因應醫療服務競爭越趨激烈，醫療實務界與研究者更有興趣了解病患如何認知其醫療服務品質與價值，進而形成滿意度與行為意圖。門診服務提供了病患與醫療提供者初次接觸的場所，且其約佔台灣健保支出的三分之二。因此，實有其重要性去了解門診病患對其服務的感受。根據行銷文獻中，將知覺價值視為服務品質的結果與滿意度及行為意圖的前因角色，本研究以實証分析以顧客導向為主的整合研究模型，其包含服務品質、知覺價值、滿意度與行為意圖間的關係。首先，以焦點團體討論探索醫療門診服務品質的因素有四：(1) 病患與醫護人員間的互動，(2) 醫護人員的確實性，(3) 服務的及時性與 (4) 有形性。之後以線性方程模型檢視醫療門診服務品質、知覺價值、病患滿意度與行為意圖間的假設關係，主要研究結果歸納如下：(1) 知覺價值對行為意圖的直接影響甚於滿意度與服務品質對行為意圖的直接效果，(2) 服務品質對行為意圖同時兼具直接效果與間接效果（經由知覺價值與滿意度），與 (3) 服務品質與知覺價值都是滿意度的前因，且服務品質是滿意度最重要的決定因素。最後，本論文根據研究結果加以討論並提供未來研究建議。

As health care services get more competitive, the health care practitioners and academic researchers are increasingly interested in exploring how patients perceive their care quality and value, form their satisfaction levels and generate their behavioral intentions. Outpatient services provide an alternate setting for patients to have initial contact with health care providers. Besides, two-thirds of Taiwan’s total NHI expenditure is spent on outpatient services. Thus, it is of great significance to note outpatients’ perceptions of health care services. Drawing from marketing literature, perceived value can be viewed as the consequence of service quality and as the antecedent role of satisfaction and behavioral intentions. This study conducted empirical test an integrative model of customers’ perceptions of outpatient services based on the established relationships among four key constructs (service quality, perceived value, satisfaction and behavioral intentions). First, this study conducted focus group discussion to identify the factors of quality of outpatient services as follows: (1) the personal interaction between medical staff and patients, (2) the assurance from medical staff, (3) the speed of timely access to a service, and (4) tangible aspect. Later, structural equation model was used to examine the research model which addresses the hypothesized relationships among the four constructs of interest in the health care industry. The main findings are summarized as follows: (1) perceive value had a greater direct influence on behavioral intentions than did service quality and patient satisfaction; (2) service quality had both an indirect effect (through perceived value and satisfaction) and a direct influence on behavioral intentions; and (3) both service quality and value are antecedents of patient satisfaction; the most important determinant of patient satisfaction is quality of health care. Finally, this dissertation ends with a discussion of the results and implications for the managerial practices, followed by suggestions for future research.

ACKNOWLEDGMENT …………………………………….…………….……… i
ABSTRACT …………………………………….………………………….…….. ii
TABLE OF CONTENTS …………………………………….…………….…….. iv
LIST OF TABLES …………………………………….…………………….…….vii
LIST OF FIGURES …………………………………….…………………….……viii
CHAPTER 1 INTRODUCTION …………………………………….……….…... 1
1.1 Research Purpose …………………………………….…………………….…. 1
1.2 Background …………………………………….………………………..….… 3
1.3 Research Questions …………………………………….……………………... 4
1.4 Organization of the Dissertation …………………………………….………... 5
CHAPTER 2 LITERATURE REVIEW …………………………………….…….. 7
2.1 Service Quality …………………………………….………………………….. 7
2.1.1 Service Quality of Health Care …………………………………….………10
2.1.2 Applications of SERVQUAL in Health Care Research ………………….. 12
2.2 Perceived Value …………………………………….…………………………. 14
2.3 Satisfaction …………………………………….………………………..…..... 16
2.3.1 Patient Satisfaction …………………………………….……………..….. 18
2.3.2 Measurement pf Satisfaction …………………………………………..…. 18
2.4 Behavioral Intentions …………………………………….………………….... 19
2.5 Taiwan Health Care System …………………………………….…………….. 20
2.6 Hypotheses Development …………………………………….……………..… 22
2.6.1 Relationship between Service Quality and Satisfaction ………………..…. 25
2.6.2 Relationship between Service Quality and Perceived Value ……………... 27
2.6.3 Relationship between Perceived Value and Satisfaction ………………….. 28
2.6.4 Antecedents of Behavioral Intentions …………………..…………..…….. 30
CHAPTER 3 RESEARCH DESIGN …………………..……..….…………..……. 33
3.1 Research Framework …………………..….….………………………………... 33
3.2 Focus Group Discussion …………………..….….…………………………..... 37
3.2.1 Study Design …………………..….….…………………………………… 38
3.2.2 Content Analysis Results …………………..….….…………..…………... 39
3.2.3 Conclusions …………………..….….…………………………..………… 42
3.3 Questionnaire Design …………………..….….……………………..………... 47
3.4 Data Collection …………………..….….……………………………....…….. 52
3.5 Data Analysis …………………..….….………………………………..……... 53
CHAPTER 4 ANALYSIS RESULTS …………………..….….……………..…… 55
4.1 Factor Analysis of Service Quality …………………..….….……………..….. 56
4.2 Measurement Model …………………..….….……………………………...... 60
4.2.1 Measurement Model of Service Quality …………………..….….…….... 60
4.2.2 Overall Measurement Model …………………..….….……………..…… 67
4.3 Structural Model …………………..….….………………………………..….. 71
4.3.1 Hypotheses Testing …………………..….….…………………………..... 75
4.3.2 Total and Indirect Effects …………………..….….…………………….... 79
4.3.3 Alternative Model for Comparison …………………..….….……………. 80
CHAPTER 5 DISCUSSION AND IMPLICATIONS …………………..……..… 83
5.1 Discussion …………………………..….……….………………………….… 83
5.2 Implications …………………..….….………………………………………... 86
5.3 Future Research …………………..….….…………………………………... 89

REFERENCES …………………..….….……………………………………….. 93
APPENDIX Questionnaire …………………..….….…………………………... 104

Alexandris C., Dimitriadis, N., & Markata, D. 2002. Can perceptions of service quality predict behavioral intentions? An exploratory study in the hotel sector in Greece. Managing Service Quality, 12(4): 224–31.
Andaleeb, S. S. 2001. Service quality perceptions and patient satisfaction: A study of hospitals in a developing country. Social Science and Medicine, 52(9): 1359-1370.
Andaleeb, S. S., Siddiqui, N., & Khandakar, S. 2007. Patient satisfaction with health services in Bangladesh. Health Policy and Planning, 22(4): 263-273.
Anderson, E. W. 1998. Customer satisfaction and word-of-mouth. Journal of Service Research, 1(1): 1-14.
Anderson, E. W., & Sullivan, M. W. 1993. The antecedents and consequences of customer satisfaction for firms. Marketing Science, 12(2): 125-143.
Anderson, E. W., Fornell, C., & Lehmann, D. R. 1994. Customer satisfaction, market share, and profitability: Findings from Sweden. Journal of Marketing, 58(3): 53-66.
Anderson, J.C., & Gerbing, D. W. 1988. Structural equation modeling in practice: A review and recommended two-step approach. Psychological Bulletin, 103(3): 411-423.
Babakus, E., & Boller, G. W. 1992. An empirical assessment of the SERVQUAL scale. Journal of Business Research, 24(3): 253-268.
Babakus, E., & Mangold, W. G. 1992. Adapting the SERVQUAL scale to hospital services: An empirical investigation. Health Services Research, 26(6): 767-786.
Bagozzi, R. P. 1992. The self-regulation of attitudes, intentions, and behaviour. Social Psychology Quarterly, 55(2): 178-204.
Baker J., & Crompton, J. L. 2000. Quality, satisfaction and behaviour intentions. Annals of Tourism Research, 27(3): 758–804.
Baker, T. L., & Taylor, S. A. 1997. Patient satisfaction and service quality in the formation of customers' future purchase intentions in competitive health service settings. Health Marketing Quarterly, 15(1): 1-15.
Bitner, M. J. 1990. Evaluating service encounters: The effects of physical surroundings and employee responses. Journal of Marketing, 54(2): 69-82.
Bojanic, D. C. 1996. Customers perceptions of price, value and satisfaction in the hotel industry: An exploratory study. Journal of Hospitality and Leisure Marketing, 4(1): 5-22.
Bolton, R. N., & Drew, J. H. 1991. A longitudinal analysis of the impact of service changes on customer attitudes. Journal of Marketing, 55(1): 1-9.
Boulding, W., Kalra, A., Staelin, R., & Zeithaml, V. A. 1993. A dynamic process model of service quality: From expectations to behavioral intentions. Journal of Marketing Research, 30(1): 7-27.
Bowers, M.R., Swan, J.E., & Koehler, W. 1994. What attributes determine quality and satisfaction with health care delivery. Health Care Management Review, 19(4): 49-55.
Bowers, M. R., & Kiefe, C. I. 2002. Measuring health care quality: comparing and contrasting the medical and the marketing approaches. American Journal of Medical Quality, 17(4): 136-144.
Brady, M.K., & Cronin, J. J. Jr. 2001. Customer orientation: Effects on customer service perceptions and outcome behaviors. Journal of Service Research, 3(3): 241-251.
Brady, M.K., Cronin, J.J. Jr and Brand, R.R. 2002. Performance-only measurement of service quality: A replication and extension. Journal of Business Research, 55(1): 17-31.
Brady, M. K., & Robertson, C. J. 2001. Searching for a consensus on the antecedent role of service quality and satisfaction: An exploratory cross-national study.
Journal of Business Research, 51(1): 53-60.
Brady, M. K., Robertson, C. J., & Cronin, J. J. Jr. 2001. Managing behavioral intentions in diverse cultural environments: An investigation of service quality, service value, and satisfaction for American and Ecuadorian fast-food customers.
Journal of International Management, 7(2): 129-149.
Brown, T. J., Churchill, G. A., Jr., & Peter, J.P. 1993. Improving the measurement of service quality. Journal of Retailing, 69(1): 127–139.
Capon, W., Farley, J. U., & Hoenig, S. 1990. Determinants of financial performance: A Meta-analysis. Management Science, 36(10): 1143-1149.
Carman, J. M. 1990. Consumer perceptions of service quality: An assessment of the SERVQUAL dimensions. Journal of Retailing, 66(1): 33–55.
Chao, P., Fu, H., & Lu, I. 2007. Strengthening the quality-loyalty linkage: The role of customer orientation and interpersonal relationship. Service Industries Journal, 27(4): 471-494.
Chen, J., Cheng, C., Fang, S. 2005. Effects of outpatient medical service quality and patient satisfaction on relationship-oriented behavior. Journal of Health Science, 7(2): 187-202. (in Chinese)
Cheng, T.M. 2003. Taiwan's new national health insurance program: genesis and experience so far. Health Affairs, 22(3): 61-76.
Cheng, S. Wei, Y., & Chang, H. 2006. Quality competition among hospitals: The effects of perceived quality and perceived expensiveness on health care consumers. American Journal of Medical Quality, 21(1): 68-75.
Choi, K., Cho, W., Lee, S., Lee, H., & Kim, C. 2004. The relationships among service quality, value, satisfaction and behavioral intention in health care provider choice: A South Korean study. Journal of Business Research, 57(8): 913-921.
Choi, K., Lee, H., Kim, C., & Lee, S. 2004. The service quality dimensions and patient satisfaction relationships in South Korea: Comparisons across gender, age and types of service. Journal of Services Marketing, 19(3): 140-149.
Cronin, J. J. Jr., Brady, M. K., Brand, R. R., Hightower, R., & Shemwell, D. 1997. A cross-sectional test of the effect and conceptualization of service value. Journal of Services Marketing, 11(6): 375-391.
Cronin, J. J. Jr., Brady, M. K., & Hult, M. 2000. Assessing the effects of quality, value and customer satisfaction on consumer behavioral intention in service environments. Journal of Retailing, 76(2): 193-218.
Cronin, J. J. Jr., & Taylor, S. A. 1992. Measuring service quality: A reexamination and extension. Journal of Marketing, 56(3):55-68.
Cronin, J. J. Jr., & Taylor, S. A. 1994. SERVPERF versus SERVQUAL: Reconciling performance-based and perceptions-minus-expectations measurement of service quality. Journal of Marketing, 58(1):125-131.
Churchill, G.A. Jr. 1979. A paradigm for developing better measures of marketing constructs. Journal of Marketing Research, 16(1): 64-73.
Dabholkar, P.A., Thorpe, D.I., & Rentz, J.O. 1996. A measure of service quality for retail stores: scale development and validation. Journal of the Academy of Marketing Science, 24(1): 3-16.
Dabholkar, P.A., Shepherd, C.D., & Thorpe, D.I. 2000. A comprehensive framework for service quality: An investigation of critical conceptual and measurement issues through a longitudinal study. Journal of Retailing, 76(2): 139-73.
DeMan, S., Gemmel, P., Vlerick, P., VanRijk, P., & Dierckx, R. 2002. Patients’ and personnel’s perceptions of service quality and patient satisfaction in nuclear medicine. European Journal of Nuclear Medicine, 29(9): 1109-1117.
DeRuyter, K., Bloemer, J., & Peeters, P. 1997. Merging service quality and service satisfaction: An empirical test of an integrative model. Journal of Economic Psychology, 18(4): 387-406.
Dodds, W. B., Mornoe, K. B., & Grewal, D. 1991. Effects of price, brand and store information on buyers’ product evaluations. Journal of Marketing Research, 28(3): 307-319.
Donabedian, A. 1982. Explorations in quality assessment and monitoring: The criteria and standards of quality, Vol. 2. Ann Arbor, MI: Health Administration Press.
Donabedian, A. 1996. The Effectiveness of quality assurance. International Journal of Quality Health Care, 18(4): 401–407.
Eggert A., & Ulaga, W. 2002. Customer perceived value: A substitute for satisfaction in business markets? The Journal of Business & Industrial Marketing, 17(2/3): 107-118
Fornell, C. 1992. A national customer satisfaction barometer: The Swedish experience. Journal of Marketing, 56(1): 6-21.
Fornell, C., Johnson, M.D., Anderson, E.W., Cha, J., & Bryant, B.E. 1996. The American customer satisfaction index: Nature, purpose, and findings. Journal of Marketing, 60(4): 7-18.
Fornell, C., & Larcker, D. F. 1981. Evaluating structural equation models with unobservables and measurement error. Journal of Marketing Research, 18(1): 39-50.
Fullerton, G., & Taylor, S. 2002. Mediating, interactive, and non-linear effects in service quality and satisfaction with services research. Canadian Journal of Administrative Sciences, 19(2): 124-136.
Gabbott, M., & Hogg, G. 1995. Grounds for discrimination: Establishing criteria for evaluating health services. Service Industries Journal, 15(1): 90-101.
Gauld R., Ikegami, N., Barr, M.D., Chiang, T., Gould, D., & Kwon, S. 2006. Advanced Asia’s health systems in comparison. Health Policy, 79(2/3): 325-336.
Goldstein, S. M., & Schweikhart, S. B. 2002. Empirical support for the Baldrige award framework in U.S. hospitals. Health Care Management Review, 27(1): 62-75.
González, M. E. A., Comesana, L. R., & Brea, J. A. F. 2007. Assessing tourist behavioral intentions through perceived service quality and customer satisfaction. Journal of Business Research, 60(2): 153-160.
Gooding, S. K. S. 1995. Quality, sacrifice, and value in hospital choice. Journal of Health Care Marketing, 15(4): 24-31.
Gotlieb, J. B., Grewal, D., & Brown, S. W. 1994. Customers satisfaction and perceived quality: Complementary or divergent constructs? Journal of Applied Psychology, 79(6): 875-885.
Gronroos, C. 1984. A service quality model and its marketing implications. European Journal of Marketing, 18(4):36-44.
Hair, J. F., Anderson, R. E., Tatham, R. L., & Black, W. C. 1998. Multivariate data analysis (5th Ed.). New Jersey: Prentice-Hall.
Hausman, A. 2004. Modeling the patient-physician service encounter: Improving patient outcomes. Journal of the Academy of Marketing Science, 32(4): 403-417.
Heskett, J. L. Jones, T. O. Loveman, G. W. Sasser, W. E., & Schlesinger, L. A.1994. Putting the service-profit chain to work. Harvard Business Review, 72(2): 164-174.
Holbrook, M. B. 1994. The nature of customer value: an axiology of services in the consumption experience. In R. T. Rust and R. L. Oliver (Eds.), Service quality: New directions in theory and practice (pp. 21-71). New York: Sage.
Hu, L., & Bentler, P. M. 1999. Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Structural Equation Modeling, 6(1): 1-55.
Jen, W., & Hu, K. 2003. Application of perceived value model to identify factors affecting passengers’ repurchase intentions on city bus: A case of the Taipei metropolitan area. Transportation, 30(3): 307-327.
Jun, M., Perterson, R.T., & Zsidisin, G.A. 1998. The identification and measurement of quality dimensions in health care focus group interview results. Health Care Management Review, 23(4): 81-96.
Joreskog K.G., & Sorbom D. 1993. LISREL 8: Structural equation modeling with the SIMPLIS command language. Chicago, IL: Scientific Software.
McDougall, G. H. G., & Levesque, T. 2000. Customer satisfaction with services: Putting perceived value into the equation. Journal of Services Marketing, 14(5): 392-410.
Mummalaneni, V., & Gopalakrishna, P. 1997. Access, resource, and cost impacts on consumer satisfaction with health care: A comparison across alternative health care modes and time. Journal of Business Research, 39(3): 173-186
Newcome, L. N. 1997. Measuring of trust in health care. Health Affairs, 16(1): 50-51.
Nunally, J. C. 1978. Psychometric theory. New York: McGraw-Hill.
O’Connor, S., & Shewchuk, R. 1989. The influence of perceived hospital service quality on patient satisfaction and intentions to return. Academy of Management Proceedings: 95-99.
Oh, H. 1999. Service quality, customer satisfaction, and customer value: A holistic perspective. International Journal of Hospitality Management, 18(1):67-82.
Oliver, R. L. 1980. A cognitive model of the antecedents and consequences of satisfaction decisions. Journal of Marketing Research, 17(4): 460-469
Oliver, R. L. 1993. A conceptual model of service quality and service satisfaction: Compatible goals, different concepts. In A. S. Teresa., E.B. David, and W. B. Stephen (Eds.), Advances in Marketing and Management (pp. 65-85). Greenwich, CT: JAI Press.
Oliver, R. L. 1997. Satisfaction: A behavioral perspective on the consumer. Boston, MA: McGraw-Hill.
Oliver, R. L. 1999. Whence consumer loyalty? Journal of Marketing, 63(4): 33-44.
Parasuraman, A., Zeithaml, V. A., & Berry, L. L. 1985. A conceptual model of service quality and its implications for further research. Journal of Marketing, 49(3): 41-50.
Parasuraman, A., Zeithaml, V. A., & Berry, L. L. 1988. SERVQUAL: A multiple-item scale for measuring customers perceptions of service quality. Journal of Retailing, 64(1): 12-40.
Parasuraman, A., Zeithaml, V. A., & Berry, L. L. 1994. Reassessment of expectations as a comparison standard for measuring service quality: Implications for future research. Journal of Marketing, 58(1): 111-124.
Parasuraman, A., & Grewal, D. 2000. The impact of technology on the quality-value-loyalty chain: A research agenda. Journal of the Academy of Marketing Science, 28(1): 168-174.
Ramsaran-Fowdar, R. R. 2005. Identifying health care quality attributes. Journal of Health and Human Services Administration, 27(4): 428-443.
Reidenbach, R.E., & Sandifer-Smallwood, B. 1990. Exploring perceptions of hospital operations by a modified SERVQUAL approach. Journal of Health Care Marketing, 10(4): 47-55.
Rohini, R., & Mahadevappa, B. 2006. Service quality in Bangalore hospitals: An empirical study. Journal of Services Research, 6(1): 59-82.
Rust, R. T., & Oliver, R. L. 1994. Service quality: Insights and managerial implications from the frontier. In R. T. Rust and R. L. Oliver (Eds.), Service Quality: New Directions in Theory and Practice (pp. 1-19). Thousand Oaks, CA: Sage.
Rust, R. T., Zahorik, A. J., & Keiningham, T. L. 1995. Return on Quality (ROQ): Making service quality financially accountable. Journal of Marketing, 59(2): 58-70.
Spreng, R. A., & Mackoy, R. D. 1996. An empirical examination of a model of perceived service quality and satisfaction. Journal of Retailing, 72(2): 201-214.
Tam, J. L. M. 2004. Customer satisfaction, service quality and perceived value: An integrative model. Journal of Marketing Management, 20(7/8): 897-917.
Tam, J. L. M. 2007. Linking quality improvement with patient satisfaction: A study of a health service centre. Marketing Intelligence and Planning, 25(7): 732-745.
Taylor, S. A. 1997. Assessing regression-based importance weights for quality perceptions and satisfaction judgements in the presence of higher order and/or interaction effects. Journal of Retailing, 73(1): 135-159.
Taylor, S. A., & Baker, T. L. 1994. An assessment of the relationship between service quality and customer satisfaction in the formation of customers’ purchase intentions. Journal of Retailing, 70(2): 163-178.
Taylor, S. A., & Cronin, J. J., Jr. 1994. Modeling patient satisfaction and service quality. Journal of Health Care Marketing, 14(1): 34-44.
Teas, R. K. 1993. Expectations, performance evaluation, and customers’ perceptions of quality. Journal of Marketing, 57(4): 18-34.
Tsai, W., Kung, P., Weng, R., & Shih, H. 1994. Analysis of service quality gaps between primary care physicians and patients. Journal of Healthcare Management, 5(4): 385-402. (in Chinese)
Tzeng, L, Chen, C. 1998. Hospital outpatients service quality evaluation in Tainan. Fu Jen Management Review, 5(1): 117-135. (in Chinese)
Vandamme, R., & Leunis, J. 1993. Development of a multiple-item scale for measuring hospital service quality. International Journal of Service Industry Management, 4(3): 30-49.
Wakefield, K. L., & Barnes, J. H. 1996. Retailing hedonic consumption: A model of sales promotion of a leisure service. Journal of Retailing, 72(4): 409-427.
Wang, M., & Chen, R. 2005. The study on hospital service quality: An empirical study of the hospital in Hualien. Management Science Research, 2(1): 35-55. (in Chinese)
Woodruff, R.B. 1997. Customer value: The next source for competitive advantage. Journal of the Academy of Marketing Science, 25(2): 139-153.
Woodside, A. G., Frey, L. L., & Daly, R. T. 1989. Linking service quality, customer satisfaction and behavioral intention. Journal of Health Care Marketing, 9 (4): 5-17.
Yeh, S. J., Lo, Y., & Wan, T. T. H. 2005. Ambulatory care visits and quality of care: Does the volume-control policy matter? Health Policy, 74(3): 335-342.
Yu, T., Ting, C., Su, C. 2006. An analysis for the County of Yunlin Health Center's service quality indices. Journal of Public Administration, 19: 55-89. (in Chinese)
Zeithaml, V.A. 1988. Customers’ perceptions of price, quality, and value: A means-end model and synthesis of evidence. Journal of Marketing, 52(3): 2-22.
Zeithaml, V.A. 2000. Service quality, profitability and economic worth of customers: What we know and what we need to learn. Journal of the Academy of Marketing Science, 28(1): 67-85.
Zeithaml, V.A., Berry, L. L., & Parasuraman, A. 1996. The behavioral consequences of service quality. Journal of Marketing, 60(2): 31-46.
Zeithaml, V. A., & Bitner, M. J. 2003. Services Marketing (3rd Ed.). New York: McGraw-Hill.