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A Customer-Oriented Modelfor Managing Quality in HumanServicesKatherine Selber PhD a & Calvin Streeter PhD ba School of Health Professions, Depart-ment of SocialWork, Southwest Texas State University, San Marcos,TX, 78666, USAb School of Social Work, University of Texas-Austin,Austin, TX, 78712, USAVersion of record first published: 15 Oct 2008.

To cite this article: Katherine Selber PhD & Calvin Streeter PhD (2000): A Customer-Oriented Model for Managing Quality in Human Services, Administration in SocialWork, 24:2, 1-14

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A Customer-Oriented Modelfor Managing Quality

in Human ServicesKatherine Selber, PhDCalvin Streeter, PhD

ABSTRACT. The authors examine the unique challenges of establish-ing and maintaining a quality focus in human services. They also pro-pose a model, the Gap Model, for measuring and managing quality inhuman services. Key concepts on both the customer and provider sidesof the model are explained within the context of human services. Theauthors address the implications for adapting the model for human ser-vice managers. [Article copies available for a fee from The Haworth DocumentDelivery Service: 1-800-342-9678. E-mail address: <getinfo@haworthpressinc.com> Website: <http://www.haworthpressinc.com>]

KEYWORDS. Total quality management, management, quality man-agement, service quality

Quality has been an important part of the public debate in healthand human services in recent years. Budget constraints, calls for out-come-based accountability, and a growing sensitivity to a service qual-ity culture have increased the calls for policy and organizational trans-formations to quality. The change to managed care has paralleled thismovement with a dual focus on cost containment and attention tocustomer-focused quality. Such challenges in the external environ-

Katherine Selber is Assistant Professor, School of Health Professions, Depart-ment of Social Work, Southwest Texas State University, San Marcos, TX 78666.Calvin Streeter is Associate Professor, School of Social Work, University of Texas-Austin, Austin, TX 78712.

Administration in Social Work, Vol. 24(2) 2000E 2000 by The Haworth Press, Inc. All rights reserved. 1

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ADMINISTRATION IN SOCIAL WORK2

ment have intensified pressures to understand, measure, and managequality from a customer perspective (Brannen & Streeter, 1995; Ham-mer & Champy, 1993; Hammer & Stanton, 1995; Martin, 1995;Moore, Kelly, & Lauderdale 1998; Selber, 1997).

In the United States, approaches emphasizing a relentless focus oncustomer-defined quality such as Total Quality Management (TQM)have been applied throughout the private sector since at least the early1980s (Saraph, Benson, & Schroeder, 1991; Spencer, 1994). Humanservice organizations, however, have been slower to respond to thesemanagement approaches (Martin, 1993; Moore & Kelly, 1996). Giventhe rapidly changing and competitive environment found in the privatesector, coupled with the ongoing re-examination of the role and mis-sion of government services, a continued emphasis on managementstrategies designed to improve quality and customer satisfaction insuch areas as mental health, juvenile and criminal justice, rehabilita-tion, and general government services seems likely (Milakovich,1996; Mintzberg, 1996; Wagenheim & Reurnik, 1991).

The authors examine the challenges of establishing and maintaininga quality focus and describe the Gap Model for managing quality inhuman services. They also address the implications for adapting themodel for human service organizations.

CUSTOMER-ORIENTED QUALITY IN HUMAN SERVICES

Quality is still a multifaceted and elusive construct for many humanservice organizations, in part due to the challenges inherent in shiftingto a customer-oriented focus. Two challenges are particularly complexin human services, including ensuring a more active role for the cus-tomer with resultant changes in employee roles and the blending ofmultiple customer requirements.

However, defining quality based on customer information is criticalsince the central principle of the quality paradigm is the importance ofunderstanding and utilizing customer data to drive operational andstrategic decisions. This shift to a customer-oriented focus often ne-cessitates a fundamental change in the way employees think about andidentify those who use the organization’s products and services. Rec-ognizing the importance of an active customer who provides criticalinput in defining quality has implications regarding the level of cus-tomer participation. In effect, the customer-oriented focus implies a

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Katherine Selber and Calvin Streeter 3

more comprehensive participation in the service design process, aswell as the delivery and evaluation of human services. Although tradi-tionally the medical model and professionalization of human serviceshave influenced the design of services in this sector, the customer-fo-cused quality model expands the roles and increases the levels ofparticipation of customers. Instead of a linear, unidirectional commu-nication process from employee to patient, seeing clients as customersimplies that an interactive feedback loop exists linking the customerand the employee together. The roles for professionals and other staffare no longer exclusively those of independent practitioners who pre-scribe needed services.

The required role shift for human service professionals necessitatesan open dialogue with the customer around expectations for servicequality. Frequently, employees emphasize professional standards forcare. Such a discussion with the customer often leads to priorities thatare driven by professional judgments and upper management ratherthan what customers want and perceive they need. In addition, theexpectations of customers and employees are not always the same. Forexample, in a study of human service organizations, only 32% ofemployee respondents agreed that what was expected by customersand management were the same (Selber, 1997). Exploration of issuessuch as a customer’s reaction to the process of obtaining services,alternative methods for addressing change, and hours of service aregenerally not undertaken.

Once the importance of a customer perspective is understood, de-ciding who the customer is remains an equally difficult task (Martin,1993; Gummer & McCallion, 1995; Selber, 1997). This is illustratedby the dilemma of the juvenile court employees. A long list of externalcustomers can be identified--the juveniles, their families, the judges,the police, local boards and elected officials, the programs they areremanded to, the schools, social workers and therapists, and the com-munity at large. Traditionally, human service staff have identified onlythe end users as the customers of their services. In addition, they havealso viewed funders as a high priority customer, making decisionsabout strategic planning and quality standards on the basis of inputfrom this group.

Having multiple customers often means having multiple expecta-tions among customer groups. These expectations may place compet-ing and conflicting demands on the staff of the organization (Carr,

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ADMINISTRATION IN SOCIAL WORK4

Littman, & Condon, 1995; Gummer & McCallion, 1995). For exam-ple, in a recent survey of human service programs, 52% of employeerespondents reported that they lacked control over their jobs due tocompeting demands from many customers and yet only 32% reportedthat they had the opportunity to satisfy those demands (Selber, 1997).Frequently managers fail to recognize or resolve at the organizationallevel the conflicts stemming from multiple customer groups. Sinceservice quality is closely linked to the behavior and attitudes of custom-er-contact employees, stress on staff from such demands is often feltultimately by the customer (Parasuraman, Berry, & Zeithaml, 1988).

THE GAP MODEL FOR MANAGING QUALITY

Although challenges in moving to a quality focus do exist for humanservice organizations, this only serves to underscore the need to moveforward with empirical work in this area. The importance of measuring,monitoring, evaluating, and managing levels of service quality which arecustomer-focused is enhanced under the present system of managed care.

One potential model for managing quality is the Gap Model, origi-nally developed in the late 1980s and used extensively in serviceorganizations in the private sector (Parasuraman, Berry, & Zeithaml,1985, 1986, 1988, 1990, 1991, 1993; 1994; Zeithaml, Parasuraman, &Berry, 1994). The model posits that quality can be viewed as gaps onthe customer and provider sides. On the customer side, the gap be-tween what the customer expects and actually receives defines quality.On the provider side, the model posits a series of internal operatinggaps that can impact the customers’ view of quality.

As shown in Figure 1, the Gap Model proposes that the four gaps on theprovider side (Gaps 1-4) can determine quality as the customer experiencesit, and Gap 5 defines the service quality actually received by the customer.

The implications of a comprehensive conceptual framework formanaging quality seem evident. First, frameworks that focus on quali-ty provide a holistic view of the organization. Also, as an evaluativetool, a customer service focus can provide a yardstick for humanservices that have traditionally struggled, usually without the help of profitoutcomes, to measure performance (Patti, 1987; Wagenheim & Reurnik,1991). In addition, using a more comprehensive framework such as theGap Model provides the manager with more information. A closerlook at the components of the model is detailed following.

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Katherine Selber and Calvin Streeter 5

FIGURE 1. The Gap Model of Service Quality and Customer Satisfaction

CUSTOMER

Expected Service

PROVIDER

Perceived Service

Gap 4Service

Gap 3

External Communications

as adapted from Parasuraman et al., 1988

Gap 5

Gap 2

Gap 1

Service Quality

Management’s Perceptions

Delivery to Customers

Specifications

of Customer Expectations

Defining Customer Perceptions and Expectations of Quality

At the heart of the model is an instrument called SERVQUAL, usedto measure customer-focused quality. The instrument is unique in thatit attempts to measure both customer expectations as well as percep-tions of quality. A major problem in conventional attempts to measurequality is that customer surveys generally focus on perceptions ofservice delivery--what customers think of the quality of a service re-ceived. These attempts do not include gathering information on whatcustomers expect from human services, a simple, yet important, dis-

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ADMINISTRATION IN SOCIAL WORK6

tinction. Missing the opportunity for this balance provides managerswith an incomplete picture of customers’ real opinions.

The SERVQUAL instrument is based on the premise that customerswho rate expectations higher than perceived services (E > P) willexperience service quality that is less than adequate. Conversely, custom-ers who perceive performance as higher than their expectations (P > E)will rate the service as of higher quality. Likewise, customers who rateexpectations and perceptions with similar scores (E = P) are satisfied.

The instrument poses a set of structured, paired questions designedto assess the dimensions for both the customer’s expectations of ser-vice provision and the customer’s perceptions of what was actuallydelivered. A seven-point Likert scale is anchored by strongly disagreeto strongly agree. Thus, two sets of questions are asked. For example,customers are asked what should be provided in an excellent healthcare program, and then what their program actually provided.

Determinants of Quality

What constitutes quality is complex, often controversial, and nouniversal definition of quality has emerged in the literature. Qualitydimensions which have been recognized as uniquely important forhuman services include accessibility, continuity, timeliness, consisten-cy, humaneness, efficiency, and outcomes, just to name a few (Patti,1987; Pruger & Miller, 1991; Rapp & Portner,1992). However, thereis little empirical evidence about the important characteristics of quali-ty in human services (Selber, 1997).

In developing the SERVQUAL instrument Parasuraman et al. (1988)identified five major dimensions of service quality which were constantacross the service sector regardless of the organizational setting or field.Customers use these factors to both develop their expectations and evalu-ate the services that they receive. These determinants of quality are de-scribed below.

Tangibles. This dimension covers the appearance of the physicalfacilities, equipment, personnel, and materials of the organization.Customers evaluate tangibles such as the neatness of waiting roomsand offices, clarity of materials and forms, and the appearance of staffwith whom they interact. In the absence of products that can be moreeasily evaluated, such tangibles for human services may become moreimportant. However, in human services some aspects of this dimen-sion are challenging to evaluate, especially in outreach programs

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Katherine Selber and Calvin Streeter 7

where services are often delivered in the home or varying places in thecommunity.

Reliability. This dimension involves rendering the service in a con-sistent and dependable fashion. This means that the service is doneright the first time and every time, such that a customer develops ahistory with the service that can be counted on in the future. In thisway, the customer expects that the service will continue to perform asit did in the past, dependably and error free. For example, in humanservices customers expect that staff delineate the criteria for serviceeligibility the same every time. Such customer expectations involvehuman service staff communicating with customers about what can bedelivered and then doing it.

Responsiveness. This involves the willingness to help customersand provide prompt service. As customers use services they formimpressions about how the services should be performed including thetimeliness of those services. In human services, this may mean an-swering the phone after only a few rings, staff following up withclients when promised, or processing paperwork in a timely fashion.

In addition, responsiveness entails knowing the customer’s needson an individual basis in order to be helpful. In human services be-cause past customer experiences and history are so unique and con-tribute to present customer needs, responsiveness is of central impor-tance to the customer.

However, responsiveness to customers does not imply giving thecustomer everything that is requested or desired if it is outside thepossibilities of the organization. This is just as true for human serviceas for other services. Resources are finite in all organizations makinglimitations necessary. However, responsiveness is also attitudinal innature and has to do with the way staff deal with customers whensetting limits, negotiating services, and handling complaints. A sign inone public sector service organization--Be Patient Our Services AreFree--sums up a frequent attitude which unfortunately has become astereotype for the way citizens view human services.

Assurance. This dimension involves the knowledge and courtesy ofemployees and their ability to inspire trust and confidence. Humanservice customers expect staff who are competent and have the skillsnecessary to serve, solve problems, and respond to questions and re-quests. Customers also expect that employees treat them with respect

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ADMINISTRATION IN SOCIAL WORK8

and courtesy. This dimension is particularly important in human ser-vices, given the vulnerability of many populations that utilize services.

Issues of confidentiality and protection of human subjects have longbeen deemed as important by social workers and other helping profes-sions. Thus, it is important for providers to view aspects of trust andconfidence from the perspective of the customer. This means viewingrisks entailed in service provision from the eyes of the customer.

Empathy. This last determinant involves the caring, individualizedattention the staff provides its customers. This includes individualiz-ing responses to customers and being able to relate to them as people.In human services, this has traditionally been a highly valued charac-teristic of the customer-staff interaction.

SERVQUAL was developed and standardized on the basis of thesefive dimensions within private sector services. However, an extensivetesting of the instrument in twenty health and human service programshas yielded promising results (Selber, 1997). The utility of theSERVQUAL instrument is that it captures data on customer expecta-tions as well as perceived performance yielding a measure of overallquality from the customer’s perspective. It also allows for an examina-tion of customer priorities in terms of these dimensions. SERVQUALcan provide a comparison across programs, agencies, or geographicalunits facilitating benchmarking. The instrument can also yield anoverall customer rating of service quality, a yardstick for measuringcustomer service.

The Provider Side of Quality

The Gap Model has potential for analyzing more than the custom-er’s expectations and perceptions of quality. The gaps explicated bythe model encompass the provider side as well and include the follow-ing potential areas for managing quality.

Customer Information Gap. This gap is the potential for differencesbetween the customer’s expectations and staff’s perceptions of those ex-pectations. This gap is in essence the understanding which managementand staff have of customers’ expectations. Central to the quality paradigmis an understanding of what customers expect and perceive they receivedin the service process. Providers such as human service organizationsrarely ask customers how satisfied they were with services. Moreover, staffdo not ask what customers expect to receive. Usually what is defined as

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Katherine Selber and Calvin Streeter 9

quality is internally driven by managers who frequently are far removedfrom the day-to-day interaction of customers.

A central question is ‘‘How do employees’ perceptions of whatcustomers expect and actual customer expectations differ?’’ In otherwords, is there a gap between customer expectations and employeeperceptions of those expectations? This is important within a qualityframework since standards for quality flow from employee’s inter-pretation of customers’ expectations and needs.

The Customer Information Gap may be caused by a number offactors such as: lack of research on customer’s perceptions and expec-tations; failure to identify multiple customer groups with competingpriorities; and professional staff who pay closer attention to profes-sional standards of quality rather than customer-focused quality stan-dards. In general, staff in health and human service organizations wantto provide quality services but often begin at the wrong place. Insteadof starting ‘‘where the customer is’’ they begin where they think thecustomer should be. This inside-to-outside thinking should be re-versed, if this gap is to be narrowed. In addition, in some organizationswhere management is far removed from customer contact, manage-ment may in fact understand less about customer expectations. In thiscase, narrowing the gap means that managers must seek out data fromstaff about customers’ expectations for quality or utilize differingmethodologies to understand the customer’s perspective.

Standards Gap. This gap represents the extent to which manage-ment has formalized quality standards. Specifications of quality stan-dards in such areas as waiting time, case management work processes,and error rates for records may be formal or informal in nature. Sincevariation is viewed as a source of decreased quality, more formalizedstandards for quality help decrease variation and, thus, increase quality.

The Standards Gap may be caused by a number of potential factorssuch as: inadequate commitment to quality standards; a lack of com-munication and training on quality standards; inexperienced manage-ment; or setting inappropriate goals in this area. For example, staffmay not be formally trained on quality standards, or rapidly changingquality standards may not be communicated in a timely manner tostaff. In a survey of human service programs, only 39% of all em-ployee respondents agreed that their programs had a formal processfor setting quality goals and only 46% believed that their programs set

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ADMINISTRATION IN SOCIAL WORK10

specific quality goals (Selber, 1997). Thus, this is a potentially largegap in organizations in the human service area.

Service Performance Gap. This is the gap between the quality stan-dards and the service actually delivered. This performance gap hastraditionally been considered as the greatest potential problem forhuman services. Several unique characteristics of human servicesmake the Performance Gap a challenge to manage. Service organiza-tions, especially those with a high labor content as in human services,are heterogeneous. Their performance is difficult to standardize andoften varies from staff to staff, from customer to customer and fromday-to-day. Variations in individual characteristics of employees andcustomers also influence the production processes and relationships(Austin, 1994; Hasenfeld, 1992). Uniform quality in the form of con-sistent behavior of staff is also difficult to assure in most serviceorganizations. In addition, human service organizations present highlevels of variation of service processes. In such organizations, com-plex judgments are often needed in the service delivery process thatmay occur under crisis. Such factors as individual characteristics ofclients who may be under stress at the time of service delivery cangreatly impact the likelihood that variations will and should occur tomeet individualized needs. Such conditions make the management ofquality considerably difficult for such organizations.

Another characteristic distinguishing human services is the insepara-bility of production and consumption of service. This means that theconsumer comes into intimate contact with the production process andoften affects the process. This interaction between customer and staffsuggests that quality occurs during service delivery, and, thus, the orga-nization may have less managerial control over quality. In addition,centralized mass production of quality services is difficult to achieve. Inhuman service organizations, factors such as motivation of clients toengage in the co-production process as well as other client characteris-tics heavily influence the service delivery process. For example, theextent of motivation of families of juvenile justice clients, abusiveparents, and substance abusers calls for the use of differing technologiesthan working with children in a school setting or clinic customers.

Key contributing factors to the Standards Gap include: lack ofproper role definition; a poor fit between job and employee; lack oftechnology and other resources to perform duties; a lack of propersupervision; and a lack of control over one’s own job. Many of the

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Katherine Selber and Calvin Streeter 11

factors associated with this gap revolve around human resourceissues and can be reduced with proper staff selection, training, andsupervision. In addition, especially in the public sector, lack ofadequate resources in health and human services has created prob-lems in meeting demands of customers. For example, in the samestudy of human services looking at the employees of the publichealth clinics, only 28% of these employee respondents reportedthat the programs adequately used technology to serve customersconsistently. In addition, 63% reported that the program would goover budget if customer expectations were met and only 17% saidthat the programs had sufficient technology (Selber, 1997). Suchfactors make performing to standards a challenge.

Communications Gap. This is the gap between actual service deliv-ered and what was promised through external communications tocustomers. This potential gap has the possibility of impacting custom-er expectations and, therefore, influencing the way customers evaluateservices actually delivered.

The potential for overpromising services is great in human serviceprograms. This may be due in part to fragmentation of services or adesire to help beyond the possible technologies available. Selber(1997) indicated highest rates of overpromising occurred in healthclinics, juvenile justice programs, and community outreach programs.In addition, according to employees in participating programs, thegreatest tendency to overpromise related to two dimensions, tangiblesand reliability.

Since human services are usually delivered within an interdisci-plinary teamwork format, consistency about what is to be deliveredacross the various professionals who interface with the customers isdifficult. In addition, this gap occurs when staff do not educate thecustomers about what is being done on their behalf. This causesuncertainty on the part of customers and impacts their perceptionsof services delivered. Inadequate communication, a tendency tooverpromise services, or rapidly changing standards are some fac-tors which can produce this gap.

CONCLUSIONS AND IMPLICATIONS

Offered here is a model for measuring customer perceptions andexpectations for quality and linking them to provider activities that are

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ADMINISTRATION IN SOCIAL WORK12

predicted to improve quality performance. The use of the Gap Modelhas several implications for the future of human services.

Re-examining the role of the end user as customer is essential ifhuman service organizations are serious about the importance of quali-ty. This means seeing customers as active participants in the servicedesign, delivery, and evaluation process. Quality is not consistent witha passive customer.

Using a customer-oriented model such as the Gap Model also ne-cessitates a change in roles for the provider of services as well. Thecomfortable structures and techniques that have supported our profes-sional status are being challenged by the quality paradigm’s emphasison an outside-in definition of quality. Quality is an integrating conceptlinking provider processes and activities and pulling them closer to thecustomer. Quality management replaces administrative routines tied tostructured tasks, with work processes tied to a vision that is customer-centered.

Part of this external focus includes understanding the importance ofdefining and balancing multiple customer expectations. Although so-cial work has long recognized multiple constituents, this is differentfrom viewing these as customers. The difference can be qualitativelyimportant. Constituent relationships are often seen as political in na-ture whereas customer relationships are viewed as service-oriented.

The Gap Model also provides a more complete understanding of thenature of service quality within human service organizations. Themodel provides a more complex and thorough understanding of thecustomer’s perspective by examining both expectations and percep-tions of quality. Most customer satisfaction studies in human serviceshave provided only descriptive information about perceptions of qual-ity in service delivery, primarily through stories about poor delivery ofservices. The Gap Model provides empirical results to understand bothcustomer expectations and perceptions in human services. When wefocus only on customer’s perceptions of the services they have re-ceived, we get a limited picture of service quality from the customer’sperspective. The model suggests that research quantifying the custom-er’s expectations is equally important in understanding the customer’soverall evaluation of the quality of services delivered, especially inpublic sector organizations. As research in other sectors has alsoshown, quality service does not depend on the provider’s beliefs aboutquality but on what the customer believes is true.

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Katherine Selber and Calvin Streeter 13

In addition, data collected on the provider side gaps can also beused diagnostically to assist in managers’ decision making aroundneeded changes. This data can also be collected over time after inter-ventions for enhancing services have been implemented.

The Gap Model provides an opportunity for human services toexplore both the measurement and management of service quality inhuman services. The model is descriptive, predictive, and prescriptivein nature and, thus, has advantages over other models that are notempirical in nature. Understanding a complete picture of how custom-ers view us as service providers as well as how employees can impactquality is critical to managing performance and delivering qualityservices. What should remain central to human service providers isthat quality must be defined by the customer yet created by the em-ployee. The Gap Model can provide social work managers and re-searchers with assistance in thinking about and managing quality.Hearing the voice of the customer provides not only a measure oforganizational outcome but also has a role in the professional develop-ment of social work managers.

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