Keywords

1 Introduction

These days, dental clinics in japan have been exposed to a fierce competition. One of the causes of this is the upsurge of dental clinics. There are 102 thousand registered dentists [2] out of 303 thousand, the entire number of registered doctors in the whole country. Moreover, according to the survey report conducted in August 2014, there are 68,836 dental clinics in Japan [3]. There are 1.3 times more dental clinics than convenience stores that count 51,367(Japan Franchise Association: JFA Convenience Store Statistics Survey).

Greater competition between dental clinics means more beneficial opportunities for the customers to be able to select the optimal dental services for them. Dental clinics have been trying on the latest equipments, therapeutic methods, and the best materials for treatments. Under this age of over-competition, faced with the growth of the number of dental clinics, as well as repetitive cut-down on the fee, and the decline in the number of the cases of dental caries, some dental clinics are changing their customer gathering methods so that they can meet the needs of the patients who seek dental treatments not covered by the medical care, such as dental prophylaxis, tooth bleaching, and orthodontics.

Since the situation has changed that the customers began to be able to choose which dental clinic to go, medical treatment is now said to have become service industry [1]. The primary service of dental clinics as a service industry is to provide medical treatment to their customers, and the provision of the medical services appropriate for each customer is the most important thing. In other words, the provision of the appropriate therapeutic knowledge and skills is crucial. However, knowing what the customers are seeking is also necessary, not just qualified skills such as dental technique, but also intangible communicative skills to deal with the customers are becoming significant matter [4]. From when a customer comes to a clinic until the treatment is done and he/she leaves, everyone including dentist, dental hygienist, and receptionist is required to have communication and build relationships with the customers for the sake of smooth treatment. This kind of attitude at a dental clinic is assumed to have a possible impact on the customer satisfaction that made them feel as “I made a best choice!”

Like running a goods-selling or service-providing store, retaining repeat customers is necessary for the management of a dental clinic. In order to meet this criterion, it is inevitable to evoke the customers’ desire to come back for another service. As a step towards achieving this, some measures have been taken which incorporate the viewpoint of customer service with the aim of raising the customer satisfaction level. For example, For example, at the dental clinic competition, “D1 Grand Prix Dentist Tournament” [5], held by Japan Dental Clinic Competition Association, they are competing the customers’ satisfaction level. Some of the higher-ranked clinics at this tournament proclaim Japanese “Omotenashi” hospitality which goes beyond a mere idea of customer service. Those clinics strive to become a central part to contribute to the local community through providing their patients with the world’s most cutting-edge treatment and care, to stay aspiring and innovative to build up a system that enables the provision of the best dental care, and to give constant higher-than-expectation support to their patients. Under the banner of this management policy, they have accumulated practical methods to enhance the quality of their customer service which would result in the improvement of the customer satisfaction.

Nevertheless, when it comes to evaluating the quality of customer service at a dental clinic, it is quite hard for a patient to assess the outcome of the highly professional medical treatment. For this reason, evaluation is often conducted from the stand point of assessing the impression of the dentist and the receptionist in service. Because this type of evaluation is usually susceptible to the subjective factors and the difference of the atmosphere at each clinic, it is difficult to carry out an objective evaluation. Considering this problem, this paper primarily aims to invent and introduce a new scale that is suitable to assess impression towards overall customer service felt by the customers at each dental clinic, by referring to the evaluation criteria used in D1 Grand Prix Dentist Tournament.

In addition to that, because there is much ambiguity regarding how much the evaluation of the impression towards overall customer service at a dental clinic can affect customer satisfaction, quantitative evaluation how much customer service given by a receptionist, a dentist, and other medical practitioners can affect the total satisfaction level is set as the second purpose on this paper. Furthermore, taking into account the ever fiercer competition between clinics, it is critical for a dental clinic to retain repeat customers and to have its customers to spread favorable reviews to other prospective customers. Therefore, elucidation of the correlation of overall customer service at a clinic and the total satisfaction level with the customers’ desire to come back and their intention to recommend to others is set as the third purpose.

2 Study Methods

2.1 Study Subjects and Methods

This research was conducted at two dental clinics in Kanto region and three dental clinics in Kansai region. These clinics have been in operation for 5 to 32 years (Average: 24.6 years and SD: 10.1 years), and have around 7 to 40 staff (Average: 16.2 years and SD: 12.0 years). Four of them see about 50 patients in average per day, and the other treats about 140 patients a day. Oral or written requests were sent to prospective subjects, and then questionnaire form was sent to the dental clinics that accepted the requests.

The survey was carried out over 19 days from 12th to 30th of November during which period patients who received any type of medical treatment or service were chosen as a target of this survey at the subject clinics. Each clinic was instructed to ask their patients to fill in the questionnaire at the end of their treatment. Request to patients to participate in the survey was made by a staff at each dental clinic. The purpose of this survey was explained to patients, and it was clarified that their personal information and privacy shall be discreetly protected. Those patients who agreed with this condition were asked to answer the questionnaire, and their response was collected on the spot.

1,108 responses were gathered, out of which 898 valid responses, excluding incomplete or false responses, were selected for the analysis. 898 responses comprise 300 male participants (Average age: 52.6 ± 18.1 years old) and 598 female participants (Average age: 48.9 ± 16.6 years old).

2.2 Survey Contents

For this survey, we utilized questionnaire invented originally that is composed of three categories: basic information, impression evaluation of customer service at each dental clinic, and overall evaluation. Basic information includes participants’ gender, age, the purpose of visit, the number of years attended, and the motive of visit. The purpose of visit needs to be chosen out of the following four items: “Medical treatment (health insurance)”, “Medical treatment (own expense)”, “Tooth bleaching”, and “Maintenance”. Likewise, the number of years attended is to be chosen from: “First time”, “Second time”, “Third time but less than 1 year”, “1 to 3 years”, “3 to 5 years”, and “More than 5 years”. The motive of visit shall be chosen from multiple choices such as “HP”, “Referral”, and “Reputation”.

With respect to impression evaluation of customer service at each dental clinic, original questionnaire was invented based on the undercover inspection conducted by Japan Dental Clinic Competition Association. Five different categories relating to the customer service at each dental clinics were put on the questionnaire, and several questions for each of these five categories were asked. The categories include: “Telephone support before visit”, “Reception service at the time of visit”, “Service during the consultation and the actual medical treatment”, “Facility environment and cleanliness in appearance of staff”, and “Medical treatment and communication during the actual practice”. Answers for each of these items shall be chosen out of the following choices: “Very pleasant or satisfied (5p)”, “Pleasant or satisfied (4p)”, “Fair or somewhat satisfied (3p)”, “Somewhat unpleasant or dissatisfied (2p)”, and “Very unpleasant or dissatisfied (1p)”.

As for the actual question items for “Telephone support before visit”, the following five questions were asked: “Clinic staff responded clearly with bright tone of voice”, “Clinic staff was considerate enough to repeat your name or request”, “Clinic staff gave considerate remark like ‘Sorry to keep you waiting’ when he/she was slow to answer the phone or made you hold on”, and “The overall impression of telephone support”.

Question items for “Reception service at the time of visit” were the following five: “Receptionist immediately recognized and responded to you”, “Receptionist gave you a welcoming eye contact with smile and greet”, “Receptionist gave you an appreciation like ‘Thank you for coming’ or ‘We have been waiting for your visit’ for your reservation or visit”, “Receptionist received your insurance card, ID, or patient’s ticket with both hands, and handled them with courtesy”, “Receptionist paid attention to and consideration for patients at the waiting room”, “Receptionist ushered you to the consultation room with smile and courtesy”.

Question items for “Service during the consultation and the actual medical treatment” were the following three: “Inquiry/consultation and treatment started on time, and if there was any delay, they gave you an explanation”, “The dentist and other medical staff were easy to talk to with comfort”, and “Did you feel like getting medical treatment at this dental clinic?”

Question items for “Facility environment and cleanliness in appearance of staff” were the following three: “The waiting room, the entrance, and the entrance hall were tidy and clean”, “Appearances of the dentist and other staff were clean”, “Language and behavior of the dentist and other staff were appropriate”.

Question items for “Medical treatment and communication during the actual practice” were the following four: “Did you received their thoughtful words or felt their consideration when they reclined the chair or while you were sitting?”, “Did you feel their thoughtfulness or consideration from the way they touched the inside of your mouth or when they put medical equipments into it?”, “Did you feel they were proactively trying to communicate with you during treatment?”, and “Did you feel comfortable about the overall responses and services during consultation and medical treatment?”.

The overall evaluation is composed of three categories; The degree of overall satisfaction was measured from the answer to the question “On the whole, you were satisfied with the environment and the service by clinic staff”. Similarly, intention to repeat was estimated from the answer to the question “Did you feel like coming back for another service, or would like to repeat in the future?”. Intention to recommend to others was evaluated from the question “Did you feel like recommending this clinic to others?”. Answers for each of these questions above were to be chosen from: “Very pleasant or satisfied (5p)”, “Pleasant or satisfied (4p)”, “Fair or somewhat satisfied (3p)”, “Somewhat unpleasant or dissatisfied (2p)”, and “Very unpleasant or dissatisfied (1p)”.

2.3 Analysis Methods

With regard to the question items of the impression evaluation focused on the service at a dental clinic, factor analysis was performed to spot factor structure, and should there be any reliability confirmed, the average of all the question items that constitute each factor was computed. ANOVA for double factors was conducted in order to examine the effect of patients’ gender and the number of years attended on the evaluation of the service at a dental clinic and their overall evaluation. In a technical sense, when dealing with the number of years attended, new groups of respondents were made by properly reallocating respondents from the original groups so there would be equally the same number of respondents in each of the new groups. Furthermore, Pearson’s correlation coefficient was calculated to examine the correlation between the variables, and multiple regression analyses (Forced entry method) were performed taking the comprehensive evaluations such as the overall satisfaction level, the intention to repeat, and the intention to recommend to others as the dependent variables, and the evaluation of the responses and services at a dental clinic, participants’ age, and gender as independent variables. Statistics package software (IBM SPSS22) was used for the statistical processing.

3 Result

3.1 Factor Analysis

Factor analyses (Maximum likelihood estimation and Promax rotation) were conducted as for the 20 question items of the impression evaluation which concerns the responses and services at a dental clinic (Table 1). An item has to have factor loading greater than 0.45 to be valid as a factor. Under this condition, considering the attenuation of eigenvalues at an initial solution and their interpretability, two factors were determined. The first factor was named “Telephone and reception service” factor, which was found to be related to the telephone response and reception service, and was reflected in the questions such as “The overall impression of telephone support” and “Receptionist gave you a welcoming eye contact with smile and greet”. The second factor was named “Consultation and treatment service” factor, which was assumed to be associated with the responses and services at the time of medical consultation and treatment, and was reflected in the questions like “Did you feel they were proactively trying to communicate with you during the treatment?” and “Language and behavior of the dentist and other staff were appropriate”.

Table 1. Result of factor analysis
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In order to examine the internal consistency, Cronbach’s α coefficient was computed from the question items which mainly constitute each of the aforementioned factors. As a result of this examination, α coefficient for both factors were high enough to guarantee the internal consistency (α = 0.959 for the 1st factor, and α = 0.956 for the 2nd factor). Given these findings, the average score of each item on the first factor was considered as “Telephone and reception service” score, and the average score of each item on the second factor was considered as “Consultation and treatment service” score, and then impression evaluation scale concerning the responses and services of a dentist was determined taking above-mentioned scores as subscales.

3.2 Basic Statistic

Basic statistic including impression evaluation scale regarding the responses and services at a dental clinic, participants’ age, the overall satisfaction level, the intention to repeat, and the intention to recommend to others were given, and then influences of gender and the number of years attended were investigated (Table 2). As a result of ANOVA for double factors taking gender (male/female) and the number of years attended (1st time / > 1 year /1 to 5 years / < 5 years) as the factors, no significant interaction effect was spotted between any of the variables. Also none of these variables appeared to have a significant main effect upon participants’ gender. The number of years attended was found to exert a significant main effect on the following items: Participants’ age, telephone and reception service score, the overall satisfaction level, the intention to repeat, and the intention to recommend to others. As a consequence of multiple comparisons, it was made clear that those participants with the longer history of attending a clinic are generally older than others, while their telephone and reception service score, overall satisfaction level, intention to repeat, and intention to recommend to others were inclined to be lower compared to the participants with the shorter history of attending a clinic.

Table 2. Result of basic statistic
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Table 3 shows the correlation coefficients in between each of the following variables: The score of the two factors in the evaluation of the responses and services at a dental clinic, the overall satisfaction level, the intention to repeat, and the intention to recommend to others. Participants’ age was found to have a significant and negative correlation with each of the other variables. Similarly, it became clear that the score of the two factors in the evaluation of the responses and services had significant and positive correlations with the overall satisfaction level, the intention to repeat, and the intention to recommend to others.

Table 3. Result of correlation coefficients six items of basic statistic
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3.3 Multiple Regression Analyses

Next, the influences of the evaluation of the responses and services at a dental clinic on the overall satisfaction level, the intention to repeat, and the intention to recommend to others were studied (Table 4). At this analytic study, for the sake of eliminating the influences of participants’ age, gender, and the number of years attended, multiple regression analyses (Forced entry method) were carried out, under whose condition, independent variables were set as follows: The score of the two factors in the evaluation of responses and services, participants’ age, gender (Dummy variables), and the number of years attended. Also dependent variables were the following three: The overall satisfaction level, the intention to repeat, and the intention to recommend to others. In consequence, each of the three dependent variables rendered a significant multiple regression coefficient. The values of the adjusted R-square stretched from 0.304 to 0.470.

Table 4. The multiple regression coefficient result of the evaluation of the responses and services at a dental clinic on the overall satisfaction level
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The overall satisfaction level yielded a significant standardized partial regression coefficient on participants’ age, telephone and reception service score, and consultation and treatment service score. The intention to repeat rendered a significant standardized partial regression coefficient on participants’ age and consultation and treatment service score. In the same way, the intention to recommend to others showed a significant standardized partial regression coefficient on the number of years attended, telephone and reception service score, and consultation and treatment service score.

After that, in an attempt to eliminate the influences of the overall satisfaction level, concerning the correlation between the intention to repeat and the intention to recommend to others, partial correlation coefficient was calculated taking the overall satisfaction level as the control variable. Although there was a significant and positive correlation (p < .01), the value of partial correlation coefficient was low as r = .145.

4 Result

4.1 Impression Evaluation Scale Concerning the Responses and Services at Dental Clinics

As a result of factor analyses, it turned out that telephone responses and reception services were put together to construct single factor, even though those two items were initially classified in different categories. Similarly, the following three categories were combined to make one factor: Inquiry/consultation, treatment, and the adjustment of the facility environment and appearance of staff. It can be said that telephone responses and reception services have a lot in common because they do not involve physical contact with a patient themselves. Impression evaluation exhibited the same tendency. Conversely, inquiry/consultation, treatment, and the adjustment of the facility environment and appearance of staff are a series of actions from the beginning to the end of the medical services, all of which involve physical contact with a patient. They were treated as an independent factor in the study. In this kind of situation, the responses and services given by the dentist and other medical staff to the patient were supposed to attenuate the patient’s nervousness and fear, and thus these responses and services to the patient have great similarity to each other. Behind this is the fact that the patient did not seem to be able to assess precisely the responses and services of the dentist and other medical staff, for he/she was nervous about medical consultation or treatment.

All of the dental clinics that were the subjects of this study marked good evaluations on each and every item. Therefore, it might be possible that five categories were unable to be extracted after factor analyses. Given this, it might be possible to increase the number of factors by inquiring more dental clinics or various types of dental clinics.

4.2 The Influences of Patients’ Age, Gender, and the Number of Years Attended

Because there was a significant and negative correlation between patients’ age and the impression evaluation concerning the responses and services at a dental clinic as well as between patients’ age and the overall satisfaction level, it would be safe to say that older patients tend to have lower impression evaluation towards the responses and services and the lower overall satisfaction level. In an aging society like Japan, dental clinics in general, excluding pediatric dental clinics, are treating older and older patients, so customer service to satisfy elderly patients more is becoming an important factor. Nevertheless, since the number of years attended was found to have a significant correlation with patients’ age, it is quite hard to specify which one of the number of years attended or patients’ age is the cause of degrading evaluation.

Also, patients who have visited a dental clinic more than others exhibited lower impression evaluation concerning the responses and services at a dental clinic. It is presumably because the more a patient visits a dental clinic, the better he/she comes to realize the details of the actual medical settings, and thus the more a patient visits a dental clinic, the severer his/her evaluation of the medical settings in comparison to his/her initial evaluation. In addition to that, A new patient with a dental disease is usually nervous at the first time of visit, so he/she would feel higher satisfaction if a dentist and other medical staff can make him/her feel comfortable by creating a good atmosphere in a clinic or communicating effectively with an intention to get rid of a patient’s nervousness or fear.

As for the impression evaluation concerning the responses and services at a dental clinic, there was no gender difference, which assumably means that gender difference may not especially define the quality of the responses and services. Hereafter, patient’s age and the number of years attended were adjusted for the sake of examining the influences of the impression evaluation on the overall satisfaction level and so forth.

4.3 Evaluation of the Responses and Services Affecting the Satisfaction Level

As a result of multiple regression analyses, both telephone and reception service, and consultation and treatment service have a positive impact on the overall satisfaction level. It is believed to be natural that the evaluation of medically functional services provided at a dental clinic ought to be high and it has a tremendous impact on whether to continue medical treatment at the clinic or not. It was noteworthy that services of psychological and emotional aspect like communication with a dentist and other medical staff at the time of consultation and treatment were revealed to have positive effect on the overall satisfaction level. Even though people often distinguish a dental clinic from general service industry, communicative skills for reception service and the general atmosphere at a medical institution are also regarded as important factors.

Fujimura’s survey targeting medical service has shown that the outcome of treatment had the greatest impact on the overall satisfaction and then medical staff had the second greatest influence [6]. It seems that relationship between a service provider and a customer which respects their respective humanity is crucial. The outcome of treatment is the quality concerning the outcome of service, and it is an important factor for a customer. Whereas, humane communication is also a meaningful factor especially when the outcome of treatment is up to sufficiently satisfactory standard, or when the outcome of a treatment is hard to evaluate due to its high specialty. This is the fact that implies the importance of human relations at the time of provision of service.

Currently, the oversupply of dental clinics is becoming a social problem, and there are many dental clinics that provide specialized dental care services in an attempt to differentiate themselves from other dental clinics. Unlike other fields of medical care, a lot of dental clinics offer a medical treatment that combines a preventative insurance-covered care with medical care at patient’s own expense, a plan of regular medical check-up, and visiting care as a family doctor for the elderly. It is assumed that the impression of the responses and services was added as a factor that can affect the satisfaction level.

4.4 The Intention to Repeat /to Recommend to Others

The intention to repeat and the intention to recommend to others were found to have significant correlation with the overall satisfaction level. Also, the intention to repeat and the intention to recommend to others had a significant and positive correlation (r = .582) with each other, but partial correlation coefficient taking the overall satisfaction level as the control variable was as low as r = .145, and was barely significant.

First of all, upon examining the intention of repeat, or the desire to attend continuously, it has to be noted that retention of repeater affects greatly on the profitability. Especially, in the case of a dental clinic, they need to retain more repeater seeking tooth bleaching, regular check-up, and maintenance, inclusively. Also, from the standpoint of a dental clinic, in the case of handling a repeater, it would be more cost-effective because they don’t need to gather information about patients, their medical history, and the condition of their dental diseases, unlike when they deal with a new customer, so it would be favorable to have more repeaters. Furthermore, as the change of the environment inside people’s mouth, the case of dental caries are becoming rare, and more people come to think of switching to a medical treatment including check-up and prevention that combines insurance-covered care with medical care at patient’s own expense, so there is another reason which necessitates the retention of repeaters.

The survey displayed that consultation and treatment service score positively affected the intention to repeat, but telephone and reception service score did not make a significant impact on the intention to repeat. Medical practitioners who have a direct contact with a patient take a vital role in motivating more patients to repeat. Although it was out of the scope of this study, the satisfaction level with regard to the expense and medical treatment itself and optional responses or services other than an actual treatment can have a possible influence, and so they are worth further examination in the future.

Next, as for the intention to recommend to others, comparison of different medical services that requires an actual experience incurs a customer costs and risks. It is impossible for a customer to evaluate services before an actual consultation and treatment. In this case, recommendation by word of mouth is greatly reliable. The intention to recommend to others had a positive effect on both telephone and reception service score, and consultation and treatment service score. Not just consultation and treatment service score, but also telephone and reception service score exerted a positive influence. It can be said that not only medical practitioners but other staff are important.

Telephone and reception service did not have an impact on the intention to repeat, but it positively influenced the intention to recommend to others. Being able to listen carefully to a patient to meet each patient’s needs and to provide a patient with both psychological and medical care would result in earning patient’s trust and consequently getting more repeaters. However, when it comes to recommendation to others by word of mouth, patients seem to tell others about the comprehensive impression of a dental clinic including the impression of reception service.

4.5 Limitation of the Survey and the Prospective Research

Our questionnaire survey was performed only at those dental clinics that consented to it. In order to attain more generality, it is necessary to conduct the survey at many more dental clinics and to continue on further consideration. Not just a questionnaire survey as a form of evaluation method, more integrated manner of survey would be required that takes account of not only the responses and services and an ideal of communication, but also informed-consent and practical consultation and treatment.

5 Conclusion

This study made the following discoveries. A new patient and a patient who has visited a clinic fewer times than others tend to have higher evaluation of the customer satisfaction level. Although it was found that recommendation to others by word of mouth can be affected by reception factor, the overall satisfaction level such as a patient’s desire to visit continuously was greatly affected by the responses and services of a dentist and other medical staff at the time of consultation and treatment.