Personalizing the reference level: Gold standard to evaluate the

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Rev Esp Med Nucl Imagen Mol. 2014;33(2):65–71
Original Article
Personalizing the reference level: Gold standard to evaluate the quality of service
perceived夽
I. Rodrigo-Rincón a,∗ , M. Reyes-Pérez b , M.E. Martínez-Lozano c
a
Investigación y Gestión del Conocimiento, Departamento de Salud del Gobierno de Navarra, Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Spain
Servicio de Medicina Preventiva y Gestión de la Calidad, Complejo Hospitalario de Navarra, Pamplona, Spain
c
Servicio de Medicina Nuclear, Complejo Hospitalario de Navarra, Pamplona, Spain
b
a r t i c l e
i n f o
Article history:
Received 14 January 2013
Accepted 3 March 2013
Keywords:
Service quality
Gold standard
Threshold
Survey
a b s t r a c t
Objective: To know the cutoff point at which in-house Nuclear Medicine Department (MND) customers
consider that the quality of service is good (personalized cutoff).
Material and method: We conducted a survey of the professionals who had requested at least 5 tests to
the Nuclear Medicine Department. A total of 71 doctors responded (response rate: 30%). A question was
added to the questionnaire for the user to establish a cutoff point for which they would consider the
quality of service as good. The quality non-conformities, areas of improvement and strong points of the
six questions measuring the quality of service (Likert scale 0 to 10) were compared with two different
thresholds: personalized cutoff and one proposed by the service itself a priori. Test statistics: binomial
and Student’s t test for paired data.
Results: A cutoff value of 7 was proposed by the service as a reference while 68.1% of respondents suggested a cutoff above 7 points (mean 7.9 points). The 6 elements of perceived quality were considered
strong points with the cutoff proposed by the MND, while there were 3 detected with the personalized threshold. Thirteen percent of the answers were nonconformities with the service cutoff versus
19.2% with the personalized one, the differences being statistically significant (difference 95% CI 6.44%:
0.83–12.06).
Conclusions: The final image of the perceived quality of an in-house customer is different when using the
cutoff established by the Department versus the personalized cutoff given by the respondent.
© 2013 Elsevier España, S.L. and SEMNIM. All rights reserved.
Personalización del nivel de referencia: patrón oro para evaluar la calidad de
servicio percibida
r e s u m e n
Palabras clave:
Calidad percibida
Patrón oro
Punto de corte
Encuestas
Objetivo: Conocer el punto de corte a partir del cual los clientes internos del servicio de medicina nuclear
(MN) consideran que la calidad de servicio es buena (punto de corte personalizado).
Material y método: Se realizó una encuesta a los profesionales que hubieran solicitado al menos 5 pruebas
al servicio de medicina nuclear. Contestaron 71 médicos (tasa de respuesta del 30%). Se añadió al cuestionario una pregunta para que el usuario estableciera el punto de corte a partir del cual el encuestado
considera que la calidad de servicio es buena. Se compararon las no conformidades, las áreas de mejora
y los puntos fuertes de las 6 preguntas que medían la calidad de servicio (escala Likert de 0 al 10) con 2
dinteles de referencia: el punto de corte personalizado y el que propuso a priori el propio servicio. Test
estadísticos: binomial y t de Student para datos pareados.
Resultados: El servicio propuso el valor de 7 como punto de corte, mientras que el 68,1% de los encuestados
propuso un valor superior a 7 puntos (media 7,9 puntos). Los 6 elementos de calidad percibida fueron
considerados puntos fuertes con el punto de corte propuesto por el servicio de MN, mientras que fueron
3 los detectados con el punto de corte personalizado. El 13% de las valoraciones fueron no conformes con
el punto de corte del servicio frente al 19,2% con el punto de corte personalizado, siendo las diferencias
estadísticamente significativas (diferencia 6,44%; IC 95%: 0,83-12,06).
Conclusiones: La imagen final de la calidad percibida por los clientes internos de un servicio es diferente si
se utiliza el punto de corte que establece el servicio frente al que indica el propio individuo que responde
al cuestionario.
© 2013 Elsevier España, S.L. y SEMNIM. Todos los derechos reservados.
夽 Please cite this article as: Rodrigo-Rincón I, Reyes-Pérez M, Martínez-Lozano ME. Personalización del nivel de referencia: patrón oro para evaluar la calidad de servicio
percibida. Rev Esp Med Nucl Imagen Mol. 2014;33:65–71.
∗ Corresponding author.
E-mail address: mi.rodrigo.rincon@cfnavarra.es (I. Rodrigo-Rincón).
2253-8089/$ – see front matter © 2013 Elsevier España, S.L. and SEMNIM. All rights reserved.
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66
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Introduction
50
43.9
45
Material and methods
The framework of the sample was made up of professionals from
the clinical departments of a tertiary level hospital requesting tests
or consultations from the DNM. The subjects constituting the sample were physicians from other departments who had requested at
least 5 tests from the DNM in 2010.
On identifying these professionals they were sent a questionnaire designed to evaluate the quality of service provided by the
DNM (Annex 1). Two modalities of questionnaire completion were
provided. The questionnaire in paper form was sent to each professional by internal mail of the hospital together with an envelope
for returning the questionnaire. In addition, the professionals were
sent an email with a link in order to answer the questionnaire
anonymously. They were told that the two modalities were incompatible. Two reminders were sent. The collection period of the
40
% of answers
One of the most relevant elements for improvement in the quality of organizations is knowing the satisfaction and the quality of
the services perceived by the consumers.1–3
Although the concepts of satisfaction and service quality service
are apparently simple, there is no consensus with regard to their
meaning or how to conceptualize the relationship between satisfaction and the quality of the service provided or the most correct
method for their measurement.3 Nonetheless, most institutions use
some type of tool for their measurement.4
The method most frequently used to measure both satisfaction
as the service quality is with questionnaires.5,6 Most questionnaires use scales following a structure of Likert-type response
with a series of categories of response along the continuum
“favorable/unfavorable”. On numerous occasions, the question only
indicates the meaning of the initial and final points with intermediate values remaining unspecified. One example of this is question
number 3 of the healthcare barometer which asks: “Are you satisfied or dissatisfied with the way in which the public healthcare
system works in Spain?” To answer, the individual is shown a card
with numbers from 1 to 10, with 1 corresponding to very dissatisfied and 10 to satisfied,7 without specifying the intermediate
values.
Analysis of the results of questions with this type of scale is not
simple. How can the cutoff or reference value to be considered as
a good result be determined? Above what score should the institution consider an aspect as a strong point or at what value is there
an area of improvement?
To answer this question different approaches have been used
such as the determination of an objective value from a benchmark8
or a desired value. That is, users are asked about their perception
of an aspect with the aim of involving the users in the evaluation
of a department, but the interpretation of the results is performed
with a subjective aim established by the service provider.
To measure the service quality other authors9,10 have used the
model of discrepancies or “gaps” model comparing the perceptions
of the user with respect to their expectations.
In the present study we considered an alternative to the setting
of a subjective cutoff point by the Department of Nuclear Medicine
(DNM). The proposal consisted in having the internal customers
requiring tests from the DNM themselves establish the cutoff at
which the quality perceived is deemed good.
We compared the strong points, the areas of improvement
detected and those discrepant with 2 reference levels, that proposed by the DNM and the internal consumers.
The objective was to determine the cutoff at which the internal
consumers of the DNM consider the service quality as good.
35
30
25.8
25
19.7
20
15
10
6.1
5
4.5
0
1
2
3
4
5
6
Scores
7
8
9
10
Fig. 1. Distribution of the frequencies of the score given to the question “Above what
score do you consider that the service quality is good?”.
questionnaires was from June to September, 2011. Of a total of 237
professionals, 71 answered (30% response rate).
The questionnaire consisted of 14 items, 6 of which involved
items related to the quality of the services. The scale used for the
questions ranged from 0 (worst possible score) to 10 (best possible
score).
The reliability of the questionnaire measured with the Cronbach
alpha coefficient was of 0.643, with the general alpha value with
typified items being 0.790.
At the end of the questionnaire there was an item asking the
professional to state at what numerical score they would consider
the service quality as good, considering this score as a personalized
cutoff. Prior to the incorporation of the item to the questionnaire, 5
interviews of professionals were undertaken to perform cognitive
validation of the question and thereby confirm that the statement
was correct and comprehensible.
Prior to the analysis of the results the DNM was requested to set
a cutoff at which they considered that the service quality provided
was good. By consensus the department determined the cutoff of 7
and this value was denominated the “department cutoff”.
An element evaluated was considered as a strong point of the
department if its lowest value of the confidence interval of 95% was
greater than the reference level, and an area of improvement was
considered if the highest value of the confidence interval of 95%
was lower than the value of this level.
Using the personalized cutoff the number of discrepancies was
calculated by the difference between the score given to each question and the value at which the subject considered that the service
quality was good. For example, if an individual gave an item referring to the service quality the reports 8 points and considered that
9 was the score that should be obtained to provide good quality
service, we have a value of −1 point (8 minus 9). All the negative values such as the example indicated were considered to be
discrepant. Likewise, the number of discrepancies was calculated
applying the value of 7 as the threshold of reference. This value was
what had been established by the DNM.
The statistical tests used included the binomial method for
dependent samples and Student’s t test for paired data.
Results
Table 1 shows the results of the analysis of the items measuring
the service quality.
With regard to the question “Above what score do you consider
that the service quality is good?” 68.1% of the subjects gave a value
greater than 7. That is, the level of reference established a priori
by the service was below the reference level given by many of the
professionals (Fig. 1).
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67
Table 1
Results of the items referring to the quality of service together with the question threshold.
Item
Mean (CI 95%)
SD
Minimum
Maximum
Attitude to collaborate in organizational problems
Speed in the performance of tests/consultation
Speed in emitting reports
Reports quality
Information on criteria for not performing tests
Capacity of resolution
Satisfaction with DNM
Recommendation of service to other professionals
Score at which the service quality may be considered good
8.34 (7.77–8.91)
7.96 (7.557–8.36)
8.33 (7.97–8.7)
8.79 (8.46–9.13)
7.93 (7.06–8.80)
8.51 (8.22–8.80)
8.89 (8.60–9.19)
8.67 (8.31–9.02)
7.91 (7.68–8.14)
1.81
1.64
1.48
1.27
2.24
1.15
1.12
1.14
0.75
1
4
4
5
1
6
6
6
6
10
10
10
10
10
10
10
10
10
Analysis of the results from the mean thresholds of reference
One of the fundamental objectives of the study was to know the
strong points and areas of improvement in the DNM. On analyzing
the results of each of the questions we found that of the 6 questions
measuring the quality of the service all were strong points with the
cutoff set by the department while 3 were not so on considering
the mean personalized cutoff (Fig. 2).
No areas of improvement were detected with either of the 2
methods used since the confidence interval was not below the levels established for any variable.
The axis of ordinates was from −10 to +10, being the range of
possible scores.
No element was given a mean negative value indicating that
the scores of quality perceived by the professionals were higher
than the cutoff set by themselves or that established by the DNM
(value 7). Nonetheless, on comparing the mean values of all the elements evaluated, statistically significant differences were observed
on comparing the 2 cutoffs, with the mean differences for threshold
7 being greater than for the personalized cutoff (p < 0.05, Student’s
t test for paired data).
Discussion
Analysis of the disagreement with each item evaluated
The number and percentage of discrepancies per question with
both cutoffs are shown in Table 2.
Using the personalized cutoff a total of 62 discrepancy values
(19.2%) were detected while the mean cutoff of the department
detected 41 (13%), with these differences being statistically significant (difference: 6.44%; CI 95%: 0.83–12.06).
No statistically significant differences were observed in the item
by item analysis.
The mean values for each item of the variables “difference in
perception with regard to the personalized cutoff” and “difference
in perception with respect to the department cutoff” are shown in
Fig. 3.
The main objectives on undertaking a questionnaire of the quality of service perceived are to determine the strong points and the
areas of improvement from the point of view of those surveyed.
However, the methodology used for the analysis of the results,
and thus, the interpretation of these results is conditioned by the
type of scale of the variables and the cutoff established for evaluation.
The analysis of the results indicates that the interpretation of
the strong points differs based on the method used. Of the 6 items
measuring the quality of service all were considered strong points
from the cutoff set by the DNM while only 3 were considered strong
points with the personalized cutoff. There were no discrepancies
with regard to the areas of improvement, with none being detected
10
9
8
8.8
8.3
8.5
8.3
8.0
Threshold surveyed
7.9
7
Threshold purveyor
Scores
6
5
4
3
2
1
Attitude to
collaborate in
organizational
problems
Speed in
the performance
of tests/consultation
Speed in
emitting reports
Report quality
Information on
criteria for not
performing tests
Evaluated items
Fig. 2. Mean values and confidence intervals of 95% of the items referring to the service quality.
Capacity of
resolution
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68
I. Rodrigo-Rincón et al. / Rev Esp Med Nucl Imagen Mol. 2014;33(2):65–71
Table 2
Analysis of discrepancies: individual threshold and threshold established by the department of nuclear medicine.
Item
n
Attitude to collaborate in organizational problems
Speed in the performance of tests/consultations
Speed in emitting reports
Reports quality
Information on criteria for not performing tests
Capacity of resolution
Total
41
67
66
58
28
63
323
Individual threshold
DNM threshold
No. of discrepancies
%
% over total of
discrepancies
No. of discrepancies
%
% over total of
discrepancies
8
20
15
5
6
8
62
19.5
29.9
22.7
8.6
21.4
12.7
19.2
12.9
32.3
24.2
8.1
9.7
12.9
100
5
15
11
4
3
3
41
12.2
22.4.
16.7
6.9
10.7
4.8
13.0
12.2
36.6
26.8
9.8
7.3
7.3
100
n indicates the number of persons answering each item of the questionnaire; % indicates the percentage of individuals considering discrepancy with this item; % over the
total of discrepancies indicates what percentage of the total of discrepancies corresponds to each item.
10.00
8.00
6.00
4.00
1.34
2.00
0.05
0.00
Service attitude
1.79
1.33
0.96
0.58
Test speed
0.41
Report speed
1.51
0.93
1.00
0.08
Report quality
0.63
Inf. not perform test
–2.00
Capacity of
resolution
–4.00
–6.00
–8.00
–10.00
Individual threshold
Threshold 7
Fig. 3. Quality of service: mean values of the differences between perceptions and the threshold of reference.
independently of the method used. That is, when the cutoff was
established by the evaluator, fewer strong points were detected
than those that would have been detected by the DNM using its
own threshold. Similarly, a greater number of discrepancies were
detected on using the personalized cutoff versus the department
cutoff, with the differences being statistically significant. Likewise,
on calculating the difference between the mean values of quality
perceived given and the reference levels, the values obtained were
significantly higher for the department than for the personalized
cutoff in all the items.
The discrepancy as to the areas of improvement and strong
points and the number of discrepancies varied based on how far
the personalized cutoff was from the other threshold established.
The problem is that since the user is not consulted with regard
to the value at which the quality of service may be considered as
good, the error committed in the interpretation of the results is
not known. Nonetheless, regardless of the results obtained, from
a conceptual point of view the reference cutoff and thus, the gold
standard, should be that indicated by the subject responding to the
questionnaire.
On the other hand, analysis of the differences or discrepancies is not a new method since this has been used since the
1980s. The discrepancy method considers that the evaluation of
quality is the result of the divergence between perceptions and
expectations.7,10–12
The method proposed in this study differs from the discrepancy models such as that by Parasuraman et al.10 in 2 ways. The
first is that with the methodology which we used expectations
were not considered. The debate regarding the measurement of
expectations is explained in other studies.13–15 Nevertheless, the
detractors of the discrepancy model indicate that the inclusion of
expectations may be inefficient and unnecessary because individuals tend to indicate high levels of expectation and thus, the values
of perception are rarely surpassed.
Secondly, with our method it is not necessary for the subject to provide a level of reference for each item. It is therefore
not necessary to duplicate the number of items made but
rather to add one more question to the questionnaire. To avoid
duplicity of items, other authors16 have used a questionnaire in
which the scale of response combines expectations and perceptions.
With respect to the type of scale, polytomous variables allow
relatively simple classification of the categories referring to the discrepancies. Nonetheless, many organizations use an ordinal scale in
which only the final cutoffs of the scale are set. This option presents
some inconveniences. First, the use of digits – numbers – does not
guarantee adequate psychometric properties for using the usual
statistical tests. Second, there is the problem of defining a reference
threshold of a cutoff at which a strong point or area of improvement
may be considered.
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The method described takes into account the opinion of the
subjects surveyed when setting the level of reference versus other
systems in which it is the service purveyor who subjectively establishes this value, often a posteriori and after knowing the results.
That is, grant the value of judgment to the individual, which is, on
the other hand, implicit when wishing to obtain the user’s opinion
of the quality of service.
In addition, most studies published focus on the evaluation by
patients, with studies centered on assessment by professionals
being less frequent. This study did not ask patients about the quality
of service but rather the professionals requesting tests or consultations to the DNM and thus, these results cannot be extrapolated to
patients, although the conceptual basis is the same.
The DNM considered the cutoff to be 7 because the professionals are, in general, less generous in giving scores than patients.17
The cutoff set by the DNM would have been higher if the quality
perceived was to have been evaluated by the patients.
Comparative data of cutoffs given by users (internal or external
consumers) in other studies are not provided since we did not find
any article applying this type of focus.
69
In summary, the novelty of this study lays in that it proposes
that the users who respond to the questionnaire should establish
the cutoff at which the quality is perceived to be good since the final
image of quality perceived by the internal consumers of a department is different if the cutoff set by the department is used versus
that indicated by the individuals responding to the questionnaires.
Author contribution
M. Isabel Rodrigo Rincón participated in all the phases of article
preparation including the design, data analysis and redaction.
María Reyes Pérez participated in the field work and data analysis.
M. Eugenia Martínez contributed to the conception and design of
the study as well as the approval of the final version for publication.
Conflict of interests
The authors declare no conflict of interests.
Annex 1. Questionnaire to internal consumers
This questionnaire has the objective to know your opinion on the global quality of all the actions of the
Department of Nuclear Medicine. The aim of this questionnaire is to know the “image of competence” of
the specialty of Nuclear Medicine to detect aspects which will allow us to continue improving.
Please put a cross on the option which best reflects your opinion as a professional. If you make a mistake,
cross out the incorrect option and place another cross on the option you consider the most adequate.
Please remember that all the questions are aspects which you would expect from the specialty of Nuclear
Medicine. To respond, please use the questionnaire below.
Thank you for your collaboration.
P1- The degree of relationship between the department to which you belong and the Department o
Nuclear Medicine (evaluated by the need for this department in your usual practice: number of patients
undergoing tests, number of tests requested, importance the tests requested have for your department in
relation to correct diagnosis or treatment of the patients...):
No relationship
□
Low relationship
□
Moderate relationship □ Very close relationship □
P2- Approximately how many tests do you request from the Department of Nuclear Medicine per year?
Less than
□
From 5 to 9
□
From 10 to 15 □
More than 15
□
Please circle the option most closely approaching your perception of each of the following statements.
The score ranges from ZERO (minimum possible score) to TEN (maximum possible score).
P3- Evaluate the attitude of the Department of Nuclear Medicine in collaborating with you in the
resolution of organizational problems (patient management, channels or circuits of communication for
data of clinical relevance, etc.).
0
None
1
2
3
4
5
6
7
8
9
NA
10
Excellent
P4-The speed of the performance of the tests/consultations of the Department of Nuclear Medicine
is (from the time of the request to the performance of the test).
0
1
Very slow
2
3
4
5
6
7
8
9
NA
10
Very fast
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I. Rodrigo-Rincón et al. / Rev Esp Med Nucl Imagen Mol. 2014;33(2):65–71
P5 -The reports, registries or results of the tests/(consultations emitted by the Department of Nuclear
Medicine with regard to:
P5-1 The speed (from the time of the test/consultation to the emission of the results)
0
1
2
3
4
5
6
7
8
9
Very slow
10
NA
Very fast
P5-2- The quality you perceive of the reports or results:
0 1
Very bad
2
3
4
5
6
7
8
9
NA
10
Very good
P6- When the Department of Nuclear Medicine decides not to carry out the test requested for a patient
from your department please score from 0 to 10 the information provided in relation to the criteria for
not performing the test.
0 1 2
No criteria
3
4
5
6
7
8
9
10
NA
Excellent
P7- Assess the capacity of resolution of the Department of Nuclear Medicine for the patients referred
by yourself.
0
1
Very low
2
3
4
5
6
7
8
9
10
NA
Very high
P8- In your opinion, evaluate from 0 to 10 the quantity of human resources available in the Department of Nuclear Medicine to perform their work.
0
1
Very scarce
2
3
4
5
6
7
8
9
10
NA
Very abundant
P9- In your opinion evaluate from 0 to 10 the technological resources available in the Department of
Nuclear Medicine to perform their work.
0
1
2
Very precarious
3
4
5
6
7
8
9
10
NA
Excellent
P10- ¿What IMAGE do you have of the professional competence of the staff of the Department of
Nuclear Medicine?
0
1
Very bad
2
3
4
5
6
7
8
9
10
NA
Excellent
P11- As a whole, evaluate your satisfaction with the Department of Nuclear Medicine.
0
1
Very low
2
3
4
5
6
7
8
9
10
NA
Very high
P12 Would you recommend the Department of Nuclear Medicine to other professionals if they were
in the same situation and could choose a department?
0
Never
0
1
2
3
4
5
6
7
8
9
10
NA
Always
P13- In each of the questions of the questionnaire, Above what score do you consider that the
service quality is good?
NA
1
2
3
4
5
6
7
8
9
10
P14- Would you like to add any comment concerning any aspect related to the Department of Nuclear which
was not included in the questions above?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
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