A dual-level relationship marketing analysis of service quality and patient loyalty: examining the mediating effects of switching costs and hospital reputation

Amid intensifying competition in Taiwan’s healthcare sector, sustaining patient loyalty is vital for hospitals. Prior research on relationship marketing has often overlooked the risks inherent in strong patient-physician relationships, particularly patient attrition following physician turnover. The dual-level nature of these relationships — spanning patient-physician (employee-level) and patient-hospital (firm-level) loyalty — has also received insufficient attention. This study proposes a framework incorporating relationship antecedents (physician and hospital service quality), mediators (physician and hospital switching costs and hospital reputation), and outcomes (physician and hospital loyalty) at both levels. SmartPLS was used to analyze data from 368 outpatients at three branches of a private teaching hospital in central Taiwan. Physician loyalty did not directly translate into hospital loyalty. Physician service quality influenced physician loyalty, while hospital service quality shaped hospital loyalty. Findings are consistent with switching costs and hospital reputation reflecting partial indirect associations in the quality-loyalty relationship at each respective level. Patient loyalty develops within distinct levels: physician service quality and switching costs are associated with physician loyalty, while hospital service quality, switching costs, and reputation show analogous indirect patterns with hospital loyalty. Because physician loyalty did not directly translate into hospital loyalty, hospitals should strengthen physician competence, enhance service quality, and manage reputation to build sustainable institutional loyalty.