This study aimed to evaluate clinics service quality of teaching hospitals in Iran from the patients’ viewpoint and results showed that the overall services quality was assessed as good by 57.5% of the patients while 2.5% of the patients defined it as poor. The findings of the study indicated a better status of service quality compared with the service quality in Shiraz teaching hospitals clinics where about 37% of the patients were satisfied with service quality . In a study conducted by Mpinganjira, the patients reported status of service quality as good . In another study at cancer clinics in Canada , the quality score was reported above average (3.66) which is consistent with our result.
The findings demonstrated that the highest score of service quality was attributed to the physician’s consultation. Patients often lack sufficient information and knowledge to assess the medical staff, and perhaps this is the reason why they tend to assess them positively . It should also be noted that in the process of health service delivery, patients are more sensitive to care provided by physicians and nurses [17, 18]; in fact, human elements are more important compared with non-human elements in patient perception of care quality . Doctor-patient interpersonal relationship also plays a key role in shaping service quality judgments . Personal relationships greatly affect the service quality perception since the services are intangible and inseparable from consumers . The findings of studies in Greece, Norway, France and Finland, also indicated that the highest mean score was related to the quality of physician’s consultation [22,23,24,25].
Service costs and admission process ranked as the second and third highest dimensions of outpatient services quality. A study in Iran also showed that patients were satisfied with the cost of outpatient services which is similar to our findings . According to the health insurance law in Iran, the amount of patient copayment for outpatient services is 30% of the services cost  and in public hospitals, outpatient services such as physician’s consultation are fully covered by health insurance plans. Therefore, patients pay a small amount for the outpatient services and are expected to be satisfied with this dimension of service quality.
The provision of information to patients which had a high correlation with service quality, took the fourth rank in this study. This is in contrast with the findings of other studies in which the patients did not give a high score to the quality of information; consequently, this dimension was not included in the highest ranked dimensions [8, 14, 16, 27].
The appointment process, which ranked fifth, was perceived as moderate and good by approximately 72% of the patients. The negative perception could be attributed to bureaucratic processes, lack of proper appointment systems, or inappropriate staff behavior. The results are in line with those the findings of studies conducted in Greece and Norway where the patients also perceived the quality of appointment process as good and moderate [16, 22, 23].
The sixth rank was related to the clinic environment where the most important reason for dissatisfaction seemed to be due to poor hygiene and insufficient numbers of seats. This is in accord with the findings of other studies in which the quality of facilities and physical environment ranked four among five items [28, 29]. Although the quality of clinic environment does not stand in a good position in the overall ranking, the majority of the patients had positively perceived it as moderate and good (about 83%). This is also in line with the findings of a study in Johannesburg private clinics, South Africa  as well as a study in outpatient cancer clinics in Canada  where the patients had a positive perception of the physical environment.
The least positive perception of service quality was related to waiting time and accessibility to outpatient services. Long waiting time is the most important reason for dissatisfaction and decreases patients’ positive perception of services quality . Previous studies have also indicated that long waiting time at the clinic and inaccessibility to hospital outpatient services, affect patients’ dissatisfaction with service quality . It has also been found that patients had the least positive perception of waiting time for visiting the physician [14, 15, 31].
Furthermore, the results indicated a significant relationship between gender, education level, reason for admission, source of recommendation, health status and waiting time in the clinic, and service quality. In this study, unlike the previous studies, the male patients had higher expectations compared with the female patients and were dissatisfied with service quality [6, 32]. There was a statistically significant difference between the patients’ perceptions of quality and their education, meaning that less educated patients had the least positive perception of service quality. It seems that lower education leads to more illogical expectations, and this is in contrast with the results of other studies .
Those patients, who referred to clinics due to new health problems, had a more positive perception in comparison with the other patients. This could be attributed to some factors, such as recovery from their previous illnesses, hoping for recovery in the selected clinic, or lack of familiarity with the details and shortcomings in the service delivery processes. The findings showed that the patients who got familiar with clinics through media, gave higher scores to service quality, this could be due to the fact they might have received the same services. It was also found that the patients with better health status had lower expectations and more positive perceptions. This was consistent with other studies in which health status was confirmed to be one of the determinants of patient satisfaction with service quality [6, 24, 32, 33].
There was no significant relationship between service costs and age with service quality; however, they were negatively correlated with the perception of service quality, meaning that higher cost and older age led to less positive perception of quality. Waiting time in clinics had a significant inverse relationship with the perception of service quality which has been expected. It means that long waiting time was associated with lower positive perceptions of service quality. The same relationship was found in other studies [12, 31].
Delays in the provision of hospital services are one of the key issues in care quality and can lead to a negative perception of the provided service quality if considered as unreasonable and unnecessary by patients . Therefore, hospitals should design patient-oriented service processes rather than personnel-oriented and improve quality of service delivery through education and system design .
As any other study, this research has some limitations. Healthcare quality is a broad concept that is affected by several factors and cannot be adequately explored through quantitative studies. However, a triangulation of key informant interviews and focus group discussion with patients and service providers would provide more insight into this area. Therefore, it is suggested that potential researchers use the triangulation design to assess the quality of services.