sustainability

Article
Utilizing Multi-Criteria Decision Making to Evaluate the
Quality of Healthcare Services
Mohammed Al Awadh

Department of Industrial Engineering, King Khalid University, Abha 64231, Saudi Arabia;
mohalawadh@kku.edu.sa

Abstract: Today’s patients are more informed and quality-conscious than ever before, which is crucial
for healthcare practitioners as they interact with people’s lives daily. One of the most important
challenges facing the healthcare sector worldwide concerns how to improve the overall quality of
hospital care. As a result of the highly competitive nature of the economy in which healthcare services
are offered, both public and private hospitals in Saudi Arabia must have their patient satisfaction
rates assessed to help consumers make more informed decisions. As a result, we used the analytical
hierarchy process (AHP) model to ascertain how patients in Saudi Arabia perceive the quality of
the service that is provided by hospitals. The objective of the research work is to identify criteria for
enhancing healthcare services using the analytic hierarchy process (AHP) technique to model the
five SERVQUAL dimensions along with 2 dimensions and 31 sub-criteria. Three healthcare service
organizations were selected for the study and evaluated based on their service quality performance.
The AHP-based model has been demonstrated systematically for ranking the hospitals based on the
healthcare system. It is observed that hospitals should concentrate the most on reliability, tangibles,
and security and the least on consistency. In addition, according to the sub-criteria, the hospitals’
primary priority should be infection prevention and hygiene, with completeness receiving the least
attention. Based on a survey of dimensions and their sub-criteria, the best hospital is Abha Private
Hospital, followed by AHH, and then Asir General Hospital. Therefore, this study has implications
for choices on the efficient monitoring of the overall health system to improve quality service delivery
Citation: Al Awadh, M. Utilizing that would boost patient happiness, which is the goal of creating hospitals.
Multi-Criteria Decision Making to
Evaluate the Quality of Healthcare Keywords: analytic hierarchy process (AHP); healthcare services; ranking; SERVQUAL service quality
Services. Sustainability 2022, 14, 12745.
https://doi.org/10.3390/su141912745

Academic Editor: Jozsef Mezei

1. Introduction
Received: 21 July 2022
The decision-making process in the complex service sector of healthcare necessitates
Accepted: 21 September 2022
Published: 6 October 2022
the participation of several stakeholders with varying interests and values [1,2]. In the past
few decades, researchers have used a variety of multi-criteria decision making (MCDM)
Publisher’s Note: MDPI stays neutral techniques, such as the analytic hierarchy method (AHP) and hybrid methods [3], to handle
with regard to jurisdictional claims in real-time issues in the healthcare system. The bulk of prior research has concentrated on
published maps and institutional affil-
integrating multiple MCDM approaches to discover the optimal solutions [4]. Most present
iations.
MCDM techniques provide conclusions based on a single stakeholder group’s perspective.
However, integrating stakeholders in the decision-making process is vital for the healthcare
industry, even though their diverse opinions might make reaching a consensus challenging.
Copyright: © 2022 by the author.
In fact, a lack of agreement among stakeholders leads to a number of solutions reached
Licensee MDPI, Basel, Switzerland.
through the process of collaborative decision making ultimately being unsustainable [5].
This article is an open access article
Recently various studies have been carried out. For instance, Dezert et al. [6] created the
distributed under the terms and rank reversal-free stable preference ordering towards an ideal solution approach (SPOTIS).
conditions of the Creative Commons The determination of the attribute weights plays a crucial role in various MCDM techniques,
Attribution (CC BY) license (https:// as shown by Kizielewicz et al. [7] in their study. A framework for performance evaluation
creativecommons.org/licenses/by/ was created by Khan et al. [8]. Fartaj et al. [9] coupled BWM with rough strength relation
4.0/). to anticipate transportation disruption issues, allowing managers to focus on the specific

Sustainability 2022, 14, 12745. https://doi.org/10.3390/su141912745 https://www.mdpi.com/journal/sustainability

Sustainability 2022, 14, 12745 2 of 21

issue rather than attempting to handle all of the connected aspects. The major obstacle to
implementing Industry 4.0 in the leather industry, according to Moktadir et al. [10], was
a “lack of technical infrastructure.” However, the BWM has consistency issues [11]. To
overcome this constraint and reach a consensus solution across stakeholders, researchers
have employed multi-objective linear programming (MOLP) [12]. MOLP can be carried
out with the use of a tool known as sequential interactive modelling for urban systems
(SIMUS), which has a long history in the decision-making sector [13].

MCDM in Healthcare SYSTEM

In the healthcare and medical sector, there are numerous methods for making decisions
regarding how to evaluate service quality. For instance, Hsu and Pan [14] investigated
the quality structure of dental services and accurately determined the ranking of the key
qualities using AHP and Monte Carlo techniques. Shieh et al. [15] created and assessed
hospital service quality standards utilizing the DEMATEL method to identify the critical
success factors for such an assessment. To evaluate the provided service quality model,
Büyüközkan et al. [16] used a fuzzy AHP technique. To rank service quality factors,
Altuntas et al. [17] combined AHP and ANP methodologies. In order to construct an
objective and high-quality index of physical treatments and conduct a systematic analysis
and innovation plan application for the hospital’s services, S.-F. Lee and Lee [18] employed
ANP and DEMATEL methodologies. To determine the significant weights of evaluation
criteria for service quality performance and to analyze the caliber of services provided in
private hospitals, Chang [19] used the fuzzy VIKOR technique. In order to determine the
most significant indicators that may be utilized for quality assessment of Iranian health
facilities, Moslehi et al. [20] employed the AHP and Delphi approaches to compute the
weights of quality management indicators. The fuzzy AHP and TOPSIS approaches were
used by Shafii et al. [21] to assess the service quality of a teaching hospital in Yazd, Iran.
In order to evaluate the service quality in the context of healthcare, La Fata et al. [22]
introduced a unique technique based on fuzzy ELECTRE III and importance-performance
analysis (IPA) among various MCDM techniques used in the healthcare system. In AHP,
each element of the hierarchy is given a numerical weight or priority, which enables
varied and sometimes incomparable items to be compared to one another in a fair and
consistent manner. The AHP stands apart from other methods of decision-making because
of this feature.
The present research deals with selecting healthcare organizations that would pro-
vide a high-quality healthcare system using the AHP technique based on surveys from
stakeholders involved in the healthcare system. One of the most significant aspects of
healthcare quality is the level of patient satisfaction. Analysis of healthcare service qual-
ity from the patient’s point of view has beneficial implications for a hospital, including
helping to devise quality improvement strategies [23]. In today’s competitive environ-
ment, providing health services that fulfill patients’ needs and expectations improves an
organization’s chance of survival [24]. To date, various definitions of healthcare quality
have been employed. According to the British National Health Service (NHS), healthcare
quality is described as providing the appropriate services to the right people at the right
time, with the right approach, and within population affordability [25]. Gronroos [26]
developed a two-dimensional quality model that includes both technical and functional
criteria; patients tend to have difficulty recognizing technical quality, although they can
quickly evaluate functional aspects [27]. Several methods have been developed to assess
the quality of healthcare services, which are frequently subject to uncertainty [28]. Thomas
L. Saaty developed AHP in the 1980s as a structured technique for analyzing complex
problems based on mathematics and psychology. Those who use the AHP method first
divide their chosen problem into a hierarchy of better-understood subproblems, each of
which may be examined separately. When the hierarchy is established, the factors are
thoroughly assessed by comparing their impact on an element above them [16].
Sustainability 2022, 14, 12745 3 of 21

Healthcare is entirely a professional service [29] and considers the patient’s perception
as a yardstick for enhancing the quality of service [30]. These days, most hospitals assess
patients’ perception of healthcare SERVQUAL and make an electronic record of their
medical history and satisfaction on a perception scale apart from paper-based records [31].
In assessing the quality of an organization’s services, it is necessary to be aware of ad-
vancements in the documented literature, which necessitates conducting a comprehensive
literature review. As a result, an up-to-date literature review was conducted to ascertain the
gaps in the existing body of knowledge regarding hospital health services. This research
then attempts to fill in some of the gaps in the existing literature. It also aims to identify
how hospital management can enhance patient satisfaction by improving and boosting
their services to the patients.
Any organization with good strategies in place can gain a sustainable competitive
advantage; therefore, it is essential to make the right choices, and as the organizational
environment evolves, it is necessary to continuously adjust or optimize the options that
have been chosen. This will eventually lead to an optimal decision. Process improvement
techniques such as Six Sigma, Lean Six Sigma, Kaizen, and others prioritize judgments
based on the analytic hierarchy process (AHP). They have proven to be helpful because
they take both concrete and intangible variables into account.
The following are the primary goals of this study:
1. To provide a comprehensive assessment of the literature on service quality and a
foundation for future study in this area.
2. To demonstrate the significance of the identified elements and dimensions in analyzing
and measuring the quality of healthcare services.
3. To create an AHP-based hierarchical model to prioritize SRVQUAL dimensions as
well as two extra dimensions and sub-criteria.
4. Utilizing the AHP technique for selecting the healthcare services that offer the best
overall value from among the available options.
The rest of the paper is organized as follows: Section 2 provides an in-depth, cat-
egorized literature review on service quality; the service quality dimension and sub-
criteria; Section 3 concentrates on research design; AHP methodology; and how the
model was developed; and highlights the prioritization of dimension and sub-criteria
of SERVQUAL. Section 4 presents a detailed discussion about results analysis, and finally,
the paper ends with Section 5 conclusions and, Section 6 future scope in the area of service
quality assessment.

2. Theoretical Concepts
This section presents an extensive review of the literature which was carried out to
gain insight into service quality. Accordingly, the literature is broadly classified into three
main concepts: service quality; an overview of healthcare quality; and dimensions and
sub-criteria of service quality.

2.1. Service Quality

The idea of quality has many facets, and it can mean different things to different
people. The concept of service quality cannot be easily defined or quantified due to its
intangible nature. A product or service is only considered to have value once a customer
has purchased it. In most cases, patients purchase items and then rate them based on
their personal experiences when using them. If customers have a good experience with a
product and decide to repurchase it, they are more likely to speak of its benefits to their
friends and family.
Consequently, the consumer’s use of a product, their evaluations of that product, and
word-of-mouth promotion are all effective ways to build its image. As a direct consequence,
the notion of service quality is vague and lacking in precision [32]. This makes it more
challenging to evaluate and control the service.
Sustainability 2022, 14, 12745 4 of 21

Service quality can be considered an attitude resulting from a comparison of expecta-

tions with actual performance, which is comparable to but not the same as pleasure [32].
It is possible to define performance expectations of a product as a belief in its capability
to deliver on the promises it has made. In healthcare, this is based on patients’ beliefs
about the service’s performance and represents their aspirations and desires. Thus, service
quality can be defined as the gap between client expectations and perceived service. When
expectations exceed performance, perceived quality falls short of adequate, resulting in
consumer discontent.

2.2. Healthcare Quality

Patients in Saudi Arabia are becoming more involved in their care and more likely
to make detailed or individualized treatment requests due to this trend. They then rate
the services provided; therefore, as a result, healthcare facilities must continue to monitor
requests and pay close attention to how customers rank their services. Thus, hospitals must
prioritize healthcare quality, caring for their customers, and offering a qualified perceived
service. For this reason, service quality has become an essential commercial strategy for
healthcare firms [33]. Numerous conceptual frameworks are presented in the research
that has been carried out on the evaluation of healthcare quality. Lee et al. [34] found the
dimensions of basic medical service and professionalism/skill to be an extra dimension to
responsiveness, assurance, and confidence. These dimensions evaluate the professionals’
knowledge, technical expertise, training, and experience. Choi, Hanjoon, Chankon, and
Sunhee [35] proposed a four-factor framework, which incorporates physician anxiety, staff
concern, ease of the process of care, and tangible things, which show physical, functional,
environmental, and administration quality.
In a similar manner, Dagger et al. [33] conducted an in-depth investigation of the qual-
ity of healthcare services and developed a scale comprising quality in terms of interpersonal
interactions, specialized expertise, ecological sensitivity, and administrative competence,
which are all critical. They found that customers’ perceptions of interpersonal quality
comprise three primary themes: manner, communication, and relationship, with expertise
and outcome being two key factors influencing customers’ judgments of technical quality.
The primary aspects underpinning customers’ environmental quality assessments were
atmosphere and tangibles. Finally, customers’ evaluations of administrative excellence
were divided into three categories: punctuality, operation, and support [33].
Kalaja et al. [36] assessed the quality of services in the Durres public regional hospital
in Albania and found no significant difference between the perceptions and expectations
of patients. Izadi et al. [37] analyzed the healthcare service using SERVQUAL to measure
patients’ expectations and perceptions of performance in Iran and found a significant
gap between the two. Pekkaya et al. [38] also used the SERVQUAL model to monitor
healthcare quality at a hospital in the UAE and found that the hospital scored highly on the
SERVQUAL scale in terms of tangible dimensions. Riono and Ahmadi [39] analyzed the
healthcare quality in an Indonesian hospital. They suggested that the results of the study
could assist the management in determining policy strategy by prioritizing attributes that
have a big gap to improve the quality of its services.
Abbasi-Moghaddam et al. [40] evaluated the SERVQUAL of a clinic at a teaching
hospital in Iran. They found that out of eight SERVQUAL dimensions, the patients were
satisfied with physician consultation, admission process, and service cost only. Schrim-
mer et al. [41] discussed the development of a healthcare quality competency framework
depicting eight dimensions required for success in healthcare.

2.3. Dimension and Sub-Criteria of Service Quality

Service quality has become an indispensable aspect of the success of an organization.
An organization dealing with services is dealing with utmost care as it affects customer
satisfaction in a big way. Many researchers have defined service quality; for example,
Vargo and Lusch [42] define it as the use of specialized competencies (knowledge and
Sustainability 2022, 14, 12745 5 of 21

skills), through actions, procedures, and performances, for the benefit of another entity
or the entity itself, while Edvardsson et al. [43] define service as “connected activities
and interactions that solve customer problems.” In both definitions, a service must have
a beneficial consequence (benefits or solutions). In other words, services are exchanges
between workers and consumers (service encounters or moments of truth) in which the
favorable outcome is recognized as value-in-use. The seven dimensions of healthcare
service quality are studied along with sub-criteria. Table 1 presents the seven dimensions
of service quality along with the sub-criterion of each dimension considered for the present
research with its definitions.

Table 1. Healthcare service quality evaluation criterion and criteria group.

Quality of Service Dimension Criterion Definition

Conveniently located within the hospital, in addition to having
Tangibles Building layout
an aesthetic appeal
Equipment Modern equipment
Hygiene Maintaining the cleanliness of both the facility and its staff
Appearance Cleanliness of the hospital
Freedom of movement allowed for patients and visitors inside the
Space
facility
Completion of all operations as well as on-time delivery of the
Responsiveness Timeliness
service promised
The ability of the medical center to deliver a diverse selection of
Completeness
services
Providing patients with willing assistance when required and
Willingness
actively listening to patients
Accessibility Easy access to hospital patient information
Promptness Providing patients with voluntary assistance
Delivering services at the agreed-upon time and in the manner
Reliability Accuracy
promised.
Expertise Authority of staff members ensuring dependability
Image Creating a positive image for the general population.
Skills Doctors’ knowledge and expertise
Knowledge Doctors and nurses addressing patients’ inquiries professionally.
The hospital is equipped to handle the patients’ medical issues
Assurance Effective
efficiently.
Guarantee The accomplishment of successful treatment
The helpfulness of the employees, in addition to their capacity to
Courtesy
inspire people to feel trust and confidence in themselves
Providing patients with some kind of assurance if something goes
Compensation
wrong.
Empathy Helpful Understanding patients’ specific needs
Manner Individualized care delivered in a pleasant manner
Concern Giving individual attention
Understanding Understanding needs and requirements
Information shared between medical staff and patients, the
Communication degree of interaction between the two groups, and the degree of
communication in both directions
Constancy Skill Staff ability and performance are being evaluated.
Honesty The credibility of the service provider
Experience Experience comes about gradually over time
Increasing hospital staff and services through training and new
Innovation
technology
Security Confidentiality Protection of the patient’s personal information
Personal safety Personal safety during patient service participation
Hospital’s infection safety Protection against infectious diseases
Sustainability 2022, 14, 12745 6 of 21

3. Research Design
According to research, tangibles, responsiveness, reliability, assurance, empathy and
constancy, and security are used to evaluate healthcare service quality. These can include
physical facilities and equipment, the usability of the hospital, and hygiene [44]. Lee and
Yom [45] considered the design or layout of a hospital to be tangible, so they included it in
the definition. Hospitals need to be easy for patients to get to. In addition to this, patients
should know how to read the signs and symbols used in medical settings to feel at ease.
Furthermore, the hospital also needs the right equipment to do a good job; this includes
bed frames, surgery tools, medicines, etc.
One of the most important aspects of service quality is hygiene, in particular, how
clean the people and the hospital are. Since hospitals are concerned with people’s health,
they are considered a symbol of hygiene. To prevent the growth of diseases, surgical
equipment, patients’ rooms, and the surrounding environment should be free of bacteria.
Responsiveness is the consistent eagerness to serve patients and provide timely, correct
service. It involves timeliness [33], the ability to offer, and the capacity to deliver, operations
and the promised service on time. Additionally, timeliness includes how simple it is to
schedule medical appointments, the length of time the patient must wait to be seen, how
simple it is to reschedule appointments, and how long the office is open. Hospitals must
be able to provide immediate aid to anyone in need, regardless of their ability to make
an appointment in advance. Completeness is an important sub-dimension for delivering
quality service. Hospitals must be able to provide all types of treatment, as the client will be
dissatisfied if their disease cannot be treated in the hospital to which medical professionals
have sent them. In conclusion, the definition of responsiveness incorporates willingness [45]
as an attribute. It implies that personnel are willing to aid patients whenever necessary,
listen to their problems, and devise solutions based on the demands of the clients they serve.
Reliability is the capacity to deliver the promised service consistently and precisely.
Accuracy relates to delivering information about a service clearly and concisely, showing
that the service provider should be concerned with human health. This includes informa-
tion provided by the hospital, such as disease diagnosis and surgical expenses. Image and
skill add to the hospital’s trustworthiness. The more positive the image presented by the
hospital, the more credible it will be. When a service provider is skilled, they can meet
strict requirements [33]. The specialization of doctors, nurses, and other medical personnel
is essential if patients are to have confidence in a hospital’s services.
The assurance dimension describes the employees’ expertise, kindness, and ability
to inspire trust and confidence in others. Since patients feel psychologically dependent
on service providers, the employees’ politeness is crucial for the patients’ confidence [32].
Protecting all types of consumer data, including patient information, is crucial for establish-
ing trust. Aspects of assurance include how an organization compensates for its patients’
issues. In the event of a problem, patients can be reassured by compensatory free services
in the future and an apology.
Moreover, a reasonable cost of therapy for patients appears to be needed. Patients
prefer the entire cost of services to be provided ahead of treatment rather than having
additional fees presented later; otherwise, hospitals risk losing patients.
In the context of healthcare service excellence, empathy demonstrates compassion and
understanding for patients. Caring is defined by customized customer service, attention
to patients, and the ability to detect and address patients’ needs. In a service setting, the
behavior and attitude of staff are just as important as their compassion. One of the most
talked-about things is how a service provider (doctor, nurse, secretary, etc.) and a patient
get along. Examples are, “The personnel are helpful” and “They are sympathetic and
caring.” Communication is essential for developing empathy. This includes the flow of
information between professionals and patients, as well as the level of interaction and
two-way communication.
Constancy includes knowledge, technical expertise, education, and experience. A per-
son’s ability and competence in their field of work, as well as their ability and competency
Sustainability 2022, 14, 12745 7 of 21

in their area of work, constitute their skill [46]. Patients place a premium on accurate initial
disease diagnosis and treatment. Experience is a collection of step-by-step occurrences
which enables hospital workers to make decisions regarding patients’ circumstances. In
judging innovation, the level of professionalism is also taken into account. The performance
of hospital staff should be enhanced through training, and the performance of hospital
services should be enhanced through new technologies.
In conclusion, security can be defined as the state of being free from any kind of danger,
risk, or uncertainty during the time spent engaging in the process of delivering patient
service. This safety is maintained on a personal level. When a patient gives information
to the hospital, it is the duty of the hospital to ensure the patient’s right to privacy [32]. It
is essential to ensure the safety of all kinds of customer data, such as patient records, to
create customer confidence. As can be seen in Table 1, the considerations that form the basis
of our criteria and qualities for assessing the level of quality provided by the healthcare
services are as follows.

3.1. Methodology
Even within the healthcare industry, service quality can be challenging to maintain. It
involves multiple criteria and unclear, qualitative features that are hard to measure. The
service quality literature describes qualitative and quantitative methodologies, with models
such as statistical analysis and decision theory. The difficulty in assessing service quality is
exacerbated by the ambiguity of novel technologies and the scarcity of professionals. Due to
the intangible and diverse criteria structure, a powerful approach that can handle ambiguity
should be used. MCDM is a popular and influential approach for analyzing service quality
performance choices, which helps decision-makers face contradicting assessments [47]. The
AHP is a helpful tool for making decisions in various contexts, including selection, ranking,
prioritization, allocation of resources, benchmarking, and process improvement. The latter
is concerned with the multifaceted aspects of quality and quality development. The analytic
hierarchy process, or AHP, was initially developed by Saaty [48]. It is a quantitative tool
that helps in the framework of a complex maldistributed problem and provides a goal
methodology for choosing between a set of attributes to find the best combination for
tackling that problem and involves a series of steps, as below [49].
First, the overall importance of the traits must be established, which can be accom-
plished by utilizing expert opinion or through an in-depth analysis of matched compar-
isons [50]. Table 2 shows Saaty’s ratio scale This scale represents a “one-to-one” mapping
between linguistic choices available to decision makers (DMs) and discrete numbers rep-
resenting the priority or weight of the previous linguistic choice (s) [50]. Then, different
weights are assigned to each attribute with the use of an algorithm. The alternative ap-
proaches to each attribute’s solution are analyzed similarly, and a single score is created
for all of the possible solutions. Finally, one might rank and arrange the many potential
solution options based on their final score and select the best option. In the present study, a
panel of six experts (two doctors, two nurses and two top administrators from each of the
three hospitals) developed the model, as shown in Figure 1.

Table 2. Nine-point scale for AHP analysis.

Intensity (1) (3) (4) (7) (9) (2,4,6,8)

Linguistic Equal Moderate Strong Demonstrated Extreme Intermediate-Value
 weights are assigned to each attribute with the use of an algorithm. The alternative ap-
proaches to each attribute’s solution are analyzed similarly, and a single score is created
for all of the possible solutions. Finally, one might rank and arrange the many potential
solution options based on their final score and select the best option. In the present study,
Sustainability 2022, 14, 12745a panel of six experts (two doctors, two nurses and two top administrators from each of 8 of 21
the three hospitals) developed the model, as shown in Figure 1.

Sustainability 2022, 14, x FOR PEER REVIEW 9 of 22

Figure 1.Figure 1. Framework
Framework for measurement
for measurement ofof
of quality quality ofin
service service in healthcare.
healthcare.

There are
There are four basic steps in AHP methodology, four basic
as shown steps in
in Figure AHP methodology, as shown in Figure 2 [49].
2 [49].

Figure2.2.AHP
Figure AHPmethodology.
methodology.

To solve decision problems, the AHP methodology can be summarized with the help
Table 2. Nine-point scale for AHP analysis
of the following equation:
Intensity (1) (3) (4) (7) (9) (2,4,6,8)
Intermediate-
Linguistic Equal Moderate Strong Demonstrated Extreme
Value
To solve decision problems, the AHP methodology can be summarized with the help
Sustainability 2022, 14, 12745 9 of 21

1. First, we build pairwise comparisons, presented by questionnaires with the expert’s

subjective perception having a set of n attributes denoted by (a ee 1 , a
ee 1 ,. . . ., a
ee m ) according to
their relative importance weights denoted by (w ee 1, w
e 2 , . . . .., w
e e m)
e

e 11 · · · a
e 
a ee 1m
Ae=  .
 . . .. .. ; m → the no. of considered evaluation criteria (1)
. . 
a
ee m1 ··· a
ee mm

(A
e ij ) where i,j = 1,2,3 . . . .m;
e ij ) = 1 for all i = j;
(A
e ij = 1 ) for i 6= j (the positive-reciprocal of the matrix elements);
(A eA ij

where A e →a real matrix of dimension (m × m);

and the diagonal element value in the above matrix ( A e) is equal to 1. ( A
eij = 1; i = j).
Founded on the three conditions listed below, the importance of one criterion, i.e.,
((equal, less and more) importance) over the other criteria can be defined as:
Condition 1—(a ee ij > 1) denotes that the ith criterion is relatively more important than
the jth criterion.
Condition 2—(a ee ij < 1) denotes that the ith criterion is relatively less important than
the jth criterion.  
Condition 3— a ee ij = 1 denotes that both criteria hold relatively equal importance.
2. For the normalization of the matrix ( A),
e find the ‘operator equation’;
n
ee =
w ∑ aee ij ; (2)
j =1

The next step, after completion of the formation of pairwise comparison matrices, is
the normalization process of the matrix by using the operator equation (Equation (2)).

a11 · · · a1m
 

ee − 1
=  ... .. · 1 , 1 , . . . . . . . . . . 1 ;
h i
A n ..
e = ∑ j =1 a
e ee ij ·w 
.
w
e j .  e e w
e1 w
e2 e w
en
am1 · · · amm
 a11 a1m (3)
···

w
ee 1 w
ee n

= .. .. .. 
 . . .


am1 amm
···
wee 1 wee n

We find the normalized principle eigenvector using Equation (4):

 1 
· · · ae1m
 a11
w w
en  1 
 1 .
e
e
fj = 1 ∑n aij =  ..
W
f . .
..  ·
  −1
..  · n ;
 . . 

n j =1 w
. 
ee j
am1
· · · aemm

we1
e w
en 1
 1 n a1j  (4)
n ∑ j =1 wee j
.
 
=
 .. 


1 n a nj

n ∑ j =1 w ee j

Using Equation (5), we find the final weight of the alternatives:

f= MMULT ( Arrayi , Array j ).

W
f (5)

In order to evaluate the level of agreement between the panel of experts, the kappa
coefficient is used. The computation is based on the difference between the actual amount
Sustainability 2022, 14, 12745 10 of 21

of agreement and the expected amount of agreement, anticipated to be there only by

coincidence. A kappa value of 0 indicates that there is a poor agreement between the
methods, and a value of 1 indicates an almost perfect agreement. For the present result, the
value of kappa is 0.83, which is close to 1. Hence, there is a close agreement in the survey.

3.2. Model Development

As indicated in the preceding section, comprehensive literature research was con-
ducted to determine service quality dimensions and sub-criteria. Prior to gathering any
data, a conceptual model for a decision problem must be developed. Hence, model de-
velopment uses 7 dimensions and 31 sub-criteria. Three hospitals, Abha Private Hospital
(APH), Asir General Hospital (AGH), and Al Haya Hospital (AHH), were chosen based on
demand in the Asir region to examine the quality of healthcare services. To conceal their
identities, the three hospitals are called Healthcare Services A, Healthcare Services B, and
Healthcare Services C, respectively.
An AHP-based questionnaire was created, developed, and administered, with several
comparison tables containing the 7 dimensions and 31 sub-criteria of service quality. A
consensus was reached by brainstorming and formal discussion on critical decision-making.
The following are the three options being assessed to find the best healthcare services:
Abha Private Hospital (APH)
Asir General Hospital (AGH)
Al Haya Hospital (AHH)
The hospital management cares for the cleaning, maintenance and feeding for the
comfort of the patient. There are 6 sections in the hospital: (1) the men’s section, (2) the
women’s section, (3) children from 1 day old to 15 years, (4) surgery, (5) intensive care
for premature babies, and (6) premature infants. The hospital also has facilities such as
outpatient clinics, specialized units, service units, radiology, laboratories, physiotherapy,
pharmacies and non-medical services. The demand for healthcare is affected by a number
of factors, including the following: needs (as perceived by patients), patient preferences,
price or cost of use, income, transportation costs, waiting times during service and the
quality of care received from the patient point of view.
Sustainability 2022, 14, x FOR PEER REVIEW 11 of 22
Figure 3 depicts a step-by-step evaluation of the best healthcare services, demonstrat-
ing how the model was created utilizing the AHP approach.

Figure 3. Model development.

Figure 3. Model development.

3.3. Prioritization of Dimensions and Sub-Criteria

All seven aspects of service quality were compared to each other in terms of the goal,
which was to evaluate the quality of service in healthcare services. Comparing two di-
mensions shows how important each is to the model’s goal. Various pairwise comparison
was made, and each pairwise comparison’s matrix was checked by calculating λ max, the
consistency index (CI), and the consistency ratio (CR). It was found that all the tables met
Sustainability 2022, 14, 12745 11 of 21

3.3. Prioritization of Dimensions and Sub-Criteria

All seven aspects of service quality were compared to each other in terms of the
goal, which was to evaluate the quality of service in healthcare services. Comparing two
dimensions shows how important each is to the model’s goal. Various pairwise comparison
was made, and each pairwise comparison’s matrix was checked by calculating λ max, the
consistency index (CI), and the consistency ratio (CR). It was found that all the tables met
the requirement of the consistency check.
The local weight of each dimension was calculated by calculating the overall prefer-
ences of seven service quality dimensions: tangibles, responsiveness, reliability, assurance,
empathy, constancy, and security. The five-sub criteria for tangibles were building layout,
equipment, hygiene, appearance, and space. The five sub-criteria considered for respon-
siveness were timeliness, completeness, willingness, accessibility, and promptness. The five
sub-criteria considered for reliability were accuracy, expertise, image, skills, and knowledge.
The four sub-criteria considered for assurance were effectiveness, guarantee, courtesy, and
compensation. The five sub-criteria considered for empathy were helpfulness, manner,
concern, understanding, and communication. Finally, the four sub-criteria considered for
constancy were skill, honesty, experience, and innovation.
The three sub-criteria considered for security were confidentiality, personal safety,
and hospital infection safety. As with the local dimension weight, the local weights of all
sub-criteria were computed. The global weight was computed by taking the product of
respective dimensions with their sub-criteria. The pairwise comparison matrices for the
seven dimensions are shown in Table 3, and the pairwise comparisons of sub-criteria are
shown in Tables 4–11. The pairwise comparison of three alternatives with respect to three
sub-criteria to enhance security criteria/dimensions is shown in Tables 11–13. The other
results were computed similarly and are incorporated in Table 14.

Table 3. Pairwise Comparison of Service Quality Dimensions.

Dimensions Tangibles Responsiveness Reliability Assurance Empathy Constancy Security E-Vector

Tangibles 1 6 1/2 1 2 3 1 0.2166
Responsiveness 1/6 1 1/2 1 1 2 1 0.1019
Reliability 2 2 1 2 2 3 2 0.2449
Assurance 1 1 1/2 1 1 2 1/2 0.1153
Empathy 1/2 1 1/2 1 1 2 1/2 0.1007
Constancy 1/3 1/2 1/3 1/21/2 1/2 1 1/3 0.0574
Security 1 1 1/2 2 2 3 1 0.1633
λ max = 7.4; CR = 0.049; CI = 0.066

Table 4. Pairwise Comparison of Five Sub-Criteria/Factors for Tangible Criteria/Dimension.

Sub-Criteria/Factors Building Layout Equipment Hygiene Appearance Space E-Vector

Building layout 1 1/2 1/3 2 3 0.1503
Equipment 2 1 1/2 3 4 0.2475
Hygiene 3 2 1 6 8 0.4650
Appearance 1/2 1/3 1/6 1 2 0.0845
Space 1/3 1/4 1/8 1/2 1 0.0527
λ max = 5.03; CR = 0.006; CI = 0.007
Sustainability 2022, 14, 12745 12 of 21

Table 5. Pairwise Comparison of Three Sub-Criteria/Factors for Responsiveness Criteria/Dimension.

Sub-Criteria/Factors Timeliness Completeness Willingness Accessibility Promptness E-Vector

Timeliness 1 9 1 1/2 1/3 0.1598
Completeness 1/9 1 1/9 1/9 1/9 0.0260
Willingness 1 9 1 1/2 1/2 0.1720
Accessibility 2 9 2 1 1/2 0.2618
Promptness 3 9 2 2 1 0.3804
λ max = 5.15; CR = 0.034; CI = 0.039

Table 6. Pairwise Comparison of Three Sub-Criteria/Factors for Reliability Criteria/Dimension.

Sub-Criteria/Factors Accuracy Expertise Image Skills Knowledge E-Vector

Accuracy 1 1/3 1/2 1/2 1/3 0.0865
Expertise 3 1 2 2 2 0.3404
Image 2 1/2 1 2 1/2 0.1801
Skills 2 1/2 1/2 1 1/2 0.1360
Knowledge 3 1/2 2 2 1 0.2571
λ max = 5.13; CR = 0.028; CI = 0.032

Table 7. Pairwise Comparison of Four Sub-Criteria/Factors for Assurance Criteria/Dimension.

Sub-Criteria/Factors Effective Guarantee Courtesy Compensation E-Vector

Effective 1 1/9 1/2 1/9 0.0414
Guarantee 9 1 9 2 0.5272
Courtesy 2 1/9 1 1/9 0.0586
Compensation 9 1/2 9 1 0.3728
λ max = 4.12; CR = 0.044; CI = 0.04

Table 8. Pairwise Comparison of four Sub-Criteria/Factors for Empathy Criteria/Dimension.

Sub-Criteria/Factors Helpful Manner Concern Understanding Communication E-Vector

Helpful 1 7 1/2 3 1/2 0.2215
Manner 1/7 1 1/5 1/4 1/6 0.0410
Concern 2 5 1 2 2 0.3380
Understanding 1/3 4 1/2 1 1/3 0.1170
Communication 2 6 1/2 3 1 0.2824
λ max = 5.28; CR = 0.06; CI = 0.07

Table 9. Pairwise Comparison of three Sub-Criteria/Factors for Constancy Criteria/Dimension.

Sub-Criteria/Factors Skill Honesty Experience Innovation E-Vector

Skill 1 1/2 2 2 0.2762
Honesty 2 1 2 2 0.3905
Experience 1/2 1/2 1 2 0.1953
Innovation 1/2 1/2 1/2 1 0.1381
λ max = 4.12; CR = 0.04; CI = 0.04
Sustainability 2022, 14, 12745 13 of 21

Table 10. Pairwise Comparison of three Sub-Criteria/Factors for Security Criteria/Dimension.

Sub-Criteria/Factors Confidentiality Personal Safety Hospital’s Infection-Safety E-Vectors

Confidentiality 1 3 1/3 0.2499
Personal safety 1/3 1 1/6 0.0953
Hospital’s infection-safety 3 6 1 0.6548
λ max = 3.01; CR = 0.019; CI = 0.009

Table 11. Pairwise Comparison of three Alternatives with respect to sub-criteria of Confidentiality to
enhance Security Criteria/Dimension.

Security
APH AGH AHH E-Vectors
Sub Criteria
APH 1 4 1/2 0.33
AGH 1/4 1 1/5 0.10
AHH 2 5 1 0.57
λ max = 3.02; CR = 0.025, CI = 0.012

Table 12. Pairwise Comparison of three Alternatives with respect to sub-criteria of Personal safety to
enhance Security Criteria/Dimension.

Security
APH AGH AHH E-Vectors
Sub Criteria
APH 1 5 2 0.56
AGH 1/5 1 1/4 0.09
AHH 1/2 4 1 0.35
λ max = 3.02; CR = 0.025, CI = 0.012

Table 13. Pairwise Comparison of three Alternatives with respect to sub-criteria of Hospital’s infection
safety to enhance Security Criteria/Dimension.

Security
APH AGH AHH E-Vectors
Sub Criteria
APH 1 4 2 0.56
AGH 1/4 1 1/3 0.12
AHH 1/2 3 1 0.32
λ max = 3.01; CR = 0.019, CI = 0.009

Furthermore, all three options, i.e., Abha Private Hospital (APH), Asir General Hospi-
tal (AGH), and Al Haya Hospital (AHH), were compared for each sub-criteria of the seven
dimensions of service quality. Then, their results were calculated to assess the healthcare
services, and the global weight of all three alternatives was computed by taking the product
of the sub-criterion global weight with the local weight of the three alternatives. Finally, the
summation of all three alternative global weights was taken. The alternative with a higher
summation value is the best, while the one with the most negligible value is considered the
worst. The synthesized comparison matrix is shown in Table 14.
Sustainability 2022, 14, 12745 14 of 21

Table 14. Composite Priority Weights for Criteria and Sub-criteria to Establish Best Healthcare Services.

Local Global
Dimension Local wt. Sub-Criteria APH Lw AGH Lw AHH Lw APH Gw AGH Gw AHH Gw
Wt. Weight
Building
Tangibles 0.21656 0.1503 0.032549 0.59363 0.157053 0.249317 0.019322044 0.005111913 0.008115011
layout
Equipment 0.2475 0.053599 0.539613 0.163425 0.296962 0.028922501 0.008759351 0.015916747
Hygiene 0.465 0.1007 0.625005 0.136505 0.238491 0.062938254 0.013746108 0.024016139
Appearance 0.0845 0.018299 0.238491 0.136505 0.625005 0.004364223 0.002497949 0.011437166
Space 0.0527 0.011413 0.097737 0.186961 0.715302 0.001115444 0.002133732 0.008163536
Responsiveness 0.101941 Timeliness 0.1598 0.01629 0.31082 0.195798 0.493382 0.005063311 0.003189583 0.008037278
Completeness 0.026 0.00265 0.31082 0.195798 0.493382 0.000823818 0.000518956 0.001307692
Willingness 0.172 0.017534 0.660759 0.131109 0.208133 0.011585651 0.002298846 0.003649373
Accessibility 0.2618 0.026688 0.31082 0.195798 0.493382 0.008295212 0.005225487 0.013167455
Promptness 0.3804 0.038778 0.333072 0.09739 0.569539 0.012915985 0.003776624 0.022085786
Reliability 0.244906 Accuracy 0.0865 0.021184 0.493382 0.195798 0.31082 0.010451986 0.004147857 0.006584526
Expertise 0.3404 0.083366 0.31082 0.195798 0.493382 0.025911821 0.016322897 0.041131285
Image 0.1801 0.044108 0.539613 0.296962 0.163425 0.023801018 0.013098272 0.00720828
Skills 0.136 0.033307 0.571429 0.142857 0.285714 0.019032709 0.004758169 0.009516338
Knowledge 0.2571 0.062965 0.184003 0.231822 0.584175 0.01158581 0.014596749 0.036782773
Assurance 0.115299 Effectiveness 0.0414 0.004773 0.654798 0.095343 0.249859 0.003125599 0.000455108 0.001192672
Guarantee 0.5272 0.060786 0.625005 0.136505 0.238491 0.037991324 0.008297543 0.014496826
Courtesy 0.0586 0.006757 0.296962 0.539613 0.163425 0.00200643 0.003645907 0.001104185
Compensation 0.3728 0.042983 0.527828 0.139646 0.332527 0.022687878 0.006002469 0.014293163
Empathy 0.100666 Helpfulness 0.2215 0.022298 0.648329 0.12202 0.229651 0.014456128 0.002720743 0.005120648
Manner 0.041 0.004127 0.527828 0.139646 0.332527 0.002178508 0.000576362 0.001372441
Concern 0.338 0.034025 0.332527 0.139646 0.527828 0.011314267 0.00475147 0.017959405
Understanding 0.117 0.011778 0.44343 0.1692 0.38737 0.005222684 0.001992824 0.004562414
Communication 0.2824 0.028428 0.539613 0.163425 0.296962 0.015340161 0.004645859 0.008442059
Local Global
Dimension local wt. Sub-Criteria APH Lw AGH Lw AHH Lw APH Gw AGH Gw AHH Gw
Wt. Weight
Constancy 0.057368 Skill 0.2762 0.015845 0.163425 0.539613 0.296962 0.002589476 0.00855019 0.004705375
Honesty 0.3905 0.022402 0.238491 0.625005 0.136505 0.005342724 0.01400149 0.003058013
Experience 0.1953 0.011204 0.296962 0.539613 0.163425 0.003327153 0.006045808 0.001831009
Innovation 0.1381 0.007923 0.587629 0.088984 0.323386 0.004655503 0.000704978 0.002562032
Security 0.163261 Confidentiality 0.249859 0.040792 0.333072 0.09739 0.569539 0.01358675 0.003972755 0.023232766
Personal safety 0.095343 0.015566 0.569539 0.09739 0.333072 0.008865326 0.001515953 0.00518453
Hospital’s
0.654798 0.106903 0.558424 0.121957 0.319619 0.059697188 0.013037566 0.034168222
infection safety
0.458516886 0.181099519 0.360405144

The MCDM helps analyze dimensions, main criteria, and sub-criteria critically to
facilitate making a decision as to which hospital has the best healthcare system (alternatives).
Since the best healthcare system plays a vital role in the selection of a hospital for any
health organization, patients can choose based on the facility provided. The selected
alternative (hospital) must be in a position to cater to the patient’s needs. Looking to the
requirements, AHP-based modeling has been used in the present condition. The AHP has
excellent potential to evaluate and rank the dimensions and sub-criteria that are significant
decision-making parameters when selecting a hospital. Based on the chosen dimensions
and subfactors, the people involved in the health system can run it smoothly and effectively,
as it is made easy for those in charge to constantly evaluate, track, and manage the criteria
to fit with their strategic goals. Since expensive infrastructure (hardware and software)
technologies are required to ensure that the healthcare system works well and is solid,
ranking dimensions and sub-criteria can help with planning and managing resources.
 sources. AHP and ranking, followed by comparison, can be used to determine the correct
order of importance for the dimension, sub-criteria, and choice of hospital.
The AHP provides the ranking of dimensions of the healthcare system as reliability
> tangibles
Sustainability 2022, 14,> security >assurance > responsiveness >empathy >constancy, where 15‘>‘of 21
12745 indi-
cate preference over another. From the result, it may be concluded that the reliability di-
mension plays a significant role. In contrast, constancy plays a comparatively less signifi-
AHP and ranking, followed by comparison, can be used to determine the correct order of
cant role in decidingimportance the preference of the sub-criteria,
for the dimension, healthcare andsystem, as shown in Figure 4. The
choice of hospital.
prioritization of this service The AHP quality dimension
provides the ranking ofhelps the organization
dimensions understand
of the healthcare system the>im-
as reliability
tangibles > security >assurance > responsiveness >empathy >constancy, where ‘>’ indicate
portance of each dimension so that the manager can use these weights and the importance
preference over another. From the result, it may be concluded that the reliability dimension
of dimensions in strategic decision-making.
plays a significant role. In contrast,All the sub-criteria
constancy of a dimension
plays a comparatively less significantare com-
role in
pared to the goal to achieve. deciding the preference
Thus, of the healthcare
31 sub-criteria ofsystem, as shown
the seven in Figure 4. The
dimensions wereprioritization
calculated,
of this service quality dimension helps the organization understand the importance of each
as were the various relationships
dimension so that between
the managerthese
can usefactors. Based
these weights onimportance
and the the sub-criteria
of dimensionsforintan-
gible dimensions, hygiene strategic > equipment >Allbuilding
decision-making. layout
the sub-criteria > appearance
of a dimension > space.
are compared to theFrom
goal to the
achieve. Thus, 31 sub-criteria of the seven dimensions were calculated, as were the various
weightage in Figure relationships
5, it may be concluded that the hygiene sub-criterion plays a signifi-
between these factors. Based on the sub-criteria for tangible dimensions,
cant role. In contrast,hygiene space >plays a comparatively
equipment > building layoutless significant
> appearance roleFrom
> space. in deciding the in
the weightage pref-
erence among tangible Figuredimensions.
5, it may be concluded that the hygiene
The results sub-criterion
of other plays a significant
dimensions’ role. In are
sub-criteria
contrast, space plays a comparatively less significant role in deciding the preference among
shown in Figure 5. tangible dimensions. The results of other dimensions’ sub-criteria are shown in Figure 5.

Reliability 0.2449

Tangibles 0.2166
Dimensions

Security 0.1633

Assurance 0.1153

Responsiveness 0.1019

Empathy 0.1007

Constancy 0.0574

0.0000 0.0500 0.1000 0.1500 0.2000 0.2500

Weightages

Figure 4. Weights of Dimensions.

Figure 4. Weights of Dimensions.

From the sub-criteria global weight, as shown in Figure 6, the sub-criterion hospital
infection is a highly influential sub-criterion, while completeness is given the least priority.
From the result of alternative pairwise comparison and global weight, as shown in
Figure 7, the AHP provides the ranking of alternatives, i.e., hospital as APH > AHH >
AGH. This indicates that the preference for the Abha private hospital is higher, and the
Abha government hospital ranks as the lowest healthcare facility to the patient.
 Sustainability2022,
Sustainability 2022,14,
14,12745
x FOR PEER REVIEW 17of
16 of21
22

Figure5.5.Weights
Figure Weightsof
ofSub-criteria.
Sub-criteria.
 ity. From the result of alternative pairwise comparison and global weight, as shown in
Figurethe
From 7, result
the AHP provides the
of alternative ranking
pairwise of alternatives,
comparison i.e., hospital
and global weight,as asAPH
shown > AHH
in >
AGH.
Figure This
7, the AHPindicates
providesthatthe
theranking
preference for the Abha
of alternatives, private
i.e., hospital
hospital as APH is higher,
> AHHand > the
AGH.Abha
Thisgovernment
indicates thathospital ranks as for
the preference the the
lowest
Abhahealthcare facility to
private hospital is the patient.
higher, and the
Abha government hospital ranks as the lowest healthcare facility to the patient.
Sustainability 2022, 14, 12745 17 of 21

Priority Based on Global Weight

Priority Based on Global Weight
33
33 31
31 29
29 27
27 25
25 23
23 21
Subcriteria

21 19
Subcriteria

19 17
17 15
15 13
13 11
11 9
9 7
7 5
5 3
3 1
1 0 0.02 0.04 0.06 0.08 0.1 0.12
0 0.02 0.04 Global
0.06 Weightages
0.08 0.1 0.12
Global Weightages

Figure 6.
Figure 6. Priorities
Priorities of
of Sub-criteria
Sub-criteria Based
Based on
on Global
Global Weight.
Weight.
Figure 6. Priorities of Sub-criteria Based on Global Weight.

Priorities of Hospital
Priorities of Hospital
APH 0.459
APH 0.459
Hospital

AHH
Hospital

0.360
AHH 0.360

AGH 0.181
AGH 0.181

0.000 0.050 0.100 0.150 0.200 0.250 0.300 0.350 0.400 0.450 0.500
0.000 0.050 0.100 0.150 0.200 Weightage
0.250 0.300 0.350 0.400 0.450 0.500
Weightage
Figure 7.
Figure 7. Ranking
Ranking of
of Hospitals
Hospitals Based
Based on
on Healthcare
HealthcareFacility.
Facility.
Figure 7. Ranking of Hospitals Based on Healthcare Facility.
4. Discussion
This study took into account the 7 criteria and 31 subcriteria for evaluating the service
quality of three hospitals in the Asir region, Saudi Arabia using the AHP technique. The
AHP lists the healthcare system’s dimensions in the following order: reliability > tangibles
> security > assurance > responsiveness > empathy > constancy. The study’s findings
showed that these seven dimensions might be used to assess how much there is a difference
in service quality in the hospitals. The study by Zarei et al. [51] done in Iranian private
hospitals revealed that the tangible dimension had the greatest average score, and the
empathy dimension had the lowest average. This is almost similar to the results of the
Sustainability 2022, 14, 12745 18 of 21

present study. The Ramez [52] research placed assurance as the lowest and reliability as
the top service quality factor, which is somewhat similar to our result. According to Abu
Kharmeh [53], responsiveness is the most crucial factor, whereas reliability is the least
crucial factor, which contradicts the present study’s findings. An appealing outpatient
environment and adequate outpatient services are regarded as one of the most important
reasons for patients to visit the hospital, and the physical environment of the hospital
plays a significant role in increasing the service quality. The tangible factor, which is
concerned with the physical infrastructure of treatment in private hospitals in Jordan,
Saudi Arabia, Iran, and Malaysia, is where expectations and perceptions were shown
to be the greatest in previous studies [53,54]. In contrast to the findings of our study,
Marzban et al.’s [55] investigation showed that the assurance component was regarded as
the most important dimension with the highest ratings. This study may be expanded to
examine the relationship between overall satisfaction and aspects of service quality. Future
research should take into account the perspectives of both service providers and patients. To
better comprehend the complexity of service quality in future studies, it is vital to perform
qualitative research with quantitative methods. It should be remembered that patients’
opinions and expectations for service quality cannot be captured by one instrument.

5. Conclusions
The purpose of this research was to develop a model that could be utilized to evaluate
the quality of services in the healthcare field and to evaluate the effectiveness of several
pioneering Asir hospitals via the application of the AHP method. As a consequence,
information from the practices of five highly qualified medical professionals in Asir was
compiled and incorporated into the model to assess the relative effectiveness of various
choices in terms of patient care (hospitals). According to the findings, hospitals should
concentrate the most on reliability, tangibles, and security and the least on consistency. In
addition, according to the sub-criteria, the hospitals’ primary priority should be infection
prevention and hygiene, with completeness receiving the least attention. Based on a survey
of dimensions and their sub-criteria, the best hospital is Abha Private Hospital, followed
by AHH, and then Asir General Hospital.
The findings of this study provide management with valuable information on the
factors that demonstrate how satisfied patients are with the standard of treatment they
receive. By addressing the specific limitations, they face, hospitals have the potential to
boost the quality of their services and provide patients and customers with an even higher
level of satisfaction. AHP was utilized to evaluate the proposed model; however, other
methods can be employed to determine the quality of healthcare service. These approaches
might be used to find a solution to the service quality and performance problem in further
studies, and the findings could then be compared to one another.

6. Recommendation for Future Research

In general, we advise using the AHP to support the evaluation of healthcare tech-
nology when faced with complex decision-making issues, when it is necessary to share
information among experts or between clinicians and patients, when there is a shortage of
knowledgeable respondents, or when it is necessary to improve decision-making rather
than merely explaining decision outcomes. Its primary benefit is that it permits talks
amongst panelists and, as a result, information sharing. AHP can help health economic
analyses of novel medical technologies, to be more precise. AHP may play a role in (1)
prioritizing various patient-related outcomes in clinical trials and (2) assessing the net
benefit of healthcare treatments, even though it has largely been established to help man-
agement decision-making. It is feasible to establish weights for individual and for groups
of patient-relevant endpoints by creating a hierarchical structure of the outcome measures
taken into account. This could be done before the benefits analysis, ideally with plenty
of informed patients. AHP has not been used frequently for this specific purpose; thus,
Sustainability 2022, 14, 12745 19 of 21

additional study is needed to determine whether it can be utilized in surveys and how it
compares to utility-based patient-reported outcome measures.

Funding: The author extends their appreciation to the Deanship of Scientific Research, the King
Khalid University of Saudi Arabia, for funding this work through the Large Groups Research Project
under grant number (RGP.2/163/43).
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Acknowledgments: The authors extend their appreciation to the Deanship of Scientific Research at
the King Khalid University, Saudi Arabia.
Conflicts of Interest: The authors declare no conflict of interest.

References
1. Sivakumar, G.; Almehdawe, E.; Kabir, G. Developing a decision-making framework to improve healthcare service quality during
a pandemic. Appl. Syst. Innov. 2021, 5, 3. [CrossRef]
2. Adunlin, G.; Diaby, V.; Xiao, H. Application of multicriteria decision analysis in health care: A systematic review and bibliometric
analysis. Health Expect. 2015, 18, 1894–1905. [CrossRef]
3. Glaize, A.; Duenas, A.; Di Martinelly, C.; Fagnot, I. Healthcare decision-making applications using multicriteria decision analysis:
A scoping review. J. Multi-Criteria Decis. Anal. 2019, 26, 62–83. [CrossRef]
4. Altuntas, S.; Kansu, S. An innovative and integrated approach based on SERVQUAL, QFD and FMEA for service quality
improvement: A case study. Kybernetes 2019, 49, 2419–2453. [CrossRef]
5. Huang, H.; De Smet, Y.; Macharis, C.; Doan, N.A.V. Collaborative decision-making in sustainable mobility: Identifying possible
consensuses in the multi-actor multi-criteria analysis based on inverse mixed-integer linear optimization. Int. J. Sustain. Dev.
World Ecol. 2021, 28, 64–74. [CrossRef]
6. Dezert, J.; Tchamova, A.; Han, D.; Tacnet, J.-M. The SPOTIS rank reversal free method for multi-criteria decision-making support.
In Proceedings of the 2020 IEEE 23rd International Conference on Information Fusion (FUSION), Rustenburg, South Africa,
6–9 July 2020; pp. 1–8.
7. Kizielewicz, B.; Watróbski,
˛ J.; Sałabun, W. Identification of relevant criteria set in the MCDA process—Wind farm location case
study. Energies 2020, 13, 6548. [CrossRef]
8. Khan, S.A.; Kusi-Sarpong, S.; Naim, I.; Ahmadi, H.B.; Oyedijo, A. A best-worst-method-based performance evaluation framework
for manufacturing industry. Kybernetes 2021, 1–38. [CrossRef]
9. Fartaj, S.-R.; Kabir, G.; Eghujovbo, V.; Ali, S.M.; Paul, S.K. Modeling transportation disruptions in the supply chain of automotive
parts manufacturing company. Int. J. Prod. Econ. 2020, 222, 107511. [CrossRef]
10. Moktadir, M.A.; Ali, S.M.; Kusi-Sarpong, S.; Shaikh, M.A.A. Assessing challenges for implementing Industry 4.0: Implications for
process safety and environmental protection. Process Saf. Environ. Prot. 2018, 117, 730–741. [CrossRef]
11. Liang, F.; Brunelli, M.; Rezaei, J. Consistency issues in the best worst method: Measurements and thresholds. Omega 2020, 96,
102175. [CrossRef]
12. Munier, N.; Hontoria, E.; Jiménez-Sáez, F. Strategic Approach in Multi-Criteria Decision Making; Springer: Berlin/Heidelberg,
Germany, 2019; Volume 275.
13. Stoilova, S.D. A multi-criteria selection of the transport plan of intercity passenger trains. In IOP Conference Series: Materials
Science and Engineering, Proceedings of the 11th International Scientific Conference on Aeronautics, Automotive and Railway Engineering
and Technologies (BulTrans-2019), Sozopol, Bulgaria, 10–12 September 2019; IOP Publishing: Bristol, UK, 2019; p. 012031.
14. Hsu, T.-H.; Pan, F.F. Application of Monte Carlo AHP in ranking dental quality attributes. Expert Syst. Appl. 2009, 36, 2310–2316.
[CrossRef]
15. Shieh, J.-I.; Wu, H.-H.; Huang, K.-K. A DEMATEL method in identifying key success factors of hospital service quality. Knowl.
Based Syst. 2010, 23, 277–282. [CrossRef]
16. Büyüközkan, G.; Çifçi, G.; Güleryüz, S. Strategic analysis of healthcare service quality using fuzzy AHP methodology. Expert Syst.
Appl. 2011, 38, 9407–9424. [CrossRef]
17. Altuntas, S.; Dereli, T.; Yilmaz, M.K. Multi-criteria decision making methods based weighted SERVQUAL scales to measure
perceived service quality in hospitals: A case study from Turkey. Total Qual. Manag. Bus. Excell. 2012, 23, 1379–1395. [CrossRef]
18. Lee, S.-F.; Lee, W.-S. Promoting the quality of hospital service for children with developmental delays. Serv. Ind. J. 2013, 33,
1514–1526. [CrossRef]
19. Chang, T.-H. Fuzzy VIKOR method: A case study of the hospital service evaluation in Taiwan. Inf. Sci. 2014, 271, 196–212.
[CrossRef]
Sustainability 2022, 14, 12745 20 of 21

20. Moslehi, S.; Manesh, P.A.; Asiabar, A.S. Quality measurement indicators for Iranian health centers. Med. J. Islamic Repub. Iran
2015, 29, 177.
21. Shafii, M.; Rafiei, S.; Abooee, F.; Bahrami, M.A.; Nouhi, M.; Lotfi, F.; Khanjankhani, K. Assessment of service quality in teaching
hospitals of Yazd University of Medical Sciences: Using multi-criteria decision making techniques. Osong Public Health Res.
Perspect. 2016, 7, 239–247. [CrossRef]
22. La Fata, C.M.; Lupo, T.; Piazza, T. Service quality benchmarking via a novel approach based on fuzzy ELECTRE III and IPA: An
empirical case involving the Italian public healthcare context. Health Care Manag. Sci. 2019, 22, 106–120. [CrossRef]
23. Soyhan, N.; Ilkutlu, N.; Sekreter, A. Dimensioning the quality of health care services (Karabuk state hospital service quality
dimensions as an example of measurement application). J. Bus. 2013, 2, 39–44.
24. Aghamolaei, T.; Eftekhaari, T.E.; Rafati, S.; Kahnouji, K.; Ahangari, S.; Shahrzad, M.E.; Kahnouji, A.; Hoseini, S.H. Service quality
assessment of a referral hospital in Southern Iran with SERVQUAL technique: Patients’ perspective. BMC Health Serv. Res. 2014,
14, 322. [CrossRef] [PubMed]
25. Haddad, S.; Potvin, L.; Roberge, D.; Pineault, R.; Remondin, M. Patient perception of quality following a visit to a doctor in a
primary care unit. Fam. Pract. 2000, 17, 21–29. [CrossRef] [PubMed]
26. Grönroos, C. A service quality model and its marketing implications. Eur. J. Mark. 1984, 18, 36–44. [CrossRef]
27. Wisniewski, M.; Wisniewski, H. Measuring service quality in a hospital colposcopy clinic. Int. J. Health Care Qual. Assur. 2005, 18,
217–228. [CrossRef] [PubMed]
28. Laroche, M.; Papadopoulos, N.; Heslop, L.A.; Mourali, M. The influence of country image structure on consumer evaluations of
foreign products. Int. Mark. Rev. 2005, 22, 96–115. [CrossRef]
29. Upadhyai, R.; Upadhyai, N.; Jain, A.K.; Roy, H.; Pant, V. Health care service quality: A journey so far. Benchmarking Int. J. 2020, 27,
1893–1927. [CrossRef]
30. Javed, S.A.; Liu, S.; Mahmoudi, A.; Nawaz, M. Patients’ satisfaction and public and private sectors’ health care service quality in
Pakistan: Application of grey decision analysis approaches. Int. J. Health Plan. Manag. 2019, 34, e168–e182. [CrossRef]
31. Ayaad, O.; Alloubani, A.; ALhajaa, E.A.; Farhan, M.; Abuseif, S.; Al Hroub, A.; Akhu-Zaheya, L. The role of electronic medical
records in improving the quality of health care services: Comparative study. Int. J. Med. Inform. 2019, 127, 63–67. [CrossRef]
32. Parasuraman, A.; Zeithaml, V.A.; Berry, L.L. A conceptual model of service quality and its implications for future research.
J. Mark. 1985, 49, 41–50. [CrossRef]
33. Dagger, T.S.; Sweeney, J.C.; Johnson, L.W. A hierarchical model of health service quality: Scale development and investigation of
an integrated model. J. Serv. Res. 2007, 10, 123–142. [CrossRef]
34. Lee, H.; Delene, L.M.; Bunda, M.A.; Kim, C. Methods of measuring health-care service quality. J. Bus. Res. 2000, 48, 233–246.
[CrossRef]
35. Choi, K.S.; Lee, H.; Kim, C.; Lee, S. The service quality dimensions and patient satisfaction relationships in South Korea:
Comparisons across gender, age and types of service. J. Serv. Mark. 2005, 19, 140–149. [CrossRef]
36. Kalaja, R.; Myshketa, R.; Scalera, F. Service quality assessment in health care sector: The case of Durres public hospital. Procedia-Soc.
Behav. Sci. 2016, 235, 557–565. [CrossRef]
37. Izadi, A.; Jahani, Y.; Rafiei, S.; Masoud, A.; Vali, L. Evaluating health service quality: Using importance performance analysis. Int.
J. Health Care Qual. Assur. 2017, 30, 656–663. [CrossRef] [PubMed]
38. Pekkaya, M.; Pulat İmamoğlu, Ö.; Koca, H. Evaluation of healthcare service quality via Servqual scale: An application on a
hospital. Int. J. Healthc. Manag. 2019, 12, 340–347. [CrossRef]
39. Riono, A.; Ahmadi, A. Analysis of healthcare services quality using servqual-fuzzy method. Int. J. Econ. Manag. Sci. 2017, 6, 1–7.
40. Abbasi-Moghaddam, M.A.; Zarei, E.; Bagherzadeh, R.; Dargahi, H.; Farrokhi, P. Evaluation of service quality from patients’
viewpoint. BMC Health Serv. Res. 2019, 19, 170. [CrossRef]
41. Schrimmer, K.; Williams, N.; Mercado, S.; Pitts, J.; Polancich, S. Workforce competencies for healthcare quality professionals:
Leading quality-driven healthcare. J. Healthc. Qual. (JHQ) 2019, 41, 259–265. [CrossRef]
42. Vargo, S.L.; Lusch, R.F. The four service marketing myths: Remnants of a goods-based, manufacturing model. J. Serv. Res. 2004, 6,
324–335. [CrossRef]
43. Edvardsson, B.; Enquist, B.; Hay, M. Values-based service brands: Narratives from IKEA. Manag. Serv. Qual. Int. J. 2006, 16,
230–246. [CrossRef]
44. Devebakan, N. Sağlık Işletmelerinde Algılanan Hizmet Kalitesi ve Ölçümü. Dokuz Eylül Üniversitesi Sağlık Enstitüsü İzmir. 2005.
Available online: https://www.aybu.edu.tr/GetFile?id=56228631-eed4-4727-a192-315bdae408e3.pdf (accessed on 20 July 2022).
45. Lee, M.A.; Yom, Y.-H. A comparative study of patients’ and nurses’ perceptions of the quality of nursing services, satisfaction and
intent to revisit the hospital: A questionnaire survey. Int. J. Nurs. Stud. 2007, 44, 545–555. [CrossRef] [PubMed]
46. Ramsaran-Fowdar, R.R. The relative importance of service dimensions in a healthcare setting. Int. J. Health Care Qual. Assur. 2008,
21, 104–124. [CrossRef] [PubMed]
47. Liu, D.; Bishu, R.R.; Najjar, L. Using the analytical hierarchy process as a tool for assessing service quality. Ind. Eng. Manag. Syst.
2005, 4, 129–135.
48. MacCormac, E.R. Review of:‘THE ANALYTIC HIERARCHY PROCES’ by Thomas L. Saaty, New York, McGraw-Hill, Inc., 1980,
xiii+ 287 pp., list $37.50. Eng. Econ. 1983, 28, 263–264. [CrossRef]
Sustainability 2022, 14, 12745 21 of 21

49. Kolios, A.; Mytilinou, V.; Lozano-Minguez, E.; Salonitis, K. A comparative study of multiple-criteria decision-making methods
under stochastic inputs. Energies 2016, 9, 566. [CrossRef]
50. Saaty, T.L. How to make a decision: The analytic hierarchy process. Interfaces 1994, 24, 19–43. [CrossRef]
51. Zarei, E.; Daneshkohan, A.; Khabiri, R.; Arab, M. The effect of hospital service quality on patient’s trust. Iran. Red Crescent Med. J.
2015, 17, e17505. [CrossRef] [PubMed]
52. Ramez, W.S. Patients’ perception of health care quality, satisfaction and behavioral intention: An empirical study in Bahrain. Int.
J. Bus. Soc. Sci. 2012, 3, 131–141.
53. Abu-Kharmeh, S.S. Evaluating the quality of health care services in the Hashemite Kingdom of Jordan. Int. J. Bus. Manag. 2012, 7, 195.
54. Butt, M.M.; de Run, E.C. Private healthcare quality: Applying a SERVQUAL model. Int. J. Health Care Qual. Assur. 2010, 23,
658–673. [CrossRef]
55. Marzban, S.; Najafi, M.; Etedal, M.; Moradi, S.; Rajaee, R. The evaluation of outpatient quality services in physiotherapy in the
teaching health centers of Shahid Beheshti University based on SERVQUAL tools. Eur. J. Biol. Med. Sci. Res. 2015, 3, 46–53.