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Journal cover: International Journal of Health Care Quality Assurance

International Journal of Health Care Quality Assurance

ISSN: 0952-6862

Online from: 1988

Subject Area: Health Care Management/Healthcare

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Patient satisfaction structures, processes and outcomes


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Article citation: Keith Hurst, (2008) "Patient satisfaction structures, processes and outcomes", International Journal of Health Care Quality Assurance, Vol. 21 Iss: 1, pp. -


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Article Type: Editorial From: International Journal of Health Care Quality Assurance, Volume 21, Issue 1.

Patient satisfaction structures, processes and outcomes

Two things prompted us to produce our second special issue this year. First, patient satisfaction remains a popular author and reader topic; manuscript submissions and author downloads steadily increased in 2006-2007. Second, although it might not be thought possible that new patient satisfaction insights can emerge, this issue’s authors not only revisit stalwart patient satisfaction debates but also explore new topics not often encountered in the literature. In short, the eight manuscripts and 50 K words amount to a themed book containing novel elements on clearly what is an important and enduring quality assurance subject.

We wanted to address private and public patient satisfaction, and we are fortunate to publish two private patient satisfaction-oriented studies. First, Arasli and his colleagues offer fascinating insights into Cypriot patient expectation and satisfaction. They used SERVQUAL notably the instruments’ five dimension to compare and contrast private and state hospital patient satisfaction. The authors remind us that service quality is one of the most important drivers behind customer attraction, retention and loyalty. They not only explore unusual elements such as patients’ perceptions after using both public and private hospitals but also they reveal SERVQUAL dimension differences between the two services. The resulting Cypriot health service strengths and weakness findings are likely to make managers and practitioners worried or proud. Readers also will benefit from the lessons Arasli et al. learned from their explorations into SERVQUAL’s psychometric properties.

The second private patient oriented manuscript emerges from Ramsaran-Fowdar’s Mauritian study, which usefully extends and develops Arasli et al.’s commentary. A unique feature in Ramsaran-Fowdar’s article is her needs and wants’ section. Long-in-the-tooth patient satisfaction researchers know this minefield well. That is, a patient needs a lower limb amputation owing to smoking-related peripheral vascular disease. He or she needs to stop smoking to preserve the remaining limb. It is harder, therefore, to satisfy the patient because he or she does not want this course of action. Ramsaran-Fowdar goes on to underline customer loyalty and retention’s importance and relevance to private healthcare discussion that adds considerably to commentaries in the related articles we publish here. One particular sobering analysis for insurance-based healthcare managers and practitioners is the cost difference between: losing loyal patients; and recruiting new ones. Ramsaran-Fowdar too unpicks, dissects and develops SERVQUAL. Her detailed psychometric explorations relate to both general and private healthcare, and her findings reveal that seven not five SERVQUAL quality dimensions are needed for Mauritian private health services.

Wicks and Chin also concentrate on SERVQUAL but in USA outpatient surgery contexts. They also spend time carefully explaining methods for modifying existing, valid and reliable patient satisfaction measures for use in different settings. They concentrate on two existing SERVQUAL segments: expectations (or pre-process) and perceptions (or post process), and introduce a middle “process” segment. Consequently, fascinating patient satisfaction issues emerge that are important for health service managers and practitioners. Unexpected findings also materialise such as staff social skills’ importance in patient satisfaction. Similarly, readers will be surprised how relatively unimportant empathy seems to be in the patients’ rankings. Unusually, the authors finish with arguments for modifying their patient satisfaction measure for non-health use. Readers familiar with customer satisfaction literature know that health service researchers usually borrow from industry and commerce. It is good that healthcare research and development leads the way!

We are also fortunate to publish the Mayo team’s and the Vinagre-Neves’ ground-breaking patient satisfaction studies. Their premise is that we should not assume patient satisfaction or dissatisfaction (as healthcare outcomes) naturally follow healthcare structures and processes. Might it be possible that patient behavioural and emotional characteristics are equally if not more important satisfaction drivers? The Mayo study, a secondary analysis of archived information, combines Minnesota Multiphasic Personality Inventory (MMPI) and patient satisfaction data. The authors extracted almost 1,300 patients that answered both questionnaires. Because some patients completed the patient satisfaction questionnaire ten years after answering the MMPI, the authors concentrate on two enduring and stable personality characteristics pessimism and hostility. Moreover, they argue that these two behaviours are more tangible during patient-physician contact another reason for concentrating on these two personalities. Readers may not be surprised to learn that pessimistic and hostile patients are less likely to rate care higher. However, despite lower satisfaction scores, they are just as likely to recommend a provider to family and friends. Clearly, patient satisfaction is a complex and multi-factorial healthcare outcome. Intriguingly, the Mayo team are following-up this study with a separate analysis about which patient types are likely to respond to patient satisfaction questionnaires; a study we hope to publish later.

Vinagre and Neves’ related project connects, among other things, Portuguese patient service expectation, satisfaction and emotions. In common with other authors in our special issue, their starting point is SERVQUAL, which they modify to fit local culture. Discussion around SERVQUAL’s history and development reinforces discussion elsewhere. However, their warnings about adopting of-the-shelf patient satisfaction studies without adjusting them to suit local culture are salutary. Their customer-provider framework and the way they dissect patient expectation and satisfaction are also useful. Specifically, the authors tie SERVQUAL data with a range of patient emotion scores from the Differential Emotional Scale II, which is often used in consumer research but infrequently if hardly ever used in patient satisfaction studies. Readers should find their method explanation and discussion educational.

Leventhal’s bitter-sweet article is a lesson to service providers. He concentrates on elderly patient and elderly care service stakeholder expectation and satisfaction. Readers will not find many finer examples of analysts borrowing broader (expectation and disconfirmation) theories and models and using them to explore and explain healthcare structures, process and outcomes. The author argues that elderly care services and user expectation and satisfaction are complex owing to the aged patients’ vulnerability particularly their retribution and reprisal fears. Moreover, other stakeholder pressures cannot be ignored. In short, the top-down (e.g., government accreditation agencies’) and bottom-up (e.g., elderly patients’ children) influences on face-to-face care become clear. Leventhal uses a case study to illustrate his arguments. It showcases poor service structures, processes and outcomes when statutory healthcare services are not up to the mark, and readers will emphasise with the case study family.

Jonnson and Øvretveit’s article could just as easily sit in our Patient Safety special issue (Vol. 20 No. 7) and it would pay to read their work in a patient safety context. The authors revisit information stored in three complaints and claims databases. Like other articles here, Jonnson and Øvretveit’s work is groundbreaking in several ways. Not only are complaints and claims results explored and explained but also important methodological issues are painstakingly aired as a warning to researchers analysing similar fields. Plainly, comparing complaints and claims information shows that the true adverse event frequency may be underestimated. What is known, however, is worrying. For example, one dataset shows incidents tripling in 25 years. However, the picture is complex since patient complaints in another database levelled in comparison. Nevertheless, the implications for practitioners and managers are clear. Merely benchmarking within and between countries and feeding back results, for example, is educational if not instrumental for improving service quality.

Another feature readers will notice in this issue is the range of countries included. Hensen and his German co-authors, for example, completed an intriguing study and report. They concentrate on “internal customers” (fellow health service professionals) rather than “external customers” (patients). Comparing referring physician (i.e. the stakeholders and gatekeepers) with provider clinician (hospital core staff) service quality perceptions proved fascinating. Referrer behaviour is tangibly observable but variations remain unexplained. In common with other articles in this special issue, readers will benefit from the authors’ thorough and clear method section. Specifically, questionnaire surveys in this context are always on thin ice. For example, clinician response rates are notoriously poor and unfortunately the authors were victims. Unperturbed, they offer explanations and solutions to poor response rates, and despite the low “turn-out”, important findings emerge. For example, provider clinicians have a strong positive image about their services, while referrers’ perceptions are less upbeat. Stakeholder analyses are paramount therefore. Patient commendations are a strong theme in the article and interestingly, geographically remote patients are less likely to recommend a service to family and friends.

Finally, the eight articles include helpful reference lists that should arm patient satisfaction researchers and writers with a valuable resource. In short, Vol. 21 No. 1 materials’ range and depth makes it an essential text for the library shelf.

Keith Hurst



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