Quality function deployment approach in measuring hospital service quality: A mixed-methods scale development

In recent years, the rapid growth in healthcare services has led to an increase in the number of healthcare institutions both globally and in Turkey. This increase has intensified competition among service providers. The need to gain a competitive advantage and ensure service sustainability has prompted sector managers to adopt customer-oriented management strategies. Accordingly, Total Quality Management (TQM), which centers on customer satisfaction, has gained prominence. Quality Function Deployment (QFD), as one of the TQM tools, aims to identify customer demands and expectations and provide higher quality services accordingly. This study investigates the extent to which measuring the service quality perceptions of healthcare workers and patients—who represent internal and external customers respectively—through the QFD approach can contribute to meeting needs and addressing service deficiencies. The main objective of the study is to develop two separate measurement tools within a holistic framework that assess both employee and patient satisfaction in healthcare services. Based on the systematic structure of the QFD approach, patient and employee expectations were analyzed and translated into service quality criteria. Initially, qualitative data were used to identify expectations and needs, after which the draft scales were tested with quantitative data and subjected to validity and reliability analyses. The findings revealed that both patient and employee satisfaction play a critical role in determining service quality and led to the development of a dual-perspective (internal and external customer-focused) assessment tool that contributes to sustainable quality improvement efforts in healthcare institutions. In the study, the "House of Quality" matrix, a key tool of QFD, was employed to systematically identify customer needs and prioritize them. Based on data collected from patients and employees, needs were analyzed in detail and associated with dimensions of service quality, then ranked in order of priority. The application of the House of Quality enabled a concrete mapping of how customer expectations should be integrated into service delivery processes, thereby grounding the developed scale in both a strong structural and functional foundation. In the qualitative research phase—the first stage of the study—semi-structured interviews were conducted with healthcare employees (n=44) working in the surgical departments of the selected hospitals and patients (n=27) who applied to these departments. The data obtained from the interviews were analyzed using thematic analysis through the MAXQDA 2020 software. For patients, the themes were "Expectations from employees, expectations from the physical environment, and expectations from the service." For healthcare employees, the themes were "Expectations from management, expectations from patients, and expectations from other employees." These themes formed the basis of the measurement scales designed to assess service quality perceptions of both stakeholder groups. The second stage of the research, the quantitative phase, was carried out in line with the findings from the qualitative phase. Another key objective was to examine the extent to which the quantitative results support the qualitative findings. The quality improvement scales derived from the qualitative phase were administered as surveys to a sample representing the population. Subsequently, the structural validity of the scales was tested through exploratory and confirmatory factor analyses. The third stage, the integration phase, involved comparing the findings from both qualitative and quantitative stages. In this stage, themes identified in the qualitative phase were compared with the dimensions found in the quantitative phase, and the results showed that qualitative findings supported the quantitative ones in terms of both the number and content of dimensions. This stage forms the core of the mixed methods design employed in this study. The fourth and final stage of the study consisted of placing the service quality-related desires, needs, and perceptions of patients and healthcare workers into the "House of Quality," the core tool of QFD, based on the findings from the previous stages. In conclusion, this study presents a comprehensive scale development process that identifies the needs based on both internal and external customer satisfaction and transforms them into service quality criteria. Through the QFD approach and the House of Quality matrix, patient and employee expectations were analytically processed into a dual-perspective healthcare service quality assessment scale. This scale identifies strategic priorities for service improvement and is proposed as an innovative, scientifically grounded evaluation tool that can guide customer-focused quality management practices in healthcare institutions. Keywords: Healthcare Quality, Quality Function Deployment, Service Quality Scale, Mixed Methods Research.