Effects of the Hospital Gradation System on Patient Behavior and Satisfaction: An Investigation of Dental Health Care

Hospital gradation systems are used to examine the performance of hospitals to promote the efficient use of medical resources (1). Patient-perceived service quality may differ for differing grades of medical institutions under gradation system , which has been rarely reported. The aim of the present study was to explore the relation between the hospital gradation system and patient perceptions under Taiwanese hospital gradation system. The specialty of dentistry was investigated due to dental care being significantly different from other medical services (2). Dental care is more personal, intimate, and lasting contact with the patient (3). Nevertheless, quality assessment of dental service remains relatively primitive (4). To explore more accurately and objectively assessment of service quality of dental care is necessary. In Taiwan, the National Health Insurance (NHI) system has provided universal and comprehensive health care to the residents at affordable costs since 1995. It utilizes a gradation system that integrates classification with accreditation to promote efficient medical resources utilization. Medical institutions are classified and divided into four grades based on the level of services provision and size of care providers: medical centers, regional hospitals, area hospitals, and basic-level institutions. Medical institutions other than basic-level institutions are required accreditation to provide quality service to obtain subsidization from Bureau of NHI (5). Dental care, excluding cosmetic services, is covered as part of the benefit package in the comprehensive NHI program of Taiwan. Dental services are provided by dental care centers in the four grades of medical institutions. Patients have freedom of choice of dental service providers with the same co-payment, regardless of the grade of the dental care center. However, in medical centers, dentists are not only tasked with providing clinical services but also participating in teaching and academic research. This has raised the question of whether the dentists' technical skills and the service quality are better at higher-grade dental care centers. Patient satisfaction is a key determinant of the service quality and can be conceptualized as the difference between a patient's perceptions and their expectations. The SERVQUAL model (6) is commonly used to examine the service quality of health care (7). In this study, the modified SERV-QUAL instrument which comprises 21 attributes was used to explore differences in patient-perceived service quality between two types of dental care centers with different grades, namely dentistry departments in medical centers (DMCs) and basic-level dental clinics (DCs). The questionnaire contains three sections. The first two …