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This research developed and empirically validated a

multidimensional hierarchical scale for measuring health

service quality and investigated the scale’s ability to

 predict important service outcomes, namely, service satis-  faction and behavioral intentions. Data were collected 

 from a qualitative study and three different field studies

of health care patients in two different health care contexts:

oncology clinics and a general medical practice. Service

quality was found to conform to the structure of the hier-

archical model in all three samples. The research identified 

nine subdimensions driving four primary dimensions, which

in turn were found to drive service quality perceptions.

The primary dimensions were interpersonal quality, tech-

nical quality, environment quality, and administrative

quality. The subdimensions were interaction, relationship,

outcome, expertise, atmosphere, tangibles, timeliness, oper-

ation, and support. The findings also support the hypothe-

sis that service quality has a significant impact on service

satisfaction and behavioral intentions and that service

quality mediates the relationship between the dimensions

and intentions.

 Keywords: scale development; service quality; health

care; satisfaction; intentions

Health care is one of the fastest growing sectors in

the service economy (Andaleeb 2001). This growth is due

in part to an aging population, mounting competitive pres-

sures (Abramowitz, Coté, and Berry 1987), increasing

consumerism, and emerging treatments and technolo-

gies (Ludwig-Beymer et al. 1993; O’Connor, Trinh, and

Shewchuk 2000). Quality in health care is currently at

the forefront of professional, political, and managerial

attention, primarily because it is being seen as a means for

achieving increased patronage, competitive advantage,

and long-term profitability (Brown and Swartz 1989;

Headley and Miller 1993) and ultimately as an approach

to achieving better health outcomes for consumers (Dagger and Sweeney 2006; Marshall, Hays, and Mazel

1996; O’Connor, Shewchuk, and Carney 1994). Against

this background, service quality has become an important

corporate strategy for health care organizations.

Journal of Service Research, Volume 10, No. 2, November 2007 123-142 DOI: 10.1177/1094670507309594 © 2007 Sage Publications

A Hierarchical Model of Health

Service Quality Scale Development and Investigation of an Integrated Model

Tracey S. Dagger The University of Queensland 

Jillian C. SweeneyThe University of Western Australia

Lester W. Johnson The University of Melbourne

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The quality of medical care has traditionally been

measured using objective criteria such as mortality and

morbidity. Although these indicators are essential to assess-

ing clinical quality, softer, more subjective assessments

are often overlooked. In reality, the health care sector has

been slow to move beyond a supply-side approach to

quality assessment. However, as the industry structure changes, the role patients play in defining what quality

means has become a critical competitive consideration

(Donabedian 1992; Jun, Peterson, and Zsidisin 1998;

O’Connor, Trinh, and Shewchuk 2000). As a consequence,

service providers are struggling to implement meaningful

customer-oriented quality assessment measures (Clemens,

Ozanne, and Laurensen 2001; Murfin, Schlegelmilch, and

Diamantopoulos 1995). Because few reliable and valid

instruments are available, many service providers are imple-

menting measures that are not aligned to the complexities

of the health care setting (Draper and Hill 1996).

The purpose of this article is to describe the develop-

ment and refinement of a multidimensional, hierarchal

scale for measuring health service quality that is appro-

priate to our research contexts, as well as to describe an

integrated model that includes health consumer outcomes.

Specifically, our key objectives were (a) to provide a

conceptualization of the health care service quality con-

struct that the captures the domain of the construct, (b) to

systematically develop a scale to measure health service

quality from the customers’ perspective, (c) to assess the

psychometric properties of the scale, and (d) to examine

the effects of this conceptualization of health service

quality on satisfaction and behavioral intentions.

PERCEIVED SERVICE QUALITY

Although a considerable amount of research has been

published in the area of service quality perceptions, much

of this research has focused on the development of generic

service quality models (e.g., Brady and Cronin 2001;

Parasuraman, Zeithaml, and Berry 1985). Relatively few

studies, in comparison, have focused on the development

of context-specific service quality models, despite indica-

tions that service quality evaluations are likely to be

context dependent (Babakus and Boller 1992; Carman

1990; Dabholkar, Thorpe, and Rentz 1996). Specifically, research has not directly examined how customers assess

health service quality. We discuss in the following sections

key issues relevant to the development of our health service

quality scale.

Measuring Service Quality Perceptions

Service quality perceptions are generally defined as a

consumer’s judgment of, or impression about, an entity’s

overall excellence or superiority (Bitner and Hubbert

1994; Boulding et al. 1993; Cronin and Taylor 1992;

Parasuraman, Zeithaml, and Berry 1985, 1988). This judg-

ment is often described in terms of the discrepancy between

consumers’ expectations of service and actual service

performance. Grönroos (1984), for example, emphasized

the use of expectations as a standard of reference against which performance can be judged, and Parasuraman,

Zeithaml, and Berry (1985) put forward service quality as

the gap between expected and perceived service. Although

commonly applied, this approach has been the subject

of substantial criticism and debate. Babakus and Boller

(1992), for example, suggested that the measurement of 

expectations adds limited information beyond what is

gained from measuring service perceptions alone.

Similarly, Dabholkar, Shepherd, and Thorpe (2000) found

that perceptions performed better than difference measures

when comparing these approaches, and both Cronin and

Taylor (1992) and Brady and Cronin (2001) focused on

performance-only measures (i.e., perceptions rather than

expectations) when modeling service quality perceptions.

Although the conceptual definition of service quality

is often specified at an abstract level, most commonly as

a second-order factor (Grönroos 1984; Parasuraman,

Zeithaml, and Berry 1988; Rust and Oliver 1994), service

quality has recently been described as a third-order factor

(Brady and Cronin 2001; Dabholkar, Thorpe, and Rentz

1996). This structure suggests that service quality

comprises several primary dimensions, which in turn share

a common theme represented by the higher order global

perceived service quality construct. Moreover, these

dimensions have subdimensions that combine relatedattributes into subgroups. Perceptions of overall service

quality are therefore represented as a third-order factor to

the subdimensions. Modeling service quality in this way

recognizes that the evaluation of service quality may be

more complex than previously conceptualized.

The complexity of service quality evaluations is also

evident in the many failed attempts to replicate the dimen-

sional structure of service quality perceptions. The widely

applied SERVQUAL scale (Parasuraman, Zeithaml, and

Berry 1985, 1988), for example, has been criticized insofar

as its five dimensions, namely, reliability, empathy, tangi-

bles, responsiveness, and assurance, are difficult to replicate

across diverse service contexts (Buttle 1996). Researchers applying the SERVQUAL scale have, for example, identi-

fied a range of factors, including 3 factors in an automotive

servicing context (Bouman and van der Wiele 1992),

4 factors in the retail clothing sector (Gagliano and Hathcote

1994), and 3 factors in the context of MBA students’ ser-

vice quality perceptions (McDougall and Levesque

1994). Furthermore, Brown, Churchill, and Peter (1993)

found service quality to be unidimensional when applying

the five-dimension SERVQUAL scale. The application of 

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