Service Quality in Iranian Hospitals From Patients' Perspectives Based on the SERVQUAL Model: A Systematic Review and Meta‐Analysis

Abstract

Background

This study aimed to evaluate the service quality in Iranian hospitals from patients' perspectives based on the SERVQUAL model.

Materials and Methods

A thorough exploration of online electronic databases, including Scopus, PubMed, Web of Science, IranMedex, and the Scientific Information Database (SID), was undertaken using keywords extracted from Medical Subject Headings such as “Quality of Health Care,” “Hospital,” and “Patients” spanning from the earliest available records up to August 11, 2023.

Results

In the context of 25 cross‐sectional studies encompassing a collective participant pool of 8021 hospitalized patients in Iranian medical facilities, an assessment of patients' perspectives on the quality of hospital services revealed a mean perception score of 3.54 (SE = 0.08). Concurrently, the mean expectation score for the quality of services was determined to be 4.43 (SE = 0.06). Using the SERVQUAL model, the overall disparity between patients' perceptions and expectations was calculated as −0.89. Subsequent examination of specific dimensions within the SERVQUAL framework revealed gaps between patients' perceptions and expectations in the tangibility dimension (−0.84), reliability dimension (−0.94), responsiveness dimension (−0.91), assurance dimension (−0.89), and empathy dimension (−0.82).

Conclusion

Therefore, healthcare administrators consider the study's findings as a motivating force to initiate measures aimed at improving service quality in Iranian hospitals. Tackling the recognized shortcomings and areas requiring enhancement holds the promise of raising patient satisfaction levels and, consequently, improving overall healthcare outcomes.

1. Introduction

Evaluating the quality of services offered in hospitals, which play a crucial role in the healthcare system, holds significant importance [1, 2]. Hospitals and health centers serve a large number of clients, making it essential to prioritize a patient‐centered approach and improve service quality to effectively address their needs [3, 4].

Traditionally, the evaluation of quality has centered on the attributes inherent to goods and services. However, this conceptualization has evolved to encompass a dual perspective that integrates both technical quality and perceived quality, acknowledging the synergistic relationship between these dimensions [5, 6]. Service quality can be described as the variance between what customers expect and what they perceive [7]. Service quality is assessed based on how effectively a client's expectations and needs are fulfilled, as evaluated and perceived by the client [8].

Among the essential indicators of health service quality, the patient's perspective serves as a fundamental standard for evaluating the quality of hospital services [9]. Patient‐centeredness is a crucial factor for hospitals' success, making patients the key measure for evaluating service quality. if a hospital's services exceed the patients' expectations, it signifies the delivery of high‐quality care [10]. Patients whose perception of service quality is in line with their expectations are more likely to adhere to treatment and care recommendations, which subsequently leads to improved treatment results [11]. Researchers have identified five key factors that clients consider fundamental in determining healthcare quality: friendly relationships, medical staff competence, equipment and technology, service accessibility, and distinctiveness [12].

The SERVQUAL model, introduced by Parasuraman et al. in 1980, is a tool for evaluating service quality based on the differences between customers' expectations and perceptions [13]. Initially used in economics, it is now increasingly applied in healthcare due to its customer‐centric approach. The model is built on the premise that patients can distinguish between their expected service and the actual service received [14]. It encompasses five dimensions: tangibles (facilities, equipment, and staff appearance), reliability (safe and dependable services), responsiveness (prompt handling of inquiries and complaints), assurance (staff competence and trust‐building), and empathy (understanding and addressing client needs). This model aids managers in identifying service gaps and understanding their causes [13].

This article highlights the importance of integrating findings from studies focused on hospital service quality to provide policymakers with informed recommendations. It notes a lack of previous meta‐analyses, specifically investigating service quality in Iranian hospitals from patients' perspectives using the SERVQUAL model. In a prior meta‐analysis, the service quality in Iranian hospitals was assessed only in 13 included studies, and the service quality of Iranian hospitals was not evaluated based on the SERVQUAL model [15]. This study undertakes a comparative analysis of hospital service quality as perceived by patients across various provinces, juxtaposed against Tehran, the capital province. Additionally, it delves into the changes in patients' perceptions and expectations over the years regarding hospital service quality, a facet heretofore overlooked in extant literature. To address this gap, the current systematic review and meta‐analysis aim to provide a comprehensive overview of hospital service quality in Iran, focusing on evaluating service quality through the SERVQUAL model.

2. Methods

The Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) checklist was used to conduct the systematic review and meta‐analysis (Table S1) [16]. This systematic review and meta‐analysis study have been registered in the International Prospective Register of Systematic Reviews (PROSPERO) database (CRD42023457467). Given the nature of this investigation as a systematic review involving the scrutiny of previously published research, it is noteworthy that the acquisition of patient‐informed consent and ethical approval was deemed unnecessary.

2.1. Search Strategy

A thorough exploration of online electronic databases, including Scopus, PubMed, Web of Science, IranMedex, and the Scientific Information Database (SID), was undertaken using keywords extracted from Medical Subject Headings such as “Quality of Health Care,” “Hospital,” and “Patients” spanning from the earliest available records up to August 11, 2023. To illustrate, the search strategy in the PubMed/MEDLINE database encompassed terms such as ((“Service quality”) OR (“Quality of healthcare”) OR (“Quality of care”)) AND ((“SERVQUAL”) OR (“SERVQUAL model”)) AND ((“Patients”) OR (“Patients perception”) OR (“Patients expectation”)) AND ((“Hospital”) OR (“Medical center”)). Keywords were combined using Boolean operators (AND/OR) to merge concepts. For searching electronic Persian databases, Persian keyword equivalents were applied. In each search phase, two researchers conducted the process independently. When differences of opinion arose between the two researchers, a third reviewer was consulted to provide an assessment.

2.2. Inclusion and Exclusion Criteria

This systematic review and meta‐analysis encompassed cross‐sectional studies written in both English and Persian. These studies specifically addressed the evaluation of service quality in Iranian hospitals from the perspectives of patients, using the SERVQUAL model. The SERVQUAL questionnaire comprises five dimensions encompassing a total of 30 items that assess both perceptions and expectations within a specified domain. These dimensions are categorized into two subgroups: perceptions and expectations, each consisting of 15 questions. The Likert scale serves as the foundational scoring mechanism, ranging from 1 to 5, where a score of 1 represents the lowest rank, and a score of 5 denotes the highest rating. Specifically, the questionnaire addresses questions 1–3 about tangibility, questions 4–6 addressing reliability, questions 7–9 focusing on responsiveness, questions 10–13 exploring assurance, and questions 14 and 15 centering on empathy [17]. The review excluded types of literature such as reviews, case reports, conference proceedings, editorials, experiments, and qualitative research designs.

2.3. Study Selection

Data management was facilitated using the EndNote 20 software. Study selection based on inclusion and exclusion criteria involved several steps: (1) initial identification of duplicate articles, using both electronic and manual methods; (2) assessment of the titles and abstracts of the studies; and (3) in‐depth review of the complete texts of the publications. Additionally, a review of the reference lists of relevant research was conducted to prevent any inadvertent omission of significant data.

2.4. Data Extraction and Quality Assessment

Data extraction from the articles included in this systematic review and meta‐analysis encompassed details such as the primary author's name, publication year, geographical location, number and types of hospitals, sample size, gender distribution, age, education level, hospital visit frequency, and utilization of the SERVQUAL model. The assessment of study quality within this review was conducted using the Appraisal tool for Cross‐Sectional Studies (AXIS tool). This evaluation instrument comprises 20 items, each rated on a 2‐point Likert scale denoting “yes” (score of 1) or “no” (score of 0). The tool gauges study quality across three domains: report quality (seven items), study design quality (seven items), and potential bias introduction (six items). The final assessment by AXIS categorizes study quality into three levels: high (70%–100%), fair (60%–69.9%), and low (0%–59.9%) [18]. Both data extraction and quality assessment were independently performed by two researchers. In instances where there was a disparity of opinion between the two researchers, a third reviewer provided an evaluation.

2.5. Statistical Analysis

The analysis utilized version 3 of the CMA program. Each study's weight was determined by its inverse variance. Heterogeneity among the studies was visualized using a forest plot. The forest plots depict the mean perception and expectation of SERVQUAL scores for individual studies and the overall mean score. The heterogeneity level was gauged by I ² statistics: 25% for mild, 50% for moderate, and 75% for high heterogeneity. Given significant result variability, a random effects model was used. To probe study heterogeneity, subgroup analyses with meta‐regression were conducted. Meta‐regression analyzed the relationship between the SERVQUAL score and study year. For study‐specific variables such as location, subgroup analyses were done to investigate the mean SERVQUAL score.

2.6. Sensitivity Analysis

A sensitivity analysis was conducted to evaluate the impact of excluding each study on the mean perception and expectation of patients on service quality based on the SERVQUAL model.

2.7. Publication of Bias

To evaluate the potential for publication bias, the Egger's test results and a Funnel plot were utilized.

3. Results

3.1. Study Selection

As shown in Figure 1, following an extensive search of electronic resources, a total of 1999 studies were initially identified. Among these, 632 duplicate items were removed. After this process, there were 1367 remaining papers. Of these, 41 studies were deemed ineligible for inclusion in this systematic review because they did not meet the cross‐sectional study criteria, and 1274 articles did not align with the study's objectives and were subsequently excluded. An additional 20 studies were disregarded due to insufficient methodology or results, and seven studies were omitted due to a lack of available data after a thorough evaluation of the full‐text publications. Consequently, the systematic review comprised 25 selected studies [9, 10, 13, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40].

Figure 1.

Flow diagram of the study selection process.

3.2. Study Characteristics

As shown in Table 1, in 25 cross‐sectional studies [9, 10, 13, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40], a collective total of 8021 patients who were hospitalized in Iranian hospitals took part. Among the participants, 50.7% were men. The average age of the patients was 40.99 (SD = 0.97).

Table 1.

Basic characteristics of the included studies in this systematic review and meta‐analysis.

First author/year	Location (province)	Number of hospitals	Type of hospitals	Sample size	M/F ratio (%)	Age (mean ± SD)	Level of education (%)	Hospital visit frequency (%)	SERVQUAL (mean ± SD)						AXIS Score
									Tangibility	Reliability	Responsiveness	Assurance	Empathy	Total
Mohammadi et al. (2004) [27]	Zanjan	N/A	N/A	256	N/A	N/A	N/A	N/A	Perception: 3.03 Expectation: 4.17 Gap: −1.13 Sig: p < 0.001	Perception: 2.91 Expectation: 4.20 Gap: −1.29 Sig: p < 0.001	Perception: 2.84 Expectation: 4.08 Gap: −1.23 Sig: p < 0.001	Perception: 2.77 Expectation: 4.07 Gap: −1.30 Sig: p < 0.001	Perception: 2.74 Expectation: 4.01 Gap: −1.27 Sig: p < 0.001	Perception: 2.86 Expectation: 4.11 Gap: −1.25 Sig: p < 0.001	Fair
Jannaabadi et al. (2011) [26]	Sistan and Baluchistan	N/A	N/A	200	59.00/41.00	N/A	Diploma or under diploma: 183 (91.50) Above diploma: 17 (8.50)	N/A	Perception: 4.25 Expectation: 4.94 Gap: −0.69 Sig: p < 0.001	Perception: 4.19 Expectation: 4.88 Gap: −0.685 Sig: p < 0.001	Perception: 4.13 Expectation: 4.92 Gap: −0.79 Sig: p < 0.001	Perception: 4.08 Expectation: 4.83 Gap: −0.75 Sig: p < 0.001	Perception: 3.97 Expectation: 4.81 Gap: −0.84 Sig: p < 0.001	Perception: 4.17 Expectation: 4.95 Gap: −0.77 Sig: p < 0.001	High
Nekoei‐Moghadam and Amiresmaili (2011) [29]	Kerman	3	Government hospital	385	54.29/45.71	37.99 (SD = 15.86)	Under diploma: 176 (45.71) Diploma: 162 (42.08) Above diploma: 47 (12.21)	N/A	Perception: 3.29 Expectation: 4.64 Gap: −1.35 Sig: p < 0.05	Perception: 3.54 Expectation: 4.74 Gap: −1.20 Sig: p < 0.05	Perception: 3.35 Expectation: 4.64 Gap: −1.29 Sig: p < 0.05	Perception: 3.67 Expectation: 4.59 Gap: −0.92 Sig: p < 0.05	Perception: 3.67 Expectation: 4.64 Gap: −0.97 Sig: p < 0.05	Perception: 3.51 Expectation: 4.65 Gap: −1.14 Sig: p < 0.05	Fair
Hekmatpou et al. (2012) [24]	Markazi	N/A	Government hospital	260	46.15/53.85	39.89 (SD = 21.17)	Under diploma: 116 (44.62) Diploma: 100 (38.46) University: 44 (16.92)	N/A	Perception: 3.66 (SD = 1.02) Expectation: 4.96 (SD = 0.15) Gap: −1.30 Sig: p < 0.001	Perception: 3.76 (SD = 0.96) Expectation: 4.97 (SD = 0.27) Gap: −1.20 Sig: p < 0.001	Perception: 3.65 (SD = 1.07) Expectation: 4.94 (SD = 0.42) Gap: −1.29 Sig: p < 0.001	Perception: 3.80 (SD = 0.99) Expectation: 4.96 (SD = 0.29) Gap: −1.16 Sig: p < 0.001	Perception: 3.61 (SD = 1.07) Expectation: 4.94 (SD = 0.56) Gap: −1.33 Sig: p < 0.001	Perception: 3.70 (SD = 1.02) Expectation: 4.95 (SD = 0.34) Gap: −1.25 Sig: p < 0.001	High
Razlansari et al. (2012) [31]	Kermanshah	5	Government hospital	400	47.75/52.25	35.00 (SD = 9.40)	N/A	N/A	Perception: 3.65 (SD = 0.57) Expectation: 4.48 (SD = 0.43) Gap: −0.83 Sig: p < 0.001	Perception: 3.44 (SD = 0.81) Expectation: 4.53 (SD = 0.39) Gap: −1.09 Sig: p < 0.001	Perception: 3.62 (SD = 0.67) Expectation: 4.65 (SD = 0.31) Gap: −1.03 Sig: p < 0.001	Perception: 3.74 (SD = 0.82) Expectation: 4.64 (SD = 0.30) Gap: −0.90 Sig: p < 0.001	Perception: 3.89 (SD = 0.88) Expectation: 4.55 (SD = 0.32) Gap: −0.66 Sig: p < 0.001	Perception: 3.67 (SD = 0.51) Expectation: 4.57 (SD = 0.38) Gap: −0.90 Sig: p < 0.001	High
Tabibi et al. (2012) [38]	Tehran	6	N/A	240	N/A	N/A	N/A	N/A	Perception: 3.70 Expectation: 4.57 Gap: −0.87 Sig: p < 0.001	Perception: 3.36 Expectation: 4.50 Gap: −1.14 Sig: p < 0.001	Perception: 3.39 Expectation: 4.59 Gap: −1.20 Sig: p < 0.001	Perception: 3.49 Expectation: 4.24 Gap: −0.75 Sig: p < 0.001	Perception: 3.44 Expectation: 4.65 Gap: −1.21 Sig: p < 0.001	Perception: 3.48 Expectation: 4.51 Gap: −1.03 Sig: p < 0.001	Fair
Zarei et al. (2012) [40]	Tehran	8	Private hospitals	983	45.98/54.02	47.9 (SD = 16.97)	N/A	N/A	Perception: 4.18 (SD = 0.62) Expectation: 4.95 (SD = 0.18) Gap: −0.77 Sig: p < 0.001	Perception: 4.05 (SD = 0.71) Expectation: 4.93 (SD = 0.21) Gap: −0.88 Sig: p < 0.001	Perception: 4.06 (SD = 0.74) Expectation: 4.92 (SD = 0.25) Gap: −0.86 Sig: p < 0.001	Perception: 4.11 (SD = 0.70) Expectation: 4.94 (SD = 0.20) Gap: −0.83 Sig: p < 0.001	Perception: 3.78 (SD = 0.78) Expectation: 4.85 (SD = 0.34) Gap: −1.07 Sig: p < 0.001	Perception: 4.02 (SD = 0.63) Expectation: 4.92 (SD = 0.20) Gap: −0.90 Sig: p < 0.001	High
Gorji et al. (2013) [21]	Tehran	1	Government hospital	116	59.48/40.51	43.38	Under diploma: 49 (42.24) Diploma: 43 (37.07) Above diploma: 24 (20.69)	1st: 66 (56.90) 2nd or higher: 50 (43.10)	Perception: 3.63 Expectation: 4.67 Gap: ‐1.04 Sig: p < 0.05	Perception: 3.73 Expectation: 4.71 Gap: −0.98 Sig: p < 0.05	Perception: 3.64 Expectation: 4.64 Gap: −0.10 Sig: p < 0.05	Perception: 4.03 Expectation: 4.72 Gap: −0.69 Sig: p < 0.05	Perception: 3.68 Expectation: 4.66 Gap: −0.98 Sig: p < 0.05	Perception: 3.74 Expectation: 4.68 Gap: −0.94 Sig: p < 0.05	High
Aghamolaei et al. (2014) [23]	Hormozgan	1	Government hospital	89	64.04/35.94	32.90 (SD = 10.50)	N/A	N/A	Perception: 3.42 (SD = 0.83) Expectation: 4.73 (SD = 0.40) Gap: −1.30 (SD = 0.96) Sig: p < 0.001	Perception: 3.49 (SD = 0.72) Expectation: 4.72 (SD = 0.43) Gap: −1.22 (SD = 0.87) Sig: p < 0.001	Perception: 3.34 (SD = 0.81) Expectation: 4.76 (SD = 0.38) Gap: −1.42 (SD = 0.91) Sig: p < 0.001	Perception: 3.56 (SD = 0.86) Expectation: 4.76 (SD = 0.47) Gap: −1.20 (SD = 0.96) Sig: p < 0.001	Perception: 3.39 (SD = 0.80) Expectation: 4.69 (SD = 0.47) Gap: −1.31 (SD = 0.96) Sig: p < 0.001	Perception: 3.44 (SD = 0.69) Expectation: 4.73 (SD = 0.34) Gap: −1.29 (SD = 0.81) Sig: p < 0.001	High
Anbari et al. (2014) [34]	Markazi	3	Government hospital	385	54.3/45.7	37.99 (SD = 15.86)	Under diploma: 176 (45.71) Diploma and associated: 162 (42.08) Bachelor's and higher: 47 (12.21)	N/A	Perception: 3.31 Expectation: 4.64 Gap: −1.33 Sig: p < 0.05	Perception: 3.54 Expectation: 4.74 Gap: −1.20 Sig: p < 0.05	Perception: 3.35 Expectation: 4.64 Gap: −1.29 Sig: p < 0.05	Perception: 3.67 Expectation: 4.59 Gap: −1.28 Sig: p < 0.05	Perception: 3.67 Expectation: 4.64 Gap: −0.97 Sig: p < 0.05	Perception: 3.51 Expectation: 4.65 Gap: −1.14 Sig: p < 0.05	High
Sina et al. (2015) [37]	Mazandaran	1	Government hospital	331	55.29/44.71	N/A	Under diploma or diploma: 101 (30.51) Above diploma: 230 (69.49)	N/A	Perception: 2.98 (SD = 0.57) Expectation: 4.00 (SD = 0.57) Gap: −1.02 Sig: p < 0.001	Perception: 2.50 (SD = 0.67) Expectation: 4.17 (SD = 0.59) Gap: −1.67 Sig: p < 0.001	Perception: 2.79 (SD = 0.72) Expectation: 4.14 (SD = 0.74) Gap: −1.35 Sig: p < 0.001	Perception: 1.91 (SD = 0.77) Expectation: 3.90 (SD = 0.73) Gap: −1.99 Sig: p < 0.001	Perception: 3.25 (SD = 0.54) Expectation: 4.30 (SD = 0.49) Gap: −1.05 Sig: p < 0.001	Perception: 2.69 (SD = 0.26) Expectation: 4.10 (SD = 0.28) Gap: −1.41 Sig: p < 0.001	Fair
Bahmei et al. (2016) [35]	Fars	1	Government hospital	582	53.61/46.39	N/A	Under diploma: 378 (64.95) Diploma:90 (15.46) Above diploma: 114 (19.59)	N/A	Perception: 3.39 (SD = 0.65) Expectation: 3.75 (SD = 0.64) Gap: −0.37 (SD = 0.83) Sig: p = 0.013	Perception: 3.23 (SD = 0.65) Expectation: 3.55 (SD = 0.62) Gap: −0.32 (SD = 0.83) Sig: p = 0.048	Perception: 3.3 (SD = 0.7) Expectation: 3.61 (SD = 0.71) Gap: −0.31 (SD = 0.98) Sig: p = 0.785	Perception: 3.23 (SD = 0.6) Expectation: 3.78 (SD = 0.57) Gap: −0.55 (SD = 0.86) Sig: p = 0.346	Perception: 3.22 (SD = 0.62) Expectation: 3.62 (SD = 0.72) Gap: −0.40 (SD = 0.96) Sig: p = 0.626	Perception: 3.27 (SD = 0.64) Expectation: 3.66 (SD = 0.65) Gap: −0.39 Sig: p > 0.05	High
Gholami et al. (2016) [20]	Fars	6	N/A	200	64.00/36.00	49.67 (SD = 16.04)	N/A	N/A	Perception: 4.21 (SD = 0.55) Expectation: 4.50 (SD = 0.41) Gap: −0.30 (SD = 0.51) Sig: p < 0.001	Perception: 4.21 (SD = 0.65) Expectation: 4.81 (SD = 0.38) Gap: −0.60 (SD = 0.65) Sig: p < 0.001	Perception: 4.29 (SD = 0.64) Expectation: 4.80 (SD = 0.38) Gap: −0.51 (SD = 0.62) Sig: p < 0.001	Perception: 4.41 (SD = 0.58) Expectation: 4.77 (SD = 0.37) Gap: −0.36 (SD = 0.55) Sig: p < 0.001	Perception: 4.39 (SD = 0.54) Expectation: 4.61 (SD = 0.44) Gap: −0.22 (SD = 0.54) Sig: p < 0.001	Perception: 4.30 (SD = 0.13) Expectation: 4.72 (SD = 0.09) Gap: −0.42 Sig: p < 0.001	High
Gholami et al. (2016) [13]	Fars	1	Government hospital	100	35.00/65.00	54.4 (SD = 19.35)	Under diploma: 43 (43.00) Diploma: 29 (29.00) Above diploma: 28 (28.00)	1st: 60 (60.00) 2nd or higher: 40 (40.00)	Perception: 3.45 (SD = 0.86) Expectation: 4.31 (SD = 0.62) Gap: −0.86 (SD = 0.98) Sig: p < 0.001	Perception: 3.42 (SD = 0.86) Expectation: 4.36 (SD = 0.61) Gap: −0.94 (SD = 0.91) Sig: p < 0.001	Perception: 3.27 (SD = 0.89) Expectation: 4.35 (SD = 1.02) Gap: −1.08 (SD = 1.35) Sig: p < 0.001	Perception: 3.55 (SD = 1.04) Expectation: 4.38 (SD = 0.61) Gap: −0.83 (SD = 1.16) Sig: p < 0.001	Perception: 3.45 (SD = 0.8) Expectation: 4.39 (SD = 1.2) Gap: −0.94 (SD = 1.42) Sig: p < 0.001	Perception: 3.295 (SD = 0.75) Expectation: 4.35 (SD = 0.62) Gap: −0.97 (SD = 0.92) Sig: p < 0.001	High
Nadi et al. (2016) [28]	Mazandaran	3	Government hospital	600	26.83/73.17	39.94	Under diploma: 115 (19.17) Diploma: 161 (26.83) Above diploma: 324 (54.00)	N/A	Perception: 3.93 (SD = 0.43) Expectation: 4.62 (SD = 0.47) Gap: −0.68 (SD = 0.54) Sig: p < 0.001	Perception: 4.31 (SD = 0.36) Expectation: 4.62 (SD = 0.47) Gap: −0.30 (SD = 0.52) Sig: p < 0.001	Perception: 3.89 (SD = 0.46) Expectation: 4.61 (SD = 0.48) Gap: −0.71 (SD = 0.57) Sig: p < 0.001	Perception: 3.82 (SD = 0.48) Expectation: 4.60 (SD = 0.46) Gap: −0.78 (SD = 0.52) Sig: p < 0.001	Perception: 3.97 (SD = 0.34) Expectation: 4.61 (SD = 0.47) Gap: −0.63 (SD = 0.54) Sig: p < 0.001	Perception: 4.00 (SD = 0.33) Expectation: 4.61 (SD = 0.45) Gap: −0.61 Sig: p < 0.001	High
Rezaei et al. (2016) [33]	Kermanshah	7	Government hospital	400	37.00/63.00	38.50 (SD = 23.60)	Under diploma or diploma: 316 (79.00) Above diploma: 84 (21.00)	N/A	Perception: 3.81 (SD = 1.12) Expectation: 4.61 (SD = 0.9) Gap: −0.80 Sig: p < 0.001	Perception: 3.65 (SD = 1.21) Expectation: 4.43 (SD = 0.8) Gap: −0.78 Sig: p < 0.001	Perception: 3.96 (SD = 1.45) Expectation: 4.52 (SD = 0.51) Gap: −0.56 Sig: p < 0.001	Perception: 3.82 (SD = 1.33) Expectation: 4.70 (SD = 0.65) Gap: −0.88 Sig: p < 0.001	Perception: 3.78 (SD = 1.60) Expectation: 4.65 (SD = 0.34) Gap: −0.87 Sig: p < 0.001	Perception: 3.80 (SD = 1.60) Expectation: 4.58 (SD = 0.59) Gap: −0.78 Sig: p < 0.001	High
Haghshenas et al. (2017) [22]	Tehran	14	Government hospital clinics	231	38.80/61.20	N/A	Under diploma: 60 (26.80) Diploma and Associates degree: 69 (30.80) Bachelor: 75 (33.50) Master and higher: 20 (8.90)	N/A	Perception: 3.72 (SD = 0.55) Expectation: 4.41 (SD = 0.47) Gap: −0.69 Sig: p < 0.001	Perception: 3.59 (SD = 0.61) Expectation: 4.43 (SD = 0.48) Gap: −0.83 Sig: p < 0.001	Perception: 3.46 (SD = 0.66) Expectation: 4.43 (SD = 0.46) Gap: −0.97 Sig: p < 0.001	Perception: 3.59 (SD = 0.66) Expectation: 4.44 (SD = 0.45) Gap: −0.85 Sig: p < 0.001	Perception: 3.54 (SD = 0.64) Expectation: 4.34 (SD = 0.48) Gap: −0.81 Sig: p < 0.001	Perception: 3.59 (SD = 0.13) Expectation: 4.41 (SD = 0.10) Gap: −0.82 Sig: p < 0.001	High
Razmjoee et al. (2017) [32]	Fars	1	Government hospital	98	68.37/31.63	N/A	Under diploma or diploma: 65 (66.33) Above diploma: 33 (33.67)	N/A	Perception: 3.38 (SD = 0.79) Expectation: 4.18 (SD = 0.67) Gap: −0.79 (SD = 1.06) Sig: p < 0.001	Perception: 3.26 (SD = 1.03) Expectation: 4.30 (SD = 0.71) Gap: −0.97 (SD = 1.16) Sig: p < 0.001	Perception: 3.50 (SD = 0.80) Expectation: 4.30 (SD = 0.69) Gap: −1.03 (SD = 1.07) Sig: p < 0.001	Perception: 3.27 (SD = 1.02) Expectation: 4.30 (SD = 0.64) Gap: −0.80 (SD = 1.04) Sig: p < 0.001	Perception: 3.23 (SD = 0.23) Expectation: 4.21 (SD = 0.68) Gap: −1.02 (SD = 0.97) Sig: p < 0.001	Perception: 3.36 (SD = 0.18) Expectation: 4.26 (SD = 0.14) Gap: −0.90 Sig: p < 0.001	High
Adhami Mogadam et al. (2017) [19]	Tehran	3	Government hospital	405	37.78/62.22	40.08 (SD = 12.96)	Under diploma: 124 (30.62) Diploma: 218 (53.83) Above diploma: 63 (15.55)	N/A	Perception: 3.21 (SD = 0.22) Expectation: 4.31 (SD = 0) Gap: −1.18 Sig: p < 0.01	Perception: 3.50 (SD = 0.08) Expectation: 4.34 (SD = 0) Gap: −0.84 Sig: p < 0.01	Perception: 3.45 (SD = 0.03) Expectation: 4.32 (SD = 0.03) Gap: −0.87 Sig: p < 0.01	Perception: 3.72 (SD = 0.05) Expectation: 4.35 (SD = 0) Gap: −0.63 Sig: p < 0.01	Perception: 3.31 (SD = 0.07) Expectation: 4.23 (SD = 0) Gap: −0.92 Sig: p < 0.01	Perception: 3.45 (SD = 0.24) Expectation: 4.31 (SD = 0.03) Gap: −0.86 Sig: p < 0.01	Fair
Hoseini Rostami et al. (2018) [25]	Golestan	5	Government and private hospitals	369	48.78/51.22	N/A	Under diploma and diploma: 325 (88.08) Above diploma: 44 (11.92)	N/A	Perception: 4.00 (SD = 0.70) Expectation: 4.55 (SD = 0.56) Gap: −0.55 Sig: p = 0.001	Perception: 3.87 (SD = 0.72) Expectation: 4.51 (SD = 0.57) Gap: −0.61 Sig: p = 0.001	Perception: 2.38 (SD = 1.02) Expectation: 1.65 (SD = 0.98) Gap: 0.73 Sig: p = 0.001	Perception: 3.86 (SD = 0.64) Expectation: 4.32 (SD = 0.65) Gap: −0.46 Sig: p = 0.001	Perception: 3.06 (SD = 0.93) Expectation: 2.20 (SD = 1.09) Gap: 0.86 Sig: p = 0.001	Perception: 3.52 (SD = 0.27) Expectation: 3.51 (SD = 0.51) Gap: 0.01 Sig: N/A	High
Qolipour et al. (2018) [30]	Khuzestan	N/A	Government and private hospitals	250	69.20/30.80	39.00 (SD = 2.20)	Under diploma: 65 (26.00) Diploma: 83 (33.20) Above diploma: 102 (40.80)	1st: 131 (52.40) 2nd: 61 (24.40) 3rd: 35 (14.00) 4th or higher: 23 (9.20)	Perception: 3.92 (SD = 0.67) Expectation: 4.61 (SD = 0.41) Gap: −0.68 Sig: p < 0.001	Perception: 3.00 (SD = 0.73) Expectation: 4.73 (SD = 0.38) Gap: −1.73 Sig: p < 0.001	Perception: 2.94 (SD = 0.74) Expectation: 4.84 (SD = 0.35) Gap: −1.89 Sig: p < 0.001	Perception: 3.26 (SD = 0.73) Expectation: 4.76 (SD = 0.38) Gap: −1.50 Sig: p < 0.001	Perception: 3.80 (SD = 0.92) Expectation: 4.82 (SD = 0.33) Gap: −1.02 Sig: p < 0.001	Perception: 3.38 (SD = 0.76) Expectation: 4.75 (SD = 0.37) Gap: −1.37 Sig: p < 0.001	High
Rezaei et al. (2018) [15]	East Azerbaijan	1	Government hospitals	300	57.67/42.33	44.99 (SD = 17.53)	Under diploma: 65 (26.00) Diploma: 83 (33.20) Above diploma: 102 (40.80)	2.91 (SD = 2.75)	Perception: 3.44 (SD = 0.87) Expectation: 4.39 (SD = 0.61) Gap: −0.95 (SD = 0.97) Sig: p < 0.01	Perception: 3.55 (SD = 0.80) Expectation: 4.42 (SD = 0.60) Gap: −0.87 (SD = 0.90) Sig: p < 0.01	Perception: 3.38 (SD = 0.90) Expectation: 4.44 (SD = 0.62) Gap: −1.06 (SD = 1.05) Sig: p < 0.01	Perception: 3.48 (SD = 0.89) Expectation: 4.48 (SD = 0.62) Gap: −1.00 (SD = 1.03) Sig: p < 0.01	Perception: 3.39 (SD = 0.90) Expectation: 4.45 (SD = 0.64) Gap: −1.06 (SD = 1.08) Sig: p < 0.01	Perception: 3.45 (SD = 0.80) Expectation: 4.44 (SD = 0.57) Gap: −0.99 (SD = 0.91) Sig: p < 0.01	High
Vizvari et al. (2018) [39]	Golestan	1	Government hospitals	170	0/100	N/A	N/A	N/A	Perception: 3.84 (SD = 0.65) Expectation: 4.02 (SD = 0.69) Gap: −0.18 Sig: p < 0.001	Perception: 3.81 (SD = 0.85) Expectation: 4.15 (SD = 0.84) Gap: −0.34 Sig: p < 0.001	Perception: 3.44 (SD = 0.82) Expectation: 3.80 (SD = 0.83) Gap: −0.36 Sig: p < 0.001	Perception: 3.77 (SD = 0.84) Expectation: 4.17 (SD = 0.79) Gap: −0.40 Sig: p < 0.001	Perception: 3.63 (SD = 0.93) Expectation: 3.88 (SD = 0.89) Gap: −0.25 Sig: p < 0.001	Perception: 3.71 (SD = 0.73) Expectation: 4.01 (SD = 0.72) Gap: −0.30 Sig: p < 0.001	High
Daghighbin and Abdolmohammadi (2020) [10]	Razavi Khorasan	2	Government hospital	271	65.31/34.69	38.16 (SD = 14.18)	Under diploma: 163 (60.15) Diploma: 68 (25.09) Above diploma: 40 (14.76)	1st: 165 (60.89) 2nd or higher: 106 (39.11)	Perception: N/A Expectation: N/A Gap: N/A Sig: p < 0.001	Perception: N/A Expectation: N/A Gap: N/A Sig: p < 0.001	Perception: N/A Expectation: N/A Gap: N/A Sig: p < 0.001	Perception: N/A Expectation: N/A Gap: N/A Sig: p < 0.001	Perception: N/A Expectation: N/A Gap: N/A Sig: p < 0.001	Perception: 2.83 (SD = 0.84) Expectation: 3.82 (SD = 0.33) Gap: −0.99 Sig: p < 0.001	High
Zarei et al. (2020) [9]	Khuzestan	N/A	Government hospitals	400	46.25/53.75	38.50 (SD = 16.80)	Under diploma and diploma: 272 (68.00) Above diploma: 128 (32.00)	1st: 173 (43.25) 2nd: 89 (22.25) 3rd: 138 (34.50)	Perception: 3.67 (SD = 1.00) Expectation: 4.35 (SD = 0.82) Gap: −0.68 Sig: p = 0.001	Perception: 3.79 (SD = 0.99) Expectation: 4.42 (SD = 0.51) Gap: −0.63 Sig: p = 0.001	Perception: 3.65 (SD = 1.09) Expectation: 4.31 (SD = 0.94) Gap: −0.66 Sig: p = 0.001	Perception: 3.80 (SD = 1.07) Expectation: 4.46 (SD = 0.81) Gap: −0.66 Sig: p = 0.001	Perception: 3.67 (SD = 1.11) Expectation: 4.33 (SD = 0.84) Gap: −0.66 Sig: p = 0.001	Perception: 3.72 (SD = 0.94) Expectation: 4.37 (SD = 0.75) Gap: −0.65 Sig: p = 0.001	High

Abbreviations: SD, standard deviation; SERVQUAL, service quality.

3.3. Methodological Quality of Included Study

As shown in Figure 2, out of the studies included, 20 [9, 10, 13, 20, 21, 22, 23, 24, 25, 26, 28, 30, 31, 32, 33, 34, 35, 36, 39, 40] were deemed to be of high quality, whereas five [19, 27, 29, 37, 38] were rated as fair quality. In 15 [13, 19, 20, 21, 24, 26, 27, 28, 29, 31, 35, 36, 37, 38, 39] of the included studies, there was no mention of limitations, and in 12 studies [19, 21, 24, 26, 27, 29, 31, 33, 37, 38, 39, 40], no information was provided regarding funding sources and potential conflicts of interest.

Figure 2.

Assessment of the quality of the included articles.

3.4. Service Quality Based on Servqual Model

As shown in Figure 3, in a total of 25 studies, the mean perception of patients about the quality of services in hospitals was 3.54 (SE = 0.08) (95% CI: 3.37–3.70; I ² = 99.814%; p< 0.001). Also, as shown in Figure 4, the mean expectation of patients about the quality of services in hospitals was 4.43 (SE = 0.06) (95% CI: 4.31–4.54; I ² = 99.899%; p < 0.001).

Figure 3.

Forest plot of patients' perceptions based on the SERVQUAL model.

Figure 4.

Forest plot of patients' expectations based on the SERVQUAL model.

As shown in Table 2, in a total of 24 studies, the mean perception of patients about the quality of services in hospitals in tangibility dimension was 3.63 (SE = 0.08) (95% CI: 3.46–3.79; I ² = 99.402%; p < 0.001). Also, the mean expectation of patients about the quality of services in hospitals in the tangibility dimension was 4.47 (SE = 0.07) (95% CI: 4.34–4.61; I ² = 99.900%; p < 0.001). The mean perception of patients about the quality of services in hospitals in the reliability dimension was 3.57 (SE = 0.08) (95% CI: 3.41–3.74; I ² = 99.581%; p < 0.001). Also, the mean expectation of patients about the quality of services in hospitals in the reliability dimension was 4.51 (SE = 0.07) (95% CI: 4.38–4.64; I ² = 99.814%; p < 0.001). The mean perception of patients about the quality of services in hospitals in the responsiveness dimension was 3.46 (SE = 0.07) (95% CI: 3.33–3.60; I ² = 99.273%; p < 0.001). Also, the mean expectation of patients about the quality of services in hospitals in the responsiveness dimension was 4.37 (SE = 0.08) (95% CI: 4.21–4.53; I ² = 99.801%; p < 0.001). The mean perception of patients about the quality of services in hospitals in the assurance dimension was 3.60 (SE = 0.08) (95% CI: 3.45–3.75; I ² = 99.455%; p < 0.001). Also, the mean expectation of patients about the quality of services in hospitals in the assurance dimension was 4.49 (SE = 0.06) (95% CI: 4.37–4.61; I ² = 99.834%; p < 0.001). The mean perception of patients about the quality of services in hospitals in the empathy dimension was 3.56 (SE = 0.06) (95% CI: 3.45–3.68; I ² = 99.511%; p < 0.001). Also, the mean expectation of patients about the quality of services in hospitals in the empathy dimension was 4.38 (SE = 0.07) (95% CI: 4.24–4.52; I ² = 99.756%; p < 0.001).

Table 2.

Perception and expectation of patients based on the SERVQUAL model.

Dimensions of SERVQUAL		Mean (SE)	Gap	95% CI		Heterogeneity			Egger's regression
				Lower limit (mean)	Upper limit (mean)	χ 2	p value	I 2	p value	t‐value
Tangibility	Perception	3.63 (SE = 0.08)	−0.84	3.46	3.79	3847.412	< 0.001	99.402	0.266	1.142
	Expectation	4.47 (SE = 0.07)		4.34	4.61	23014.726	< 0.001	99.900	0.030	2.319
Reliability	Perception	3.57 (SE = 0.08)	−0.94	3.41	3.74	5485.736	< 0.001	99.581	0.577	0.567
	Expectation	4.51 (SE = 0.07)		4.38	4.64	12334.824	< 0.001	99.814	0.030	2.320
Responsiveness	Perception	3.46 (SE = 0.07)	−0.91	3.33	3.60	3164.817	< 0.001	99.273	0.772	0.292
	Expectation	4.37 (SE = 0.08)		4.21	4.53	11584.461	< 0.001	99.801	0.272	1.127
Assurance	Perception	3.60 (SE = 0.08)	−0.89	3.45	3.75	4221.925	< 0.001	99.455	0.347	0.962
	Expectation	4.49 (SE = 0.06)		4.37	4.61	13884.317	< 0.001	99.834	0.123	1.601
Empathy	Perception	3.56 (SE = 0.06)	−0.82	3.45	3.68	4704.577	< 0.001	99.511	0.038	2.197
	Expectation	4.38 (SE = 0.07)		4.24	4.52	9422.992	< 0.001	99.756	0.021	2.481
Total	Perception	3.54 (SE = 0.08)	−0.89	3.37	3.70	12886.377	< 0.001	99.814	0.269	1.133
	Expectation	4.43 (SE = 0.06)		4.31	4.54	23735.698	< 0.001	99.899	0.169	1.421

As shown in Table 2, according to the SERVQUAL model, the overall difference between patients' perceptions and their expectations was −0.89. When examining specific aspects, the gap between patients' perceptions and expectations in the tangibility dimension was −0.84, in the reliability dimension was −0.94, in the responsiveness dimension was −0.91, in the assurance dimension was −0.89, and in the empathy dimension was −0.82.

As shown in Figure 5, the meta‐regression results showed that there was no statistically significant relationship between patients' perceptions and the year of publication (p = 0.969). However, as presented in Figure 6, the meta‐regression findings revealed a statistically significant association between patients' expectations and the year of publication (p = 0.004). The presence of this noteworthy alteration may constitute one of the contributing factors to the observed heterogeneity across the included studies.

Figure 5.

Meta‐regression based on the relationship between the patients' perceptions based on the SERVQUAL and years of publications.

Figure 6.

Meta‐regression based on the relationship between the patients' expectations based on the SERVQUAL and years of publications.

As shown in Figure 7, analyzing the data concerning patients' average perceptions in different subgroups within Iran, it was observed that patients in Tehran province (the capital) had an average perception score of 3.66 (SE = 0.08) (95% CI: 3.50−3.81; I ² = 99.482%; p < 0.001), whereas patients in other provinces had an average perception score of 3.51 (SE = 0.12) (95% CI: 3.27−3.75; I ² = 99.843%; p< 0.001). Furthermore, as shown in Figure 8, upon examining the data related to patients' average expectations in various subgroups across Iran, it became evident that patients in Tehran province had an average expectation score of 4.57 (SE = 0.14) (95% CI: 4.30−4.84; I ² = 99.956%; p < 0.001), whereas patients in other provinces had an average expectation score of 4.39 (SE = 0.07) (95% CI: 4.25−4.53; I ² = 99.790%; p < 0.001). Following the findings, an additional factor contributing to the observed heterogeneity may be associated with the execution of studies in diverse provinces within Iran. It is noteworthy that discernible distinctions exist in the perceptions and expectations of patients concerning the quality of nursing services between Tehran province and other provinces.

Figure 7.

The mean patient perception based on the SERVQUAL model in the subgroup of location.

Figure 8.

The mean patient expectation based on the SERVQUAL model in the subgroup of location.

3.5. Sensitivity Analysis

As shown in Figures 9 and 10, we performed sensitivity analyses by systematically excluding one study at a time to evaluate how each study influenced the overall outcomes and the degree of heterogeneity among the studies. The findings indicated that the exclusion of any individual study within the scope of this meta‐analysis did not yield a statistically significant alteration in the pooled mean perceptions and expectations of patients regarding hospital services. As evidenced by the results, the removal of any individual study did not yield statistically significant alterations in the levels of patients' expectations and perceptions of hospital services. This observation suggests a high precision in the outcomes of the meta‐analysis, notwithstanding the presence of heterogeneity.

Figure 9.

Sensitivity analysis of patients' perceptions based on the SERVQUAL model.

Figure 10.

Sensitivity analysis of patients' expectations based on the SERVQUAL model.

3.6. Publication of Bias

As shown in Figures 11 and 12, a funnel plot was used to assess potential publication bias in the assessment of patients' average perceptions and expectations using the SERVQUAL model. No indications of asymmetry were discerned in the funnel plot. The Egger's regression test revealed no evidence of publication bias in the assessment of patients' average perceptions (t = 1.133, p = 0.269) and expectations (t = 1.421, p = 0.169). In the tangibility subscale, Egger's test outcomes indicated the absence of publication bias in the perception section (t = 1.142, p = 0.266), whereas discernible publication bias was evident in the expectations section (t = 2.319, p = 0.030). Concerning the reliability subscale, Egger's test results demonstrated an absence of publication bias in the perception section (t = 0.567, p = 0.577), yet revealed publication bias in the expectations section (t = 2.320, p = 0.030). Within the responsiveness subscale, Egger's test findings denoted the absence of biased publication in both the perception (t = 0.292, p = 0.772) and expectation (t = 1.127, p = 0.272) sections. In the assurance subscale, the Egger's test ascertained the absence of biased publication in both the perception (t = 0.962, p = 0.347) and expectation (t = 1.601, p = 0.123) sections. Lastly, within the empathy subscale, Egger's test results revealed bias in both the perception (t = 2.197, p = 0.038) and expectation (t = 2.481, p = 0.021) sections.

Figure 11.

Funnel plot of patients' perceptions based on the SERVQUAL model.

Figure 12.

Funnel plot of patients' expectations based on the SERVQUAL model.

4. Discussion

This systematic review and meta‐analysis revealed that, according to the SERVQUAL model, patients' collective perception of service quality in Iranian hospitals averaged 4.43 (SE = 0.06), whereas their average expectation for service quality was 3.54 (SE = 0.08). The study findings indicated a negative gap between patients' perceptions and their expectations of service quality across all dimensions within the SERVQUAL model. This discrepancy underscores a failure to meet patients' anticipated standards for the quality of healthcare services in Iranian hospitals.

The quality of service in hospitals plays a pivotal role in shaping patient satisfaction, healthcare results, and the general perception of the healthcare system. To assess and enhance service quality effectively, it is crucial to consider the perspective of patients, as it offers invaluable insights into their experiences, requirements, and anticipations [41, 42].

The study's outcomes revealed that the most substantial gap between patient perception and expectation existed within the reliability and responsiveness dimensions. In concurrence with the current study, a systematic review and meta‐analysis conducted in Iran in 2018, comprising 12 studies, demonstrated that the most significant disparity between patients' perceptions and expectations of service quality was observed within the reliability and assurance dimensions [43]. In contrast to the current study, a different systematic review and meta‐analysis conducted in 2018, which included 13 studies, indicated that the responsiveness dimension exhibited the least gap between Iranian patients' perception and expectation of service quality. Nonetheless, akin to the present study, the reliability dimension had the most significant gap (Satar [15]). The reliability dimension centers on evaluating a service provider's capacity to consistently deliver services that are precise, dependable, and in line with their commitments. Essentially, it gauges the degree of trust customers have in the service provider's ability to maintain accurate and uninterrupted service delivery [44, 45]. According to the findings of this study, it appears that patients have a lack of trust in the services being offered. The responsiveness dimension centers on evaluating a service provider's readiness and capability to assist customers, offering a service experience that is both personalized and attentive to their specific needs [45]. A negative gap signifies that patients' expectations regarding the responsiveness dimension are not being fulfilled, resulting in reduced patient satisfaction with service quality. Given this, it is recommended that healthcare managers and policymakers scrutinize the deficiencies and disparities within these two dimensions and work toward resolving any potential issues.

Furthermore, the findings of this study indicated that the gap between patients' perceived and expected service quality in the empathy dimension is comparatively smaller than in the other dimensions. These findings aligned with the results of a systematic review and meta‐analysis conducted in 2018, wherein the smallest gap between patients' perception and expectation of service quality in Iranian hospitals was observed within the empathy dimension [43]. The empathy dimension centers on evaluating the service provider's capacity to demonstrate concern, comprehension, and a keen focus on addressing the unique needs and issues of individual customers [45, 46].

The findings from the subgroup location analysis revealed that patients in Tehran province, the capital, have higher expectations and a better perception of service quality in hospitals compared to other provinces [19, 21, 22, 38, 40]. The observed variance may be attributed to lifestyle disparities and cultural distinctions prevalent among inhabitants residing in Iran's capital and other urban centers. These factors likely contribute to nuanced perspectives and expectations regarding hospital service quality among diverse demographic cohorts. This observation implies that as patients' perception of service quality increases, so do their expectations. This observation raises questions about the absence of a consistent standard for hospital services in Iran.

Considering that the studies included in this systematic review and meta‐analysis were conducted in different provinces of the country, cultural differences among different Iranian ethnic groups can be one of the heterogeneity factors in this study. Also, considering that the sampling of studies was done in different departments of hospitals, it can be another factor of high heterogeneity in this meta‐analysis.

4.1. Limitations

One of the limitations worth noting is the high heterogeneity among the studies included in this analysis. The study's conclusions and the results of the meta‐analysis are contingent on the presence and quality of data obtained from the studies that were included. If certain studies lack adequate or complete data, it may affect the precision and reliability of the analysis. It is possible that despite conducting a comprehensive search across multiple databases, some relevant studies on this subject may not have been identified.

4.2. Implications for Health Managers and Policymakers

Healthcare administrators should view the study's findings as a catalyst for taking action to enhance service quality within Iranian hospitals. Addressing the identified deficiencies and areas for improvement has the potential to elevate patient satisfaction and overall healthcare outcomes. Moreover, the study's recognition of the absence of a suitable standard for hospital services in Iran underscores the necessity for creating and implementing explicit quality standards and benchmarks. Collaboration between healthcare administrators and policymakers is essential for establishing and enforcing these standards across healthcare facilities. Policymakers can also play a pivotal role in raising public awareness about the significance of providing feedback on healthcare experiences. Encouraging patients to share their thoughts and concerns can result in more comprehensive data collection and drive ongoing improvements.

4.3. Implication for Future Research

Future research can explore service quality in greater detail by focusing on the particular aspects that hold the most significance for patients. This exploration might entail conducting qualitative studies or surveys to attain a more nuanced comprehension of patient preferences and anticipations. Researchers can also engage in comparative investigations to contrast how patients perceive service quality in Iranian hospitals with those in other global regions. These comparative inquiries can shed light on areas where Iran can draw insights from international best practices. Additionally, the study of the implementation and consequences of patient‐centered care models in Iranian healthcare institutions can serve as a productive avenue for research. This investigation can provide valuable insights into how such models impact service quality and patient outcomes, thereby guiding potential healthcare reforms.

5. Conclusion

In summary, the study's results revealed a consistent gap between what patients perceive and what they expect in terms of service quality across all dimensions outlined in the SERVQUAL model. This dissonance highlights a clear failure to meet the standards of service quality that patients anticipate when it comes to healthcare services in Iranian hospitals. Hence, healthcare administrators should consider the study's findings as a motivating force to initiate measures aimed at improving service quality in Iranian hospitals. Tackling the recognized shortcomings and areas requiring enhancement holds the promise of raising patient satisfaction levels and, consequently, improving overall healthcare outcomes.

Author Contributions

Study concept and design by all authors, data acquisition by all authors, data interpretation by all authors, drafting the manuscript by all authors, revision of the manuscript by all authors, and the final version of the manuscript is approved by all authors.

Ethics Statement

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Transparency Statement

The lead authors Kobra Salami Kohan and Pooyan Ghorbani Vajargah affirm that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

Supporting information

Supporting information.

Data Availability Statement

The data sets generated and analyzed during the current study are available from the corresponding author upon reasonable request.