There are 6,801 hospitals and 463,166 hospital beds in Brazil [17
]. In 2007, Brazilian families spent US$ 77.3 billion (4.8% of the Brazilian gross domestic product) with health care goods and services, of which US$ 41.4 billion were spent with health care services [18
]. Studies have indicated an urgent need for improvement in hospital performance in Brazil in both the private and public sectors [19
]. This reflects the need for a professionalization process of hospital management, focusing on two main factors, namely, cost and quality of care. Professionalization of hospital management is one of the major challenges facing the Brazilian health policy. From a management point of view, health service quality is seen as a means of gaining competitive advantage and long-term profitability [21
]. This can be achieved by improving the quality of services offered to patients with emphasis on patient satisfaction, which is now deemed a critical element in the day-to-day operation of health care institutions seeking high performance [23
In the present study, validity of the HSQS/EPM was assessed by measuring the strength of the association between the final version of the translated instrument (a specific measure of health service quality) and the SERVQUAL scale (a generic measure of service quality). It is important to note that validity analysis does not determine whether an instrument is valid or not, but it shows the degree of validity of the instrument for specific purposes, and that it is always necessary to resort to empirical investigation to assess the validity of an instrument [24
]. Therefore, it is inaccurate to state that an instrument “has been validated”, because validity is not a dichotomous variable, but refers to the internal indicators of an instrument and the strength with which these internal indicators correlate with external indicators.
In this context, a limitation of the present study is the lack of a cross-culturally validated measure, specific for measuring health service quality, with characteristics similar to those of the Health Service Quality Scale to be compared with the HSQS/EPM. We opted for the SERVQUAL scale, which is a widely used instrument for measuring health service quality, and one of the most traditional measures of service quality [10
]. Limitations include the fact that the SERVQUAL scale is a generic instrument not specifically designed to measure health service quality, consisting of 22 items (while the HSQS/EPM has 73 items) comprising negatively worded statements that may confuse the respondents, in contrast to the HSQS/EPM that only has positively worded items.
On the other hand, the standardized Cronbach's alpha for the first and second administrations of the instrument were 0.982 and 0.986, respectively, showing that the HSQS/EPM has a high internal consistency and satisfy recommended minimum standards for reliability (α
> 0.70), and indicating homogeneity of the items that comprise the scale [26
]. For test-retest reliability, Pearson’s correlation coefficient (r
) was 0.89 and ICC was 0.90, when considering the total scores obtained on the first and second administrations of the instrument. The value of r
indicates that if the total score on the first administration is high then the total score on the second administration is also expected to be high, and vice-versa. The results were considered adequate, indicating that the HSQS/EPM is a reliable instrument [29
The HSQS/EPM is part of the current trend that supports the use of instruments that have already been tested and validated in the field instead of developing new measures. The consolidation of the HSQS/EPM in the context of professionalization of the management of health services in Brazil may contribute to the development of scientific research on topics currently considered as priority by the international community, and to the management of health systems that add value to the patient and those that foster value-based competition on results, improving health care value for patients [30