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ACKNOWLEDGEMENTS

First and foremost I would like to thank Allah SWT for making this journey possible and blessing me with family, friends and colleagues who have helped me in their different ways in completing this thesis. My deepest and sincerest thanks to my distinguish supervisor, Prof. Dr. Razli Che Razak, UMK’s Registrar (January 2012- January 2015), who invaluable advice and critical evaluation over numerous meetings regarding this thesis is greatly appreciated. Thanks for his constant and abundant resource for guidance, support, enthusiasm and learning. Your deep and insightful views over our numerous discussions have definitely helped to shape this thesis.

I must also thank the academicians and practitioners who at various stages were involved in discussing and commenting on this research. My special thanks and sincere gratitude to A/Prof.Dr.Mohammad Ismail, Prof.Dr.Murali Sambasivan, A/Prof.Dr.

Nizar Abdul Jalil (MD), A/Prof.Dr.Mohammad Iqbal Omar (MD), Dr.Abdul Aziz Abdullah, Prof.Dr.Harshita Aini Haroon, Prof.Dr.Abdul Hamid Adom, Prof.Dr.Mohd.Yusoff Mashor, Prof.Dr.Sazali Yaacob, Dr. Abd. Rahim Romle, Sharmini Abdullah, Nur Syuhadah Kamaruddin, Dr. Syed Zulkarnain Syed Idrus, Hafizah Abdul Rahim, and others who always support me with deepest motivation ever after to complete this study. A special thanks to Prof. T.Ramayah for his valuable comments and suggestions especially with regard to the research findings.

Thank you also for Ministry of Health (MOH) Malaysia, in specific, National Medical Research Register (NMRR), Institute for Health Behavioural Research (IHBR) and Medical Research Ethics Commitee (MREC) for the approval letter in conducting this research. Thank you for Ministry of Higher Education (MOHE), Malaysia for giving me the great opportunity till the end to finish this study.

Last but not least, my very special heartfelt thanks are reserved for my beloved charming and tremendous husband, Ruslizam Daud (PhD) and my greatest children Afifah An-Nur (2000), Afif Al-Ikhlas (2003), Afif Luqman (2007) and Afifah As-Syura (2008) whose prayers and support helped to encourage me and make things just that bit easier. Thanks for all your sacrifices and patience especially during the dreadful moments. Thanks to stood with me with your full understanding and constant encouragement during the study. I wish to express my sincere gratitude to my caring and loving mother Hjh.Che Esah Hj.Nor and my great father Hj.Nordin Hj.Ismail and my siblings Hjh.Norshazwani, Mohd Shahril, Mohd Hafiz, and Nailul Amal for their golden advice whenever I needed them. I am also deeply indebted to my late mother and late father-in-law and families for their continual supports and assistance.

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iv

TABLE OF CONTENTS

PAGE

THESIS DECLARATION ii

ACKNOWLEDGEMENT iii

TABLE OF CONTENTS iv

LIST OF TABLES xi

LIST OF FIGURES xx

LIST OF ABBREVIATIONS xxiii

DEFINITION OF TERMS xxvi

ABSTRACT xxviii

ABSTRAK xxix

CHAPTER I INTRODUCTION 1

1.1 Chapter Overview 1

1.2 Motivation of the Study 1

1.2.1 Non-linearity Behaviour of Patient Service Fulfilment 2 1.2.2 Local Healthcare Service Provider Constraints and Limitations 5

1.2.3 Rising Complaints Frequency 8

1.2.4 Levels of Compliments and Complaints 11

1.3 Problem Statements 12

1.4 Research Questions 16

1.5 Research Objectives 17

1.6 Significance of the Study 18

1.7 Research Scope 20

1.8 Thesis Organization 21

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CHAPTER II LITERATURE REVIEW 22

2.1 Introduction 22

2.2 Malaysian Healthcare System 22

2.2.1 Public Healthcare Admission 24

2.2.2 Healthcare Capacity and Constraint 26

2.3 Complaints and Compliments in Healthcare Service 29 2.3.1 Complaints through Public Complaints Bureau (PCB) 31 2.3.2 Complaints through Ministry of Health, Malaysia 33 2.3.3 Complaint Issues in Malaysia Healthcare Service Delivery 37 2.3.4 Complaint based on Healthcare Service Delivery

Department

42

2.4 Non-Linear Relationship in Service Satisfaction Model 44

2.5 Quality Function Deployment 49

2.5.1 QFD definition 49

2.5.2 History of QFD 52

2.5.3 QFD General Framework 53

2.5.4 General QFD Research Classification 56

2.5.5 QFD Application in Product Development 59

2.5.6 QFD Application in Services 62

2.5.7 Integrated QFD in New Service Development 63

2.5.8 QFD Application in Healthcare Services 64

2.6 Patient Satisfaction Model in Healthcare 69

2.6.1 Integrated Patient Satisfaction Model in Healthcare 74 2.6.2 QFD in Services and Healthcare Services 79

2.6.3 The Development of Kano-QFD Model 83

2.6.4 Kano-QFD in Healthcare Service 87

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vi

2.7 Patient Dissatisfaction Model in Healthcare 88

2.8 Kano-QFD Non-Linear Methodological Assumption 90 2.9 Proposed Concept of Kano-QFD Service Satisfaction Model 94 2.9.1 Conventional Kano Questionnaire Design 97

2.9.2 Kano-Service Satisfaction (Kano-SS) 99

2.9.3 Kano-Services Satisfaction Evaluation Table Development 106

2.10 Summary 114

CHAPTER III RESEARCH METHODOLOGY 115

3.1 Introduction 115

3.2 Research Design 115

3.3 Development of Kano-QFD Model Integration 117

3.3.1 Kano-QFD Phase I 117

3.3.2 Kano-QFD Phase II 121

3.3.3 Kano-QFD Phase III 122

3.4 Sampling Design 124

3.4.1 Population Definition 125

3.4.2 Sampling Frame and Respondents 127

3.4.3 Sampling Technique 128

3.4.4 Sample Size 129

3.5 Research Instrument Design 133

3.5.1 Questionnaire Design and Development of Kano-SS Questionnaire

133

3.5.2 Service Variable Measurement 137

3.5.3 Pilot Survey: Phase 1 138

3.5.4 Pilot Survey Reliability Testing 140

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3.5.5 Service Variable Construct Validity by Exploratory Factor Analysis (EFA)

142

3.5.6 Kano-QFD Instrument 143

3.6 Data Analysis: Phase 1, 2 and 3 147

3.6.1 Berger’s Coefficient and Kano Attribute Category 149

3.6.2 Kano’s Statistical Significant 149

3.6.3 Patient’s Attributes into QFD (Step 1) 151 3.6.4 Service Compliment and Service Complaint Indexes (Step 2) 152 3.6.5 Defining the Healthcare Service Attributes (Step 3) 153 3.6.6 Relationship Matrix between Patient’s Attributes and Service

Attributes (Step 4)

154 3.6.7 Correlation Matrix of Service Attributes (Step 5) 154 3.6.8 Calculation of Prioritized Patient Attributes by Compliment

and Complaint Indexes

155

3.7 Summary 156

CHAPTER IV RESULTS AND DISCUSSION 157

4.1 Introduction 157

4.2 Profile of Respondents 157

4.3 Instrument Reliability 160

4.4 Construct Validity using Confirmatory Factor Analysis (CFA) 161 4.5 Non-linear Kano Quality Attributes of Phase I 163

4.5.1 Data Analysis Berger’s Mass Coefficient and Kano Attribute Category

163 4.5.2 Data Analysis Kano’s Statistical Significant 189 4.5.3 Data Analysis Kano Quality Attributes Grid Mapping 201 4.5.4 Data Analysis Service Complaint Index and Service 215

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viii Compliments Index

4.5.5 Data Analysis of Service Gap and Service Effective 225 4.6 Non-linear Kano Quality Attributes Analysis of Phase 2 and 3 248

4.6.1 Kano-QFD HOQ for Doctor Care 250

4.6.2 Kano-QFD HOQ for Nurse Care 255

4.6.3 Kano-QFD HOQ for Surgery Care 259

4.6.4 Kano-QFD HOQ for Doctor Attitude and Personality 263 4.6.5 Kano-QFD HOQ for Nurse Attitude and Personality 266

4.6.6 Kano-QFD HOQ for Appointment 270

4.6.7 Kano-QFD HOQ for Medical Communication 273

4.6.8 Kano-QFD HOQ for Admission 278

4.6.9 Kano-QFD HOQ for Discharge 281

4.6.10 Kano-QFD HOQ for Mortuary 285

4.6.11 Summary of Kano-QFD HOQ and Service Prioritization 287 4.7 Comparison of Kano-QFD Satisfaction Model with Other Models 291

CHAPTER V CONCLUSION AND RECOMMENDATIONS 300

5.1 Introduction 300

5.2 Addressing the Research Questions 301

5.3 Contribution of Present Kano-QFD Satisfaction Model and Comparison 314

5.3.1 Theoretical Contribution 314

5.3.2 Methodological Contribution 318

5.3.3 Managerial Contribution 320

5.4 Limitations and Recommendations 321

5.4.1 Limitations 321

5.4.2 Future Research 321

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REFERENCES 324

APPENDIX - A 366

A.1 Letter from Director General of Health Malaysia 366 A.2 Institute for Health Behavioural Research (IHBR) and National

Institute of Health (NIH) Approval for Research

A.3 Official Approval Letter from Medical Research & Ethics Committee (MREC), MOH, Malaysia

368 369 A.4 National Medical Research Register (NMRR) High Level Workflow 370

APPENDIX - B Kano-QFD Questionnaire 371

APPENDIX - C Exploratory Factor Analysis (EFA) for Pilot Survey 386

C.1 Measurement model for Doctor Care 386

C.2 Measurement model for Nurse Care 387

C.3 Measurement model for Surgery Care 388

C.4 Measurement model for Doctor Attitude and Personality 389 C.5 Measurement model for Nurse Attitude and Personality 390

C.6 Measurement model for Appointment 391

C.7 Measurement model for Medical Communication 392

C.8 Measurement model for Admission 393

C.9 Measurement model for Discharge 394

C.10 Measurement model for Mortuary 395

Table C.1 Summary of Exploratory Factor Analysis (EFA) 396 APPENDIX - D Reliability Test Results for Pilot Survey 397 Table D.1 Cronbach’s α for Kano-Q and Kano-SS (N = 50) 412

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x

APPENDIX - E Confirmatory Factor Analysis (CFA) for Data Analysis 413

E.1 Measurement model for Doctor Care 413

E.2 Measurement model for Nurse Care 414

E.3 Measurement model for Surgery Care 415

E.4 Measurement model for Doctor Attitude and Personality 416 E.5 Measurement model for Nurse Attitude and Personality 417

E.6 Measurement model for Appointment 418

E.7 Measurement model for Medical Communication 419

E.8 Measurement model for Admission 420

E.9 Measurement model for Discharge 421

E.10 Measurement model for Mortuary 422

Table E.1 Summary of Confirmatory Factor Analysis (CFA) 422 APPENDIX - F Reliability Test Results for Data Analysis 423 Table F.1 Cronbach’s α for Kano-Q and Kano-SS (N=300) 438

APPENDIX - G Demographic Data 439

APPENDIX - H QFD House of Quality for Data Analysis

H.1 QFD HOQ of Doctor Care 442

H.2 QFD HOQ of Nurse Care 443

H.3 QFD HOQ of Surgery Care 444

H.4 QFD HOQ of Doctor Attitude and Personality 445

H.5 QFD HOQ of Nurse Attitude and Personality 446

H.6 QFD HOQ of Appointment 447

H.7 QFD HOQ of Medical Communication 448

H.8 QFD HOQ of Admission 449

H.9 QFD HOQ of Discharge 450

H.10 QFD HOQ of Mortuary 451

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LIST OF TABLES

NO. PAGE

1.1 Development of non-linear satisfaction model in service due to inaccuracy and deficiency of linear relationship between service delivery and customer expectation

4

1.2 Summary of healthcare system for 2011-2015 Country Health Plan 6 1.3 Area of concern that affects the healthcare service delivery 6 1.4 Public Complaint Report and Total on Malaysian Healthcare

Services which adapted from Public Complaints Bureau (PCB) (i- Aduan) through MESRA Programme, Mobile Complaints Counter (MCC) and Integrated Mobile Complaints Counter (IMCC)

10

2.1 Number of inpatient beds, bed occupancy rate (BOR) and total admission to MOH hospitals and institutions, 2007-2011

26

2.2 Summary of healthcare capacity and constraints 28

2.3 Category of complaints in Year 2008 35

2.4 Summary of service delivery variables in healthcare 40

2.5 Kano evaluation (KE) table 49

2.6 QFD penetration 50

2.7 QFD advantages 51

2.8 QFD disadvantages 51

2.9 QFD research classification 56

2.10 QFD top 10 articles most published 58

2.11 QFD research classification by publications 59

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2.12 Conventional QFD for new product development 60

2.13 QFD integration for new product development 61

2.14 QFD research classification in product development 63

2.15 Conceptual requirements 64

2.16 Operational requirements 65

2.17 Selected operational requirements for design process 65

2.18 Important parameters for new service design 66

2.19 QFD advantages in healthcare service 67

2.20 QFD drawbacks in healthcare service 67

2.21 QFD possible problem arise in implementations 67

2.22 Stakeholders target for hospitals 68

2.23 QFD research classification in services 68

2.24 Respondents number for satisfaction model in healthcare 71 2.25 Summary of satisfaction measurements in healthcare 73 2.26 Summary of previous study on satisfaction model in healthcare 78

2.27 QFD basic for new service development 80

2.28 QFD extension for new services development 81

2.29 Kano-QFD research model and objectives (1998-2011) 85

2.30 Expression of conventional Kano Answer 97

2.31 Seven point service satisfaction scale 101

2.32 Assumption of CIT and ACC 103

2.33 New Kano-SS equivalence scale assumptions 104

2.34 Importance scale and satisfaction scale reference 107

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2.35 Refined KQA by Yang (2005) 108

2.36 Refined KQA by Shahin & Nekuie (2011) 108

2.37 Comparison of satisfaction impact k 111

2.38 Proposed satisfaction impact coefficient μ 112

2.39 Refined Kano evaluation (KE) table (Kano et al., 1984) with service satisfaction scale and proposed satisfaction impact coefficient μ

112

3.1 Population description 125

3.2 Survey population 126

3.3 Sample size of the survey (N=300) 130

3.4 Sampling size summary sources of service variable 132 3.5 Sub-variable of personal details, and visiting history 135 3.6 Main sources of service attributes based on complaints local

healthcare, Malaysia Public Complaints Bureau, Ministry of Health and published satisfaction model

138

3.7 Cronbach’s alpha for pilot survey Kano-Q and Kano-SS (N = 50)

141

3.8 Summary of Exploratory Factor Analysis (EFA) 143

3.9 Summary of frequency agreement for functional question 144 3.10 Summary of frequency agreement for dysfunctional question 146 3.11 Main sources of service attributes based on complaints local

healthcare, Malaysia Public Complaints Bureau, Ministry of Health

155

4.1 Demographic profile of respondents (N=300) 158

4.2 Cronbach’s α for Kano-Q and Kano-SS (N=300) 160

4.3 Summary of Confirmatory Factor Analysis (CFA) results 162

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xiv

4.4 Kano-SS KQA for Doctor Care 164

4.5 Kano-SS KQA for Nurse Care 167

4.6 Kano-SS KQA for Surgery Care 170

4.7 Kano-SS KQA for Doctor Attitude and Personality 173 4.8 Kano-SS KQA for Nurse Attitude and Personality 176

4.9 Kano-SS KQA for Appointments 177

4.10 Kano-SS KQA for Medical Communication 179

4.11 Kano-SS KQA for Admission 182

4.12 Kano-SS KQA for Discharge 184

4.13 Kano-SS KQA for Mortuary 185

4.14 Summary of overall service index for mass survey 187

4.15 Summary of KQA for data analysis (N = 300) 188

4.16 KQA Kano-SS statistical significant for Doctor Care 191 4.17 KQA Kano-SS statistical significant for Nurse Care 191 4.18 KQA Kano-SS statistical significant for Surgery Care 192 4.19 KQA Kano-SS statistical significant for Doctor Attitude and

Personality

193

4.20 KQA Kano-SS statistical significant for Nurse Attitude and Personality

194

4.21 KQA Kano-SS statistical significant for Appointments 195 4.22 KQA Kano-SS statistical significant for Medical Communication 196 4.23 KQA Kano-SS statistical significant for Admission 198 4.24 KQA Kano-SS statistical significant for Discharge 199 4.25 KQA Kano-SS statistical significant for Mortuary 200

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4.26 Summary of KQA significant for data analysis (N = 300) 200

4.27 Summary of KQA for data analysis (N=300) 214

4.28 Doctor Care SCi and SCa Index 216

4.29 Nurse Care SCi and SCa Index 217

4.30 Surgery Care SCi and SCa Index 218

4.31 Doctor Attitude and Personality SCi and SCa Index 219 4.32 Nurse Attitude and Personality SCi and SCa Index 220

4.33 Appointment SCi and SCa Index 220

4.34 Medical Communication SCi and SCa Index 221

4.35 Admission SCi and SCa Index 222

4.36 Discharge SCi and SCa Index 223

4.37 Mortuary SCi and SCa Index 223

4.38 Summary of KQA, SCi and SCa 224

4.39 Service Gap and Service Effective for Doctor Care 226 4.40 Service Gap and Service Effective for Nurse Care 228 4.41 Service Gap and Service Effective for Surgery Care 231 4.42 Service Gap and Service Effective for Doctor Attitude and

Personality

233

4.43 Service Gap and Service Effective for Nurse Attitude and Personality

235

4.44 Service Gap and Service Effective for Appointment 237 4.45 Service Gap and Service Effective for Medical Communication 240 4.46 Service Gap and Service Effective for Admission 243 4.47 Service Gap and Service Effective for Discharge 245

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xvi

4.48 Service Gap and Service Effective for Mortuary 247 4.49

Prioritized patient attributes ( ) index by compliments for Doctor Care

251

4.50

Prioritized patient attributes ( ) index by complaints for Doctor Care and minimum improvement required

251

4.51

Prioritized service attributes ( ) index by compliments for Doctor Care

253

4.52

Prioritized service attributes ( ) index by complaints for Doctor Care

253

4.53

Prioritized patient attributes ( ) index by compliments for Nurse Care

256

4.54

Prioritized patient attributes ( ) index by complaints for Nurse Care and minimum improvement required

256

4.55

Prioritized service attributes ( ) index by compliments for Nurse Care

258

4.56

Prioritized service attributes ( ) index by complaints for Nurse Care

259

4.57

Prioritized patient attributes ( ) index by compliments for Surgery Care

260

4.58

Prioritized patient attributes ( ) index by complaints for Surgery Care and minimum improvement required

261

4.59

Prioritized service attributes ( ) index by compliments for Surgery Care

261

4.60

Prioritized service attributes ( ) index by complaints for Surgery Care

262

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4.61

Prioritized patient attributes ( ) index by compliments for Doctor Attitude and Personality

263

4.62

Prioritized patient attributes ( ) index by complaints for Doctor Attitude and Personality and minimum improvement required

264

4.63

Prioritized service attributes ( ) index by compliments for Doctor Attitude and Personality

265

4.64

Prioritized service attributes ( ) index by complaints for Doctor Attitude and Personality

266

4.65

Prioritized patient attributes ( ) index by compliments for Nurse Attitude and Personality

267

4.66

Prioritized patient attributes ( ) index by complaints for Nurse Attitude and Personality and minimum improvement required

267

4.67

Prioritized service attributes ( ) index by compliments for Nurse Attitude and Personality

268

4.68

Prioritized service attributes ( ) index by complaints for Nurse Attitude and Personality

269

4.69

Prioritized patient attributes ( ) index by compliments for Appointment

271

4.70

Prioritized patient attributes ( ) index by complaints for Appointment and minimum improvement required

271

4.71

Prioritized service attributes ( ) index by compliments for Appointment

272

4.72

Prioritized service attributes ( ) index by complaints for Appointment

273

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xviii 4.73

Prioritized patient attributes ( ) index by compliments for Medical Communication

274

4.74

Prioritized patient attributes ( ) index by complaints for Medical Communication and minimum improvement required

276

4.75

Prioritized service attributes ( ) index by compliments for Medical Communication

277

4.76

Prioritized service attributes ( ) index by complaints for Medical Communication

278

4.77

Prioritized patient attributes ( ) index by compliments for Admission

279

4.78

Prioritized patient attributes ( ) index by complaints for Admission and minimum improvement required

279

4.79

Prioritized service attributes ( ) index by compliments for Admission

280

4.80

Prioritized service attributes ( ) index by complaints for Admission

281

4.81

Prioritized patient attributes ( ) index by compliments for Discharge

282

4.82

Prioritized patient attributes ( ) index by complaints for Discharge and minimum improvement required

283

4.83

Prioritized service attributes ( ) index by compliments for Discharge

284

4.84

Prioritized service attributes ( ) index by complaints for Discharge

284

4.85 Prioritized patient attributes ( ) index by compliments for 285

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Mortuary 4.86

Prioritized patient attributes ( ) index by complaints for Mortuary and minimum improvement required

286

4.87

Prioritized service attributes ( ) index by compliments for Mortuary

286

4.88

Prioritized service attributes ( ) index by complaints for Mortuary

287

4.89 Summary of prioritized service attributes categories in ranking 290 4.90 Comparison of non-linear satisfation model using Kano and Kano-

QFD based on Kano Quality Attribute satisfaction impact

292

4.91 Service gap comparison of present non-linear satisfaction model with other models for Tangibility and Reliability

294

4.92 Service gap comparison of present non-linear satisfaction model with other models for Responsiveness

296

4.93 Service gap comparison of present non-linear satisfaction model with other models for Assurance

297

4.94 Service gap comparison of present non-linear satisfaction model with other models for Empathy and Accessibility

298

5.1 Average of service satisfaction index 302

5.2 Summary of , , , and 304 5.3 Summary of satisfaction gap and service effective 306 5.4 Summary of prioritized patient attributes and service attributes based

on complaint and compliment (Top Rank)

310

5.5 Summary of modified Kano-QFD Model with statistical approach 312

5.6 Summary of effective service attribute 313

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xx

LIST OF FIGURES

NO. PAGE

1.1 Complaints frequency received by public hospital from year 2000 – 2014 based on Malaysian Public Complaints Bureau

9

2.1 Complaints frequency received by public hospital from year 2000 – 2014 based on government, state and public health sector

32

2.2 Complaints frequency received by public hospital from year 2005 – 2008 by Ministry of Health

33

2.3 Complaints fraction received by public hospital for 2008 34 2.4 Complaints frequency resources in public hospital (2006 – 2008) 36 2.5 Complaint frequency resources based on health institution, clinic and

hospital from year 2006 - 2008

37

2.6 Distribution of complaints by department 42

2.7 Classification of complaints 44

2.8 Kano’s model of customer satisfaction 46

2.9 Example of functional and dysfunctional form in Kano questionnaire 48

2.10 Basic components of QFD or HOQ 54

2.11 Eight steps of QFD diagram for mechanical design process 55

2.12 Nine steps QFD model 55

2.13 Summary of general Kano-QFD integration model 84

2.14 QFD research problem and issues 93

2.15 Preliminary concept of Kano-QFD integration 96

3.1 Research design 116

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3.2 Kano-QFD integration framework 118

3.3 Questionnaire design in Phase 1 134

3.4 Sample of Kano-Q (DCK 1-2) questions 136

3.5 Sample of Kano-SS (DCQ3-11) question 137

3.6 Phase I Kano-QFD Step 1 flow chart for pilot survey 139

3.7 Data analysis framework of phase 1, 2 and 3 148

3.8 Kano-QFD Step 1 and 2 152

3.9 The flow of information from Kano-QFD Step 1 to Step 2 153

3.10 Service attributes category and elements 156

4.1 Service satisfaction and service dissatisfaction index for Doctor Care 166 4.2 Service satisfaction and service dissatisfaction index for Nurse Care 169 4.3 Service satisfaction and service dissatisfaction index for Surgery Care 172 4.4 Service satisfaction and service dissatisfaction index for Doctor

Attitude and Personality

174

4.5 Service satisfaction and service dissatisfaction index for Nurse Attitude and Personality

175

4.6 Service satisfaction and service dissatisfaction index for Appointment 178 4.7 Service satisfaction and service dissatisfaction index for Medical

Communication

181

4.8 Service satisfaction and service dissatisfaction index for Admission 183 4.9 Service satisfaction and service dissatisfaction index for Discharge 185 4.10 Service satisfaction and service dissatisfaction index for Mortuary 186

4.11 Grid mapping for Kano-SS Doctor Care 203

4.12 Grid mapping for Kano-SS Nurse Care 204

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4.13 Grid mapping for Kano-SS Surgery Care 205 4.14 Grid mapping for Kano-SS Doctor Attitude and Personality 207 4.15 Grid mapping for Kano-SS Nurse Attitude and Personality 208

4.16 Grid mapping for Kano-SS Appointment 209

4.17 Grid mapping for Kano-SS Medical Communication 210

4.18 Grid mapping for Kano-SS Admission 211

4.19 Grid mapping for Kano-SS Discharge 212

4.20 Grid mapping for Kano-SS Mortuary 213

4.21 Chart of service gap and service effective for Doctor Care 227 4.22 Chart of service gap and service effective for Nurse Care 229 4.23 Chart of service gap and service effective for Surgery Care 232 4.24 Chart of service gap and service effective for Doctor Attitude and

Personality

234

4.25 Chart of service gap and service effective for Nurse Attitude and Personality

236

4.26 Chart of service gap and service effective for Appointments 238 4.27 Chart of service gap and service effective for Medical Communication 241 4.28 Chart of service gap and service effective for Admission 244 4.29 Chart of service gap and service effective for Discharge 246 4.30 Chart of service gap and service effective for Mortuary 247 5.1 Mapping of satisfaction and dissatisfaction coefficient and service

satisfaction scale

303

5.2 Relationship of satisfaction gap and service effective with Kano Model

307

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LIST OF ABBREVIATIONS

A Attractive Attribute

ACC Analysis of Complaints and Compliments

ADMK Admission Kano

ADMQ Admission Question

AHP Analytical Hierarchical Process

ALOS Average Length of Stay for Acute Care ANN Artificial Neural Network

ANP Analytical Network Process

APDK Attitude and Personality Doctor Kano APDQ Attitude and Personality Doctor Question APNK Attitude and Personality Nurse Kano APNQ Attitude and Personality Nurse Question APPK Appointments Kano

APPQ Appointments Question

BOR Bed Occupancy Rate

CA Customer Attribute

CD Customer Dissatisfaction CFA Confirmatory Factor Analysis CIT Critical Incident Technique CKA Customer Kano Attribute

CKAD Customer Kano Attribute Dysfunctional CKAF Customer Kano Attribute Functional CKAS Conventional Kano Answer Scheme CKQ Conventional Kano’s Questionnaire CPD Complainant Personal Details CQI Continuous Quality Improvement CS Customer Satisfaction

CVI Clinical Visit Information DC Degree of Confidence

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xxiv DCQ Doctor Care Question

DISCK Discharge Kano DISCQ Discharge Question

DP Desired Precision

ED Extent of Dissatisfaction ES Extent of Satisfaction

FMEA Failure Mode Effect Analysis

HC Healthcare Customer

HSP Healthcare Service Provider HSV Healthcare Service Variables

HOQ House of Quality

I Indifferent Attribute

IMCC Integrated Mobile Complaints Counter IOP Inpatients and Outpatients

KAS Kano Answers Scale

KE Kano Evaluation

KEA Kano Evaluation Answer

KGM Kano Grid Mapping

KQ Kano Question

KQA Kano Quality Attribute

KSAS Kano Satisfaction Answer Scheme KSS Kano Statistical Significant

M Must be Attribute

MCC Mobile Complaints Counter MDCOMK Medical Communication Kano MDCOMQ Medical Communication Question MODM Multi Objective Decision Making MOH Ministry of Health

MORTK Mortuary Kano MORTQ Mortuary Question

O One dimensional Attribute

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PA Patient Attribute

PACap Prioritized Patient Attributes Index by Complaints PACip Prioritized Patient Attributes Index by Compliments PCA Patient Care Attributes

PCB Public Complaints Bureau PD Patient Dissatisfaction

Pi Performance Index

PS Patient Satisfaction

PSA Prioritized Service Attribute QA Quality Attribute

QBD Quality Benchmarking Deployment QCC Quality Control Circle

QFD Quality Function Deployment QI Quality Improvement Index

R Reversed Attribute

SACap Prioritized Service Attributes Index by Complaints SACip Prioritized Service Attributes Index by Compliments SCa Service Complaints

SCi Service Compliments

SCK Surgery Care Kano

SCQ Surgery Care Question SD Service Dissatisfaction

SDDM Service Design Decision Making SS Service Satisfaction

SV Service Variables

TQM Total Quality Management

TV True Variability

UQ Ultimate Question

USDF Uncertainty Service Delivery Feedback VOP Voice of Patient

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DEFINITION OF TERMS

Attractive Attribute (A) These attributes provide satisfaction when achieved fully, but do not cause dissatisfaction when not fulfilled. These are attributes that are not normally expected. Since these types of attributes of quality unexpectedly delight customers, they are often unspoken. It can be neither explicitly expressed nor expected by the customer and by fulfilling these requirements, the more customer satisfaction can be achieved.

Average Length of Stay for Acute Care (ALOS) Bed Occupancy Rate (BOR)

Average length of stay is computed by dividing the number of days stayed (from the date of admission in an in-patient institution) by the number of discharges (including deaths) during the year.

The total beds available in the hospital by number of days in the year it would be available

Customer Attribute Customer attributes includes the way the business is working and the way the customers are buying the products and the regular occasional shoppers form family status- like children's and adults.

Customer Dissatisfaction Confirmatory Factor Analysis

Critical Incident Technique

Continuous Quality Improvement

One with the ability, means and desire to buy that does not for a reason of dissatisfaction

Is a special form of factor analysis, most commonly used in social research. It is used to test whether measures of a construct are consistent with a researcher's understanding of the nature of that construct (or factor). As such, the objective of confirmatory factor analysis is to test whether the data fit a hypothesized measurement model. This hypothesized model is based on theory and/or previous analytic research.

A set of procedures used for collecting direct observations of human behaviour that have critical significance and meet methodically defined criteria. These observations are then kept track of as incidents, which are then used to solve practical problems and develop broad psychological principles. A critical incident can be described either as one that makes a significant contribution positively or negatively to an activity or phenomenon.

Is a process to ensure programs are systematically and intentionally improving services and increasing positive outcomes for the families they serve. Is a cyclical, data- driven process, it is proactive and ongoing process that involves the Plan, Do, Study, and Act cycle.

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Customer Satisfaction The number of customers or percentage of total customers, whose reported experience with a firm, its products, or its services (ratings) exceeds specified satisfaction goals.

Degree of Confidence Is a type of interval estimate of a population parameter and is used to indicate the reliability of an estimate.

Failure Mode Effect Analysis

Is often the first step of a system reliability study. It involves reviewing as many components, assemblies, and subsystems as possible to identify failure modes, and their causes and effects.

House of Quality Is a diagram, resembling a house, used for defining the relationship between customer desires and the firm/product capabilities.

Indifferent Attribute These attributes refer to aspects that are neither good nor bad, and they do not result in either customer satisfaction or customer dissatisfaction.

Kano Model A theory of product development and customer satisfaction developed in the 1980s by Professor Noriaki Kano which classifies customer preferences into five categories; Must be Attribute, One dimensional Attribute, Indifferent Attribute, Attractive Attribute and Reversed Attribute

Must be Attribute These attributes are taken for granted when fulfilled but result in dissatisfaction when not fulfilled. An example of this would be package of milk that leaks. Customers are dissatisfied when the package leaks, but when it does not leak the result is not increased customer satisfaction.

One dimensional Attribute

These attributes result in satisfaction when fulfilled and dissatisfaction when not fulfilled. These are attributes that are spoken of and ones which companies compete for. An example of this would be a milk package that is said to have 10% more milk for the same price will result in customer satisfaction, but if it only contains 6% then the customer will feel misled and it will lead to dissatisfaction.

Quality Control Circle Is a management approach that involves input from a number of different sources within the structure of a company. Is to identify the presence of specific performance issue within the company, determine the origins of the issue, and then develop a process that helps to correct or resolve the problem without triggering additional issues elsewhere within the operational structure.

Reversed Attribute These attributes refer to a high degree of achievement resulting in dissatisfaction and to the fact that not all customers are alike. For example, some customers prefer high-tech products, while others prefer the basic model of a product and will be dissatisfied if a product has too many extra features

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xxviii

Development of Kano Model and Quality Function Deployment Integration to Assess Customer Satisfaction and Dissatisfaction of Service at Local Public

Hospital

ABSTRACT

The intensifying patient complaints on service delivery performance of local public healthcare institution are critical and incrementally raised. New methodologies are needed to address the complexity of patient expectation before the quality of service delivery can be improved. This issue needs to be solved instantly by establishing the service satisfaction model to understand the nature of patient’s expectation towards service delivery. As a result, the developed service satisfaction model has contributed to be inaccurate to understanding of patient’s behavior towards healthcare service. The non-linear assumption should be considered for better accuracy since the non-linear patient’s expectation remains undefined. This thesis aims to develop the non-linear service satisfaction model that assumes patients are not necessarily satisfied or dissatisfied with good or poor service delivery. With that, compliment and compliant assessment is considered, simultaneously. Non-linear service satisfaction instrument called Kano-Q and Kano-SS is developed based on Kano model and Theory of Quality Attributes to define the unexpected, hidden and unspoken patient satisfaction and dissatisfaction into service quality attribute. A new Kano-Q and Kano-SS algorithm for quality attribute assessment is developed based satisfaction impact theories and found instrumentally fit the reliability and validity test. The results were also validated based on standard Kano model procedure before Kano model and Quality Function Deployment (QFD) is integrated for patient attribute and service attribute prioritization.

An algorithm of Kano-QFD matrix operation is developed to compose the prioritized complaint and compliment indexes. Finally, the results of prioritized service attributes are mapped to service delivery category to determine the most prioritized service delivery that need to be improved at the first place by healthcare service provider. The results of this study indicate that the new satisfaction model is significantly effective in differentiating Kano dimensions and provides more accurate prioritization of the dimension and attribute compared to the traditional Kano approach. Although the new methodology evaluates the Kano methodology with QFD integration, the methodology is limited to a particular service industry that always encountered high dissatisfaction which expected to compose the Must-be, Attractive and One-dimensional quality attribute by ranking. As a conclusion, the new non-linear Kano-QFD service satisfaction model has been developed, tested and validated with Kano model to facilitate the analysis and decision making for better service delivery improvement. Comparison with other models has shown well agreement in terms of Kano quality attributes satisfaction impact and service gaps in healthcare service. As for future work, the comparison study on linear and non-linear patient expectation based on Kano-QFD integration is essentially recommended.

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Pembangunan Model Kano dan Integrasi Pertukaran Fungsi Kualiti untuk Menilai Kepuasan dan Ketidakpuashatian Pelanggan Perkhidmatan di Hospital

Awam Tempatan

ABSTRAK

Pertambahan aduan pesakit terhadap prestasi penghantaran servis yang dilaporkan oleh institusi kesihatan tempatan adalah pada tahap kritikal dan meningkat naik. Kaedah baru diperlukan bagi mengetengahkan kehendak pesakit yang kompleks sebelum kualiti penghantaran servis boleh dipertingkatkan. Isu ini perlu diselesaikan dengan segera bagi membangunkan satu model kepuasan servis untuk memahami kehendak pesakit terhadap penghantaran servis. Model kepuasan servis terdahulu adalah berdasarkan andaian perhubungan lelurus. Hasilnya, model kepuasan servis yang dibangunkan juga menyumbang kepada ketidaktepatan pada pemahaman kelakuan pesakit terhadap servis kesihatan. Satu andaian ketaklelurusan perlu dipertimbangkan bagi ketepatan terbaik kerana ketaklelurusan kehendak pesakit masih belum ditentukan. Tesis ini bertujuan untuk membangunkan model kepuasan servis ketaklelurusan yang mengandaikan para pesakit tidak semestinya berpuashati atau tidakberpuashati dengan kebagusan atau ketakbagusan servis kesihatan. Oleh yang demikian, aduan dan pujian perlu disekalikan dalam pembangunan model. Satu pengalatan kepuasan ketaklelurusan servis dinamakan Kano-Q dan Kano-SS telah dibangunkan berasaskan model Kano dan Teori Sifat Kualiti bagi mengenalpasti kepuasan dan ketakpuasan pesakit yang tak terjangka, tersembunyi dan tak dinyatakan kepada sifat kualiti servis. Instrumen tersebut telah digunakan untuk mengukur sepuluh pembolehubah aduan terbanyak dalam servis kesihatan. Satu algoritma Kano-Q dan Kano-SS bagi penilaian sifat kualiti telah dibangunkan berdasarkan teori impak kepuasan dan instrumen didapati mematuhi ujian kebolehpercayaan dan kesahan. Keputusan juga disahkan berasaskan prosedur piawai model Kano sebelum model Kano dan Quality Function Deployment (QFD) diintegrasikan untuk sifat bagi pesakit dan keutamaan servis. Satu algoritma bagi operasi matrix Kano-QFD dibangunkan bagi terbitan keutamaan indeks aduan dan pujian. Walaupun metodologi baru membentuk kaedah untuk integrasi Kano-QFD, metodologi tersebut terhad kepada industri perkhidmatan yang selalu mengalami ketidapuashatian yang tinggi yang mana darjah sifat kualiti adalah Mesti, Menarik and Satu-Dimensi. Kesimpulannya, satu ketaklurusan model Kano-QFD telah dibangunkan, diuji dan disahkan untuk menyokong pembuatan keputusan bagi penambahbaikan penghantaran servis. Perbandingan dengan model-model lain daripada literasi menunjukkan ciri-ciri persamaan dalam bentuk sifar kualiti Kano. Sebagai cadangan kajian pada masa hadapan, perbandingan kajian antara lelurus dan ketidak lelurusan berdasarkan integrasi Kano-QFD perlulah dibangunkan.

factor analysis, most construct a procedures us human behaviour that psychological customer satisfaction Noriaki Kano whi

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