relationships C D c d C D c d C D c d
Compared with

Cooperation and A B a b A B a b
helpfulness of = =
administrative staff C D c d C D c d
Confidentiality A B a b
between all =
healthcare staff C D c d

How important is:

Quality of food & beverage for

patients Security within hospital

Cleanliness of A B a b A B a b
= =
Compared with

facilities and premises C D c d C D c d

Security within A B a b
=
hospital C D c d

D: Extremely more important a: Moderately less important

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Please cite this article in press as: T. Lupo, A fuzzy framework to evaluate service quality in
the healthcare industry: An empirical case of public hospital service evaluation in Sicily,
Appl. Soft Comput. J. (2015), http://dx.doi.org/10.1016/j.asoc.2015.12.010. (IN PRESS)
C: Very strongly important b: Strongly less important
B: Strongly important c: Very strongly less important
A: Moderately important d: Extremely less important
=: Equally important

Table A.2: Questionnaire form to collect expectations of healthcare service.

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