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Understanding quality and satisfaction in public hospital services: A nationwide inpatient survey in Greece
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Understanding quality and satisfaction in public hospital services: A nationwide inpatient survey in Greece Panagiotis Mitropoulos, Konstantinos Vasileiou, Ioannis Mitropoulos
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Department of Business Administration, Technological Education Institute of Western Greece, GR-26500 Patras, Greece
A R T I C L E I N F O
A B S T R A C T
Keywords: Patients' satisfaction HCAHPS Nationwide survey Greece Public hospital
Health services compared to the most of other sectors' customer services present some special traits, such as extreme complexity, co-production, and intangibility, while financial and human consequences of low quality are high. This study reports on the findings of a nationwide HCAHPS questionnaire survey conducted in Greece after the implementation of the health system reform due to the financial crisis regarding the factors determining inpatient satisfaction in public hospitals. HCAHPS data were initially analysed by factor analysis followed by an ordinal regression analysis, which aimed to identify the determinants with significant impact on inpatient satisfaction. The study results are consistent with prior research which indicated that the communication with nurses is the most salient predictor of overall patients’ satisfaction followed by communication with doctors. Moreover, certain patient (age and health status) and hospital institutional (type and location) characteristics also contribute significantly to patients’ perceived overall satisfaction. Hence, health quality improvement activities should consider the critical differences among patient subgroups and hospital types in order to fulfil consumer needs and preferences more effectively.
1. Introduction
Even though patients’ perceived medical care quality is biased, in terms of the marketing principles, they are actually the “consumerscustomers” of the healthcare system (Huang et al., 2004), as well as the exclusive payers, either directly to the private or mostly indirectly through taxes to the public health providers, of the services delivered to them. Consequently, their perceived satisfaction is by far the most important criterion to evaluate the performance of the medical care system. Moreover, in several occasions patients’ satisfaction may play an important role to their willingness to get involved in their care and conform to the treatment plans (Sofaer and Firminger, 2005; Vogus and McClelland, 2016; Al-Refaie, 2011). Additionally, Huang et al. (2004) supported that increased levels of patient satisfaction redound to the outcomes of the health care system in terms of reduced utilisation of medical services, advanced prognosis, less malpractice litigation, and a higher level of compliance. Therefore, as Pascoe (1983) mentioned patients’ satisfaction is hypothesised to be both a dependent variable and a predictor of future health-related behaviour. The great importance of patients' satisfaction has led to a great number of different instruments for its measurement worldwide, that focus on the various aspects of medical care experience, such as communication with healthcare providers, access to hospital, the quality of basic amenities, waiting time to make an appointment and to be examined at the clinic (Bleich et al., 2009; Aletras et al., 2009).
Patient satisfaction has been a key issue in assessing the performance of health care providers over the last decades (Vogus and McClelland, 2016; Kleefstra et al., 2015; Schoenfelder et al., 2011; Xesfingi and Karamanis, 2015; Pini et al., 2014). Toundas et al. (2003) mentioned that over a thousand of studies regarding patient perceptions about their medical care are published each year. Patients’ perceptions with respect to the quality of services provided by the health care system suffer from subjectivity given that, inter alia, patients’ scientific and technical knowledge of medical care issues is rather limited, and the perceived healthcare quality is subject to the patients' physical and psychological situation and their sociodemographic characteristics (Schoenfelder et al., 2011; Merkouris et al., 2013; Vogus and McClelland, 2016; Dempsey et al., 2014). Moreover, the incredibly complex nature of human disease renders the health care procedures extremely complicated, only to mention that even when there is a consensus about a patient's health state diagnosis, it is very probable that doctors disagree about the best course of treatment (Nembhard et al., 2009). Additionally, the interests and targets of health providers and patients do not, compulsory, coincide, but the decision making depends, more, on health professionals’ opinion (Nembhard et al., 2009).
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Corresponding author. E-mail addresses: [email protected] (P. Mitropoulos), [email protected] (K. Vasileiou), [email protected] (I. Mitropoulos).
http://dx.doi.org/10.1016/j.jretconser.2017.03.004 Received 27 January 2016; Accepted 8 July 2016 0969-6989/ © 2017 Elsevier Ltd. All rights reserved.
Please cite this article as: Mitropoulos, P., Journal of Retailing and Consumer Services (2017), http://dx.doi.org/10.1016/j.jretconser.2017.03.004
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tion of the health system reform due to the financial crisis, utilising the data of the nationwide HCAHPS questionnaire survey conducted by the Greek Ministry of Health during the period of May 2011 to November 2011. Moreover, the impact of the demographic characteristics of the patients and the institutional characteristics of hospitals on patients’ satisfaction was also investigated. In this light, the next section presents the methodology and the sample of the study, followed by our research results. The paper concludes with a discussion of our findings, limitations of our work and recommendations.
Most of these instruments are specific to a country's health system or type of the hospital rendering comparisons between countries and over time practically rather difficult, if not unattainable. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, developed for use in the USA by the Centres for Medicare and Medicaid Services (CMS) with the collaboration of the Agency for Healthcare Quality Research (AHRQ) (Elliott et al., 2009a, 2009b; Giordano et al., 2010), has been the most known standardized, and unbiased set of measures of patient experience so far (Vogus and McClelland, 2016). The HCAHPS survey has been endorsed by the National Quality Forum (NQF) in the USA and it was also selected for the purposes of the European Commission RN4CAST project, which involved 12 countries (Belgium, England, Finland, Germany, Greece, Ireland, The Netherlands, Norway, Poland, Spain, Sweden and Switzerland) because of its potentiality to yield comparable results that would allow to obtain objective and meaningful comparisons across health systems on domains that are important to consumers among the participating European countries and the USA (Squires et al., 2012). The content validity of the Greek translation of the HCAHPS survey has already been examined by Squires et al. (2012) and achieved an 'excellent' rating. The HCAHPS survey measures discharged inpatients’ experiences of the hospital care, employing 25 patient rating items with respect to communication with nurses and doctors, the responsiveness of hospital staff, the cleanliness and quietness of the hospital environment, pain management, communication about medicines, discharge information, overall rating of hospital, and would they recommend the hospital, as well as questions regarding patients’ demographics (CMS, 2014). The interest in evaluating the patients’ expectations and demands from the public health system is considerably rising during crisis periods, where all involved stakeholders strive to optimise the efficiency and, especially, the effectiveness of the scarce public resources dedicated to health care (Pantouvakis and Bouranta, 2014; Karanikolos et al., 2013). Greece has indeed experienced a thrilling transition in the legislative, political and economic environment since early 2010 with enormous consequences on the health care system, given that the cuts to hospital budgets exceed 40% and the shortages of personnel and medical supplies dramatically raised. Kentikelenis et al. (2011) and Zavras et al. (2012) reported that Greeks’ health status self-evaluation has worsened since the outbreak of the financial crisis while the proportion of citizens that appreciate that they have limited access to medical care is steadily increasing. Although, the investigation of patients' satisfaction with the medical care provided by the Greek public hospitals is crucial for developing and implementing quality improvement strategies and activities, most of the published studies report on the patients' perceptions before the emergence of the financial crisis (Niakas et al., 2004; Gnardellis and Niakas, 2005; Priporas et al., 2008; Matis et al., 2009; Aletras et al., 2006, 2007, 2009; Panteli and Patistea, 2007; Labiris and Niakas, 2005; Papanikolaou and Ntani, 2008; Polyzos et al., 2005; Toundas et al., 2003; Pantouvakis and Bouranta, 2014; Pini et al., 2014; Chandrinou et al., 2013). Thus, the results from the aforementioned studies cannot provide a solid basis for decision making in the contemporary Greek Hospitals conditions, taking also into consideration that their sample emanated from either a single or a limited number of hospitals and that they did not follow international procedures and protocols for surveying data from General Hospitals (e.g. HCAHPS). There is only one reported study on patients’ satisfaction assessment regarding their experience of a Greek general hospital since the outbreak of the financial crisis (Xesfingi and Karamanis, 2015). However, their study sample concerns only a single general hospital in the capital Athens, therefore, it is not possible to draw firm conclusions about the whole population of Greek patients. This paper aims to fill the gap in the literature by providing evidence about the patients’ satisfaction regarding the medical care they experienced from the Greek public hospitals after the implementa-
2. Study sample The survey was administered by the Greek Ministry of Health (MOH) with the aim to include all the 131 public hospitals operating in the national health system. However, 89 hospitals denied participation, claiming that there was a lack of the necessary budget and time. Thus, data was selected by 42 hospitals, which are a fairly representative sample of hospitals to mirror the general structure of the national health system. The data were collected by the hospitals' Quality Office that has the responsibility to run the patient satisfaction survey on a yearly basis. Using the simple random sampling technique, the patients received the corresponding questionnaire the previous day before being discharged and returned it to a secured drop box at the reception before leaving the hospital. Then, at a centralised level, the sample was collected and validated by the Quality and Efficiency Department of the MOH to ensure that it was representative of each hospital. The sample that was finally selected in the survey contains 5467 inpatients stratified according to the population of patients that each hospital served. 3. Factor structure of service quality Exploratory factor analysis was conducted to explore latent factors within the questionnaire items and to verify the reliability and validity of the service dimensions. Factor analysis can identify a more reduced set of variables without interrelationships in order to explain, in the highest possible degree, the variability found in the answers to the questionnaire. The Principal Component Analysis method and orthogonal (varimax) rotation were employed to extract the factors that would improve the interpretation of the participants’ answers with respect to the core part of the questionnaire which contains 11 services attributes. In particular, we used 9 questions rated on a 4-point Likert scale (Never, Sometimes, Usually, Always) covering 3 specific hospital practices: Communication with doctors (3 items), Communication with nurses (4 items) and the physical environment (2 items). The remaining two items, rated on a dichotomous scale (No/Yes), cover the information about discharge. The analysis identified four factors with eigenvalues greater than 1. The Kaiser-Meyer-Olkin statistic is 0.87, indicating strong correlations among items and confirms that factor analysis is an appropriate analysis of the sample as it exceeds the 0.5 acceptable limit (Kaiser, 1974). In addition, the Bartlett's Test of Sphericity shows that the suitability of the intercorrelation matrix of the 11 variables for factor analysis is significant at the 0.001 level. Factors and items of the questionnaire are described in Table 1. This table also presents the mean and standard deviation of the items, their factor loadings and the Cronbach's alpha reliability index for each principal component. The results indicate strong relationships of the items within each factor that are independent of those of other factors. The four factors identified, confirmed the four dimensions under consideration of the HCAHPS questionnaire. Since all items load as expected, it is evidence that the questionnaire exhibits strong convergent validity. Then, we defined the four distinct factors which explain 69.08% of total variance as follows: doctor communication (F-doctor) that 2
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Table 1 Results of the principle component analysis – identification of core service dimensions. Identified factor
Item description
Factor loading
Mean (SD)
Doctor communication (Cronbach alpha=0.79)
Frequency that doctors treated patient with courtesy and respect Frequency that doctors explained things in a way the patient could understand Frequency that doctors listened carefully to the patient
0.793 0.800 0.848
3.79 (0.51) 3.67 (0.65) 3.75 (0.57)
Nurse communication (Cronbach alpha=0.83)
Frequency Frequency Frequency Frequency
0.789 0.798 0.690 0.568
3.78 3.73 3.63 3.73
(0.53) (0.56) (0.68) (0.63)
Physical environment (Cronbach alpha=0.72) Discharge Information (Cronbach alpha=0.60)
Frequency that the patient's room and bathroom were kept clean Frequency that the area around patient's room was quiet at night? Hospital staff talked with patient about the availability of necessary help when leaving the hospital The patient got information in writing about what symptoms or health problems to look out for after leaving the hospital
0.773 0.736 0.813 0.830
3.67 3.41 0.28 0.24
(0.65) (0.79) (0.44) (0.42)
that that that that
nurses treated the patient with courtesy and respect nurses listened carefully to the patient nurses explained things in a way the patient could understand patient got help immediately after pressing the call button
accounts for 11.59% of the variance, nurse communication (F-nurse) that accounts for 40.56% of the variance, physical environment (Fenvironment) that accounts for 7.62% of the variance, and information about discharge (F-information) that accounts for 9.30% of the variance. The internal consistency of the questionnaire was measured using Cronbach-alpha coefficient. The value of Cronbach-alpha for the total sample was 0.77, verifying the instrument's scaling is reliable since it exceeds the minimum accepted value of 0.7 (De Vaus, 2002), even though the low level of alpha is often associated with multidimensional data and in specific situations such as social sciences some researchers use smaller levels. The factor-wise internal consistency was 0.79 for doctor communication, 0.83 for nurse communication, 0.72 for physical environment and 0.60 for discharge information.
Table 2 Descriptive data for inpatients. Variable
Percentage
Overall satisfaction (scale 1–10) Health status (scale 1–5) Age, % (> 45) Gender, % female Nationality, % native
Mean (SD) 8.07 (2.30) 2.96 (1.02)
66 53 95
secondary care hospitals are offering all ranges of secondary health care. The tertiary care hospitals are equipped with advanced technology to offer highly specialised services. Finally, the specialised hospitals are dealing with specific medical needs such as psychiatric problems and certain disease categories. The academic status was a dummy variable to indicate the hospital's involvement in medical education with university hospitals being the reference category. Finally, hospitals were classified by location, in order to attribute the differences on policies implemented at the regional level. More specifically, the Greek national health system has a regional structure, allowing local administrations to play an important role in determining the responsibilities and formulating proposals to better address local needs. The location variable encapsulates the 6 health administrative regions of Greece, namely 1) Attica, 2) Aegean 3) Epirus & West Macedonia, 4) East Macedonia & Thrace, 5) Thessaly, 6) Peloponnese & West Greece. Table 3 presents the descriptive statistics of the institutional characteristics of the 42 hospitals included in the survey. As a final point in the description of the prediction variables, it should be mentioned that for all the categorical predictor variables, the largest group in our sample was selected as the reference group. The Clog-log link function was employed in the ordinal regression model. First of all, the appropriate choice of the link function had to be
4. Regression analysis An ordinal regression analysis was employed to identify the determinants that have the most significant impact on inpatient satisfaction. The survey asked from impatiens to rate their general degrees of satisfaction or otherwise from their hospital services on a 10point scale from very low to very high. Accordingly, the single item of the questionnaire that measures the overall patient satisfaction is used as a dependent variable in the regression procedure. The independent variables of the study are classified into the following three main groups. The first group of variables consists of the four factors identified in the previous section, namely the doctor communication, the nurse communication, the physical environment and the information about discharge, which capture the quality of services provided within the hospital. The second group of variables refers to the demographic characteristics of the inpatients: gender, age, nationality and the self-reported health status. More specifically, gender was a dummy variable indicating whether inpatients were female or male. Age was transformed into the two categories, indicating whether the respondent belonged to a younger (≤45 years) or to an older inpatient group (> 45 years). Nationality was also a dummy variable indicating native (Greek) or non-native inpatients. Health status was measured by the relevant single item of the HCAHPS questionnaire, which asks patients to rate their health status on a five-point scale from poor (1) to excellent (5). Table 2, presents the descriptive statistics for the demographic characteristics of inpatients that participate in the survey. The third group of variables pertains to the institutional characteristics of hospitals comprising their type, location and academic status. Particularly, the type of hospital is specified as primary, secondary, tertiary and specialised. The primary care hospitals are known as hospital-health centres offering mainly primary health care and dealing with rather trivial treatments of the secondary health care. The
Table 3 Descriptive data for hospitals.
3
Variable
Category
Frequencies (%)
Hospital type
Primary Secondary Tertiary Specialized
4 (10) 29 (69) 6 (14) 3 (7)
Academic status
Non university University
35 (83) 7 (17)
Health region
Attica Aegean Epirus & West Macedonia East Macedonia & Thrace Thessaly Peloponnese & West Greece
7 (17) 10 (23) 5 (12) 8 (19) 5 (12) 7 (17)
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addition, hospitals located in the health regions of Epirus & West Macedonia (OR 1.71), East Macedonia & Thrace (OR 1.21), and Thessaly (OR 1.27), had significantly higher satisfaction scores than did hospitals in the Attica region.
Table 4 Results of the ordinal regression model: determinants of overall inpatient satisfaction. Predictors (reference group)
Service quality F- nurse F- doctor F- information F- environment
Odds Ratio (95% Confidence interval)
p-value
1.46 1.43 1.26 1.40
< 0.001 < 0.001 < 0.001 < 0.001
5. Discussion (1.41–1.52) (1.38–1.49) (1.21–1.31) (1.35–1.46)
The communication with nurses was found to be the most salient predictor of overall satisfaction, followed by communication with doctors. These results are consistent with prior research which highlighted the importance of communication between patients and hospital staff. The major impact of nursing care on patient satisfaction and its greater meaning in comparison to physicians’ care is in agreement with the results of Elliott et al. (2009a), who also found that communication with nurses and nursing care to be more important to patients. One possible explanation is that inpatients during their stay, interact most with nurses than doctors because nurses are the first responders to patients when they have concerns or feel discomfort (Schoenfelder, 2011). The physical environment emerged as the next most important factor with respect to patients’ satisfaction. Several studies have shown that physical environment displays a strong positive correlation with patient satisfaction (Coulter and Cleary, 2001). Cleanliness is considered as an important issue, not only as a primary measure to control the infection risk, but as well as an indicator of the commitment of the hospital staff and the hospital's attention as a whole (Sofaer et al., 2005). Quietness is also important because it is directly related to the inpatient's needs to rest or sleep. The factor that the inpatients considered as less important was the information about discharge. This result is consistent with Elliott et al. (2009a), who also found discharge information to be of less importance to patients. The patient characteristics that were significantly related to overall patient satisfaction were both age and self-reported health status. Consistent with the literature, our study showed that the elderly patients tended to report higher satisfaction scores with the received services than the younger ones (Nerney et al., 2001; Gnardellis and Niakas, 2005). One possible explanation for the lower satisfaction rating of younger patients could be that they may be treated differently (e.g. less gently than older ones) or, that they have unrealistic expectations due to their lack of knowledge about hospital care (Young et al., 2000). As in previous studies (Nguyen Thi et al., 2002; Xiao and Barber, 2008), we showed that people who perceived themselves as being healthy were more likely to be more satisfied with hospital care. A possible explanation is that healthier people may be more satisfied with life generally, and this attitude stimulates their ultimate satisfaction with hospital care (Young et al., 2000). Regarding gender and nationality, both of them were not significant predictors of inpatient satisfaction. The study results are consistent with most prior research that found similar satisfaction scores between male and female inpatients (Niakas et al., 2004; Nguyen Thi et al., 2002). Nationality was unrelated with overall satisfaction showing that patients are treated in Greek hospitals without ethnic disparities. The institutional characteristics that were significantly related to overall patient satisfaction were both the location and type of hospitals. There were high regional variations in patients’ satisfaction with Epirus & West Macedonia, Thessaly, and East Macedonia & Thrace performing better than the other health regions. The patients hospitalised in the Attica region were the least satisfied. Considering that most of the largest hospitals are located in Attica since it is the biggest urban area of Greece, a possible explanation of this lower satisfaction is that the patients perceive larger hospitals as impersonal and intimidating (Young et al., 2000). Furthermore, we found that the inpatients treated in specialised hospitals were more satisfied than the others. This may be attributed to the fact that the staff and the hospital environment in specialised hospitals are more focused on patients and their specific needs, providing better attentiveness, personal care and information
Patient characteristics Gender (female) male
0.99 (0.91.1.07)
0.818
Age (> 45 years) ≤45 years
0.77 (0.70–0.85)
< 0.001
Nationality (natives) Non natives Self-reported health status
1.03 (0.86–1.23) 1.09 (1.05–1.13)
0.722 < 0.001
Type (secondary) Primary Tertiary Specialized
1.19 (0.95–1.48) 0.89 (0.66–1.18) 1.40 (1.11–1.75)
0.112 0.436 0.004
Academic status (non university) University
1.23 (0.93–1.63)
0.140
Location (Attica) Aegean Epirus & West Macedonia East Macedonia & Thrace Thessaly Peloponnese & West Greece
1.13 1.71 1.21 1.27 1.15
0.123 < 0.001 0.006 0.001 0.056
Institutional characteristics
(0.97–1.31) (1.44–2.01) (1.05–1.38) (1.09–1.47) (0.99–1.33)
made since the categories were ordered (O'Connell, 2000). Given that patients tend to report high levels of satisfaction with health care, the Clog-log link function exhibits a better fit in the regression model since it is more suitable for analysing the ordered categorical data when the higher categories are more probable among the other categories. The validity of the estimated model was then explored with the test of parallel lines. The significance of this test p=0.991 > 0.05 indicated that regression coefficients were the same across the response categories, suggesting that the model assumption of parallel lines was not violated in the model. Finally, the overall model goodness-of-fit explaining patient satisfaction was assessed by the pseudomultiple correlation squared values for Nagelkerke-R2, which was found to be 0.32.
4.1. Determinants of inpatient satisfaction Table 4 presents estimates of odds ratios (OR) for inpatients with respect to their overall satisfaction with hospital's performance. We observe that ten variables were significantly related to inpatient satisfaction (p < 0.05). It is evident that all of the four service dimensions were found significant for describing and explaining satisfaction. The most influential determinants were the communication with nurses (OR 1.46) and doctors (OR 1.43) followed by the physical environment (OR 1.40) and information at discharge (OR 1.26). Regarding the patient characteristics both older age and better health status were significantly associated with higher satisfaction. Age was a stronger determinant (OR 0.77) than the self-reported health status (OR 1.09). In contrast, gender and nationality were not significantly associated with satisfaction. Among the institutional characteristics, both the hospital type and location were significantly associated with overall satisfaction. In particular, the specialised hospitals exhibited significantly higher satisfaction score than did the other types of hospitals (OR 1.40). In 4
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almost two-thirds of public hospitals operating in the national health system failed to provide such data claiming that they have a shortage of the necessary budget and time. Moreover, there is no information available about the eligible patients that inclined to participate in the survey. However, because of the relatively large size of the sample (around 5500 patients) emanated from all the Health Regions and hospital types, it may be assumed that the nonresponse bias has a minor on research results. Moreover, the study sample consists solely of patients of public hospitals, so the study should be extended to private health providers. Finally, our data come from a single survey, thus, they provide a ‘snapshot’ of patients’ perceptions. Therefore, it would be rather important to conduct such surveys on a regular basis to understand the ways in which patients’ satisfaction changes over time as well as the importance of its determinants factors, in order to launch and implement more useful health improvement plans in care delivery and services. References Aletras, V., Papadopoulos, E., Niakas, D., 2006. Development and preliminary validation of a Greek-language outpatient satisfaction questionnaire with principal components and multi-trait analyses. BMC Health Serv. Res. 6, 6–66. Aletras, V., Zacharakis, F., Niakas, D., 2007. Questionnaire for the measurement of outpatient satisfaction in the ophthalmology clinic of a Greek public hospital. Arch. Hell. Med. 24 (1), 89–96. Aletras, V., Basiouri, F.N., Kontodimopoulos, N., Ioannidou, D.M., Niakas, D. Α, 2009. Development and psychometric assessment of a Greek-language inpatient satisfaction questionnaire. Arch. Hell. Med. 26 (1), 79–89. Al-Refaie, A., 2011. A structural model to investigate factors affect patient satisfaction and revisit intention in Jordanian hospitals. Int. J. Artif. Life Res. 2 (4), 43–56. Bleich, S.N., Özaltin, E., Murray, C.J.L., 2009. How does satisfaction with the health-care system relate to patient experience? Bull. World Health Organ. 87 (4), 271–278. Chandrinou, A., Gaitanou, K., Exarchos, K., Antoniadou, D., Tsorbanaki, C., Bissias, C., Malliarou, M., 2013. Rating of patient satisfaction factors in a clinical hyperbaric centre of a Greek navy hospital. Int. J. Caring Sci. 6 (1), 69–77. CMS, 2014. Centers for Medicare and Medicaid Services. HCAHPS questionnaire 2014. Retrieved: November 2015, from 〈http://www.hcahpsonline.org/〉. Coulter, A., Cleary, P.D., 2001. Patients' experience with hospital care in five countries. Health Aff. 20, 244–252. De Vaus, D., 2002. Analyzing Social Science Data. Sage, London. Dempsey, C., McConville, E., Wojciechowski, S., Drain, M., 2014. Reducing patient suffering through compassionate connected care. J. Nurs. Adm. 44 (10), 517–524. Elliott, M.N., Kanouse, D.E., Edwards, C.A., Hilborne, L.H., 2009a. Components of care vary in importance for overall patient-reported experience by type of hospitalization. Med. Care 47 (8), 842–849. Elliott, M.N., Zaslavsky, A.M., Goldstein, E., Lehrman, W., Hambarsoomians, K., Beckett, M.K., Giordano, L., 2009b. Effects of survey mode, patient mix, and nonresponse on CAHPS® hospital survey scores. Health Serv. Res. 44 (2p1), 501–518. Giordano, L.A., Elliott, M.N., Goldstein, E., Lehrman, W.G., Spencer, P.A., 2010. Development, implementation, and public reporting of the HCAHPS survey. Med. Care Res. Rev. 67 (1), 27–37. Gnardellis, C., Niakas, D., 2005. Factors influencing impatient satisfaction. An analysis based on the Greek National System. Int. J. Healthc. Technol. Manag. 6 (3), 307–320. Huang, J.-A., Lai, C.-S., Tsai, W.-C., Hu, W.-H., Yang, D.-W., 2004. Determining factors of patient satisfaction for frequent users of emergency services in a medical center. J. Chin. Med. Assoc. 67 (8), 403–410. Jha, A.K., Orav, E.J., Zheng, J., Epstein, A.M., 2008. Patients' perception of hospital care in the United States. New Engl. J. Med. 359, 1921–1931. Kaiser, H.F., 1974. An index of factorial simplicity. Psychometrika 39 (1), 31–36. Karanikolos, M., Mladovsky, P., Cylus, J., Thomson, S., Basu, S., Stuckler, D., McKee, M., 2013. Financial crisis, austerity and health in Europe. Lancet 381 (9874), 1323–1331. Kentikelenis, A., Karinikolos, M., Papanicolas, I., Basu, S., McKee, M., Stuckler, D., 2011. Health effects of financial crisis: omens of a Greek tragedy. Lancet 2011 (378), 1457–1458. Kleefstra, S.M., Zandbelt, L.C., de Haus, H.J., Kool, R.B., 2015. Trends in patient satisfaction in Dutch university medical centers: room for improvement for all. BMC Health Serv. Res. 15 (1), 112. Labiris, G., Niakas, D., 2005. Patient satisfaction surveys as a marketing tool for Greek NHS Hospitals. J. Med. Mark.: Device, Diagn. Pharm. Mark. 5, 324–330. Matis, G.K., Birbilis, T.A., Chrysou, O., 2009. Patient satisfaction questionnaire and quality achievement in hospital care: the case of a Greek public university hospital. Health Serv. Manag. Res. 22 (4), 191–196. Merkouris, A., Andreadou, A., Athini, E., Hatzimbalasi, M., Rovithis, M., Papastavrou, E., 2013. Assessment of patient satisfaction in public hospitals in Cyprus: a descriptive study. Health Sci. J. 7 (1), 28–40. Meterko, M., Mohr, D.C., Young, G.J., 2004. Teamwork culture and patient satisfaction in hospitals. Med. Care 42, 492–498. Nembhard, I.M., Alexander, J.A., Hoff, T., Ramanujam, R., 2009. Why does health care continue to lag? Insights from management research. Acad. Manag. Perspect. 23 (1), 24–42.
Fig. 1. Determinants of patients' satisfaction in Greek public hospitals.
than the other types of hospitals. The academic status was not significantly related with satisfaction. This result is consistent with the previous studies (Meterko et al., 2004; Jha et al., 2008) which argued that university hospitals might emphasise more on the technical aspects of quality than on improving the inpatients’ experiences. Fig. 1 summarises the conceptual framework of the study and depicts the final outcome with the statistically significant determinants of the patient satisfaction. 6. Conclusions This study aimed to investigate the factors determining the inpatient satisfaction in Greek public hospitals by utilising the data collected from a nationwide HCAHPS questionnaire survey conducted by the Greek Ministry of Health in 2011 after the outbreak of the financial crisis. The research findings from the factor and the ordinal regression analyses conducted are consistent with prior research which stressed the importance of communication between patients and hospital staff, as the communication with nurses was found to be the most salient predictor of overall satisfaction followed by the communication with doctors. Although, to a less extent, both the physical environment and the information about discharge were also found to play a significant role in patients' perceived satisfaction. Consequently, future quality improvement activities should primarily focus on the improvement of health professionals' behaviour, especially of nurses' since they assume most of the heavy load of treatment implementation and communication with patients. The study, in line with prior research, also revealed that certain patients', as well as hospitals' institutional, characteristics are significantly related to patients' perceived overall satisfaction. Therefore, the healthcare providers/managers should utilise the findings from patient satisfaction surveys in order to better understand their patient population and to adapt their quality improvement activities to the special needs of the patient groups at risk of having bad experiences in the hospital. Such an approach would contribute to the successful implementation of health reform plans by fulfilling consumer needs and preferences more effectively. Like similar surveys on patients' satisfaction, our study has some limitations. Although, the study utilised the HCAHPS data from a nationwide survey administered by the Greek Ministry of Health, 5
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Schoenfelder, T., Klewer, J., Kugler, J., 2011. Determinants of patient satisfaction: a study among 39 hospitals in an in-patient setting in Germany. Int. J. Qual. Health Care 23, 503–509. Sofaer, S., Firminger, K., 2005. Patient perceptions of the quality of health services. Annu. Rev. Public Health 26, 513–559. Sofaer, S., Crofton, C., Goldstein, E., Hoy, E., Crabb, J., 2005. What do consumers want to know about the quality of care in hospitals? Health Serv. Res. 40, 2018–2036. Squires, A., Bruyneel, L., Aiken, L., van den Heede, K., Brzostek, T., Busse, R., Ensio, A., Schubert, M., Zikos, D., Sermeus, W., 2012. Cross-cultural evaluation of the relevance of the HCAHPS survey in five European countries. Int. J. Qual. Health Care 24 (5), 470–475. Toundas, Y., Lopatatzidis, A., Chouliara, L., 2003. Degree of satisfaction among IKA beneficiaries concerning primary health care services offered. Arch. Hell. Med. 20 (5), 497–503. Vogus, T., McClelland, L., 2016. When the customer is the patient: lessons from healthcare research on patient satisfaction and service quality ratings. Hum. Resour. Manag. Rev. 26 (1), 37–49. Xesfingi S., Karamanis D., 2015. In- and Out-patient satisfaction assessment: the case of a Greek General Hospital. MPRA Paper No. 66672. Online at 〈https://mpra.ub.unimuenchen.de/66672/〉. Xiao, H., Barber, J.P., 2008. The effect of perceived health status on patient satisfaction. Value Health 11 (4), 719–725. Young, G., Materko, M., Desai, K., 2000. Patient satisfaction with hospital care. Med. Care 38, 325–334. Zavras, D., Tsiantou, V., Pavi, E., Mylona, K., Kyriopoulos, J., 2012. Impact of economic crisis and other demographic and socio-economic factors on self-rated health in Greece. Eur. J. Public Health 2012. http://dx.doi.org/10.1093/eurpub/cks143.
Nerney, M.P., Chin, M.H., Jin, L., 2001. Factors associated with older patients’ satisfaction with care in an innercity emergency department. Ann. Emerg. Med. 38, 140–145. Nguyen Thi, P.L., Briancon, S., Empereur, F., Guillemin, F., 2002. Factors determining inpatient satisfaction with care. Soc. Sci. Med. 54, 493–504. Niakas, D., Gnardellis, C., Theodorou, M., 2004. Is there a problem with quality in the Greek hospital sector? Preliminary results from a patient satisfaction survey. Health Serv. Manag. Res. 17 (1), 62–69. O'Connell, A.A., 2000. Methods for modeling ordinal outcome variables. Meas. Eval. Couns. Dev. 170–193. Panteli, V., Patistea, E., 2007. Assessing patients' satisfaction and intensity of pain as outcomes in the management of cancer-related pain. Eur. J. Oncol. Nurs. 11, 424–433. Pantouvakis, A., Bouranta, N., 2014. Quality and price – impact on patient satisfaction. Int. J. Health Care Qual. Assur. 27 (8), 684–696. Papanikolaou, V., Ntani, S., 2008. Addressing the paradoxes of satisfaction with hospital care. Int. J. Health Care Qual. Assur. 21 (6), 548–561. Pascoe, G.C., 1983. Patient satisfaction in primary health care: a literature review and analysis. Eval. Program Plan. 6 (3–4), 185–210. Pini, A., Sarafis, P., Malliarou, M., Tsounis, A., Igoumenidis, M., Bamidis, P., Niakas, D., 2014. Assessment of patient satisfaction of the quality of health care provided by outpatient services of an oncology hospital. Glob. J. Health Sci. 6 (5), 196–203. Polyzos, N., Mpartzokas, D., Mylonakis, J., Yfantopoulos, J., Mougia, V., 2005. Factors affecting outpatient and inpatient hospital satisfaction. Eur. J. Sci. Res. 11 (2), 131–144. Priporas, C.V., Laspa, C., Kamenidou, I., 2008. Patient satisfaction measurement for inhospital services: a pilot study in Greece. J. Med. Mark. 8 (4), 325–340.
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Understanding quality and satisfaction in public hospital services: A nationwide inpatient survey in Greece Panagiotis Mitropoulos, Konstantinos Vasileiou, Ioannis Mitropoulos
⁎
Department of Business Administration, Technological Education Institute of Western Greece, GR-26500 Patras, Greece
A R T I C L E I N F O
A B S T R A C T
Keywords: Patients' satisfaction HCAHPS Nationwide survey Greece Public hospital
Health services compared to the most of other sectors' customer services present some special traits, such as extreme complexity, co-production, and intangibility, while financial and human consequences of low quality are high. This study reports on the findings of a nationwide HCAHPS questionnaire survey conducted in Greece after the implementation of the health system reform due to the financial crisis regarding the factors determining inpatient satisfaction in public hospitals. HCAHPS data were initially analysed by factor analysis followed by an ordinal regression analysis, which aimed to identify the determinants with significant impact on inpatient satisfaction. The study results are consistent with prior research which indicated that the communication with nurses is the most salient predictor of overall patients’ satisfaction followed by communication with doctors. Moreover, certain patient (age and health status) and hospital institutional (type and location) characteristics also contribute significantly to patients’ perceived overall satisfaction. Hence, health quality improvement activities should consider the critical differences among patient subgroups and hospital types in order to fulfil consumer needs and preferences more effectively.
1. Introduction
Even though patients’ perceived medical care quality is biased, in terms of the marketing principles, they are actually the “consumerscustomers” of the healthcare system (Huang et al., 2004), as well as the exclusive payers, either directly to the private or mostly indirectly through taxes to the public health providers, of the services delivered to them. Consequently, their perceived satisfaction is by far the most important criterion to evaluate the performance of the medical care system. Moreover, in several occasions patients’ satisfaction may play an important role to their willingness to get involved in their care and conform to the treatment plans (Sofaer and Firminger, 2005; Vogus and McClelland, 2016; Al-Refaie, 2011). Additionally, Huang et al. (2004) supported that increased levels of patient satisfaction redound to the outcomes of the health care system in terms of reduced utilisation of medical services, advanced prognosis, less malpractice litigation, and a higher level of compliance. Therefore, as Pascoe (1983) mentioned patients’ satisfaction is hypothesised to be both a dependent variable and a predictor of future health-related behaviour. The great importance of patients' satisfaction has led to a great number of different instruments for its measurement worldwide, that focus on the various aspects of medical care experience, such as communication with healthcare providers, access to hospital, the quality of basic amenities, waiting time to make an appointment and to be examined at the clinic (Bleich et al., 2009; Aletras et al., 2009).
Patient satisfaction has been a key issue in assessing the performance of health care providers over the last decades (Vogus and McClelland, 2016; Kleefstra et al., 2015; Schoenfelder et al., 2011; Xesfingi and Karamanis, 2015; Pini et al., 2014). Toundas et al. (2003) mentioned that over a thousand of studies regarding patient perceptions about their medical care are published each year. Patients’ perceptions with respect to the quality of services provided by the health care system suffer from subjectivity given that, inter alia, patients’ scientific and technical knowledge of medical care issues is rather limited, and the perceived healthcare quality is subject to the patients' physical and psychological situation and their sociodemographic characteristics (Schoenfelder et al., 2011; Merkouris et al., 2013; Vogus and McClelland, 2016; Dempsey et al., 2014). Moreover, the incredibly complex nature of human disease renders the health care procedures extremely complicated, only to mention that even when there is a consensus about a patient's health state diagnosis, it is very probable that doctors disagree about the best course of treatment (Nembhard et al., 2009). Additionally, the interests and targets of health providers and patients do not, compulsory, coincide, but the decision making depends, more, on health professionals’ opinion (Nembhard et al., 2009).
⁎
Corresponding author. E-mail addresses: [email protected] (P. Mitropoulos), [email protected] (K. Vasileiou), [email protected] (I. Mitropoulos).
http://dx.doi.org/10.1016/j.jretconser.2017.03.004 Received 27 January 2016; Accepted 8 July 2016 0969-6989/ © 2017 Elsevier Ltd. All rights reserved.
Please cite this article as: Mitropoulos, P., Journal of Retailing and Consumer Services (2017), http://dx.doi.org/10.1016/j.jretconser.2017.03.004
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tion of the health system reform due to the financial crisis, utilising the data of the nationwide HCAHPS questionnaire survey conducted by the Greek Ministry of Health during the period of May 2011 to November 2011. Moreover, the impact of the demographic characteristics of the patients and the institutional characteristics of hospitals on patients’ satisfaction was also investigated. In this light, the next section presents the methodology and the sample of the study, followed by our research results. The paper concludes with a discussion of our findings, limitations of our work and recommendations.
Most of these instruments are specific to a country's health system or type of the hospital rendering comparisons between countries and over time practically rather difficult, if not unattainable. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, developed for use in the USA by the Centres for Medicare and Medicaid Services (CMS) with the collaboration of the Agency for Healthcare Quality Research (AHRQ) (Elliott et al., 2009a, 2009b; Giordano et al., 2010), has been the most known standardized, and unbiased set of measures of patient experience so far (Vogus and McClelland, 2016). The HCAHPS survey has been endorsed by the National Quality Forum (NQF) in the USA and it was also selected for the purposes of the European Commission RN4CAST project, which involved 12 countries (Belgium, England, Finland, Germany, Greece, Ireland, The Netherlands, Norway, Poland, Spain, Sweden and Switzerland) because of its potentiality to yield comparable results that would allow to obtain objective and meaningful comparisons across health systems on domains that are important to consumers among the participating European countries and the USA (Squires et al., 2012). The content validity of the Greek translation of the HCAHPS survey has already been examined by Squires et al. (2012) and achieved an 'excellent' rating. The HCAHPS survey measures discharged inpatients’ experiences of the hospital care, employing 25 patient rating items with respect to communication with nurses and doctors, the responsiveness of hospital staff, the cleanliness and quietness of the hospital environment, pain management, communication about medicines, discharge information, overall rating of hospital, and would they recommend the hospital, as well as questions regarding patients’ demographics (CMS, 2014). The interest in evaluating the patients’ expectations and demands from the public health system is considerably rising during crisis periods, where all involved stakeholders strive to optimise the efficiency and, especially, the effectiveness of the scarce public resources dedicated to health care (Pantouvakis and Bouranta, 2014; Karanikolos et al., 2013). Greece has indeed experienced a thrilling transition in the legislative, political and economic environment since early 2010 with enormous consequences on the health care system, given that the cuts to hospital budgets exceed 40% and the shortages of personnel and medical supplies dramatically raised. Kentikelenis et al. (2011) and Zavras et al. (2012) reported that Greeks’ health status self-evaluation has worsened since the outbreak of the financial crisis while the proportion of citizens that appreciate that they have limited access to medical care is steadily increasing. Although, the investigation of patients' satisfaction with the medical care provided by the Greek public hospitals is crucial for developing and implementing quality improvement strategies and activities, most of the published studies report on the patients' perceptions before the emergence of the financial crisis (Niakas et al., 2004; Gnardellis and Niakas, 2005; Priporas et al., 2008; Matis et al., 2009; Aletras et al., 2006, 2007, 2009; Panteli and Patistea, 2007; Labiris and Niakas, 2005; Papanikolaou and Ntani, 2008; Polyzos et al., 2005; Toundas et al., 2003; Pantouvakis and Bouranta, 2014; Pini et al., 2014; Chandrinou et al., 2013). Thus, the results from the aforementioned studies cannot provide a solid basis for decision making in the contemporary Greek Hospitals conditions, taking also into consideration that their sample emanated from either a single or a limited number of hospitals and that they did not follow international procedures and protocols for surveying data from General Hospitals (e.g. HCAHPS). There is only one reported study on patients’ satisfaction assessment regarding their experience of a Greek general hospital since the outbreak of the financial crisis (Xesfingi and Karamanis, 2015). However, their study sample concerns only a single general hospital in the capital Athens, therefore, it is not possible to draw firm conclusions about the whole population of Greek patients. This paper aims to fill the gap in the literature by providing evidence about the patients’ satisfaction regarding the medical care they experienced from the Greek public hospitals after the implementa-
2. Study sample The survey was administered by the Greek Ministry of Health (MOH) with the aim to include all the 131 public hospitals operating in the national health system. However, 89 hospitals denied participation, claiming that there was a lack of the necessary budget and time. Thus, data was selected by 42 hospitals, which are a fairly representative sample of hospitals to mirror the general structure of the national health system. The data were collected by the hospitals' Quality Office that has the responsibility to run the patient satisfaction survey on a yearly basis. Using the simple random sampling technique, the patients received the corresponding questionnaire the previous day before being discharged and returned it to a secured drop box at the reception before leaving the hospital. Then, at a centralised level, the sample was collected and validated by the Quality and Efficiency Department of the MOH to ensure that it was representative of each hospital. The sample that was finally selected in the survey contains 5467 inpatients stratified according to the population of patients that each hospital served. 3. Factor structure of service quality Exploratory factor analysis was conducted to explore latent factors within the questionnaire items and to verify the reliability and validity of the service dimensions. Factor analysis can identify a more reduced set of variables without interrelationships in order to explain, in the highest possible degree, the variability found in the answers to the questionnaire. The Principal Component Analysis method and orthogonal (varimax) rotation were employed to extract the factors that would improve the interpretation of the participants’ answers with respect to the core part of the questionnaire which contains 11 services attributes. In particular, we used 9 questions rated on a 4-point Likert scale (Never, Sometimes, Usually, Always) covering 3 specific hospital practices: Communication with doctors (3 items), Communication with nurses (4 items) and the physical environment (2 items). The remaining two items, rated on a dichotomous scale (No/Yes), cover the information about discharge. The analysis identified four factors with eigenvalues greater than 1. The Kaiser-Meyer-Olkin statistic is 0.87, indicating strong correlations among items and confirms that factor analysis is an appropriate analysis of the sample as it exceeds the 0.5 acceptable limit (Kaiser, 1974). In addition, the Bartlett's Test of Sphericity shows that the suitability of the intercorrelation matrix of the 11 variables for factor analysis is significant at the 0.001 level. Factors and items of the questionnaire are described in Table 1. This table also presents the mean and standard deviation of the items, their factor loadings and the Cronbach's alpha reliability index for each principal component. The results indicate strong relationships of the items within each factor that are independent of those of other factors. The four factors identified, confirmed the four dimensions under consideration of the HCAHPS questionnaire. Since all items load as expected, it is evidence that the questionnaire exhibits strong convergent validity. Then, we defined the four distinct factors which explain 69.08% of total variance as follows: doctor communication (F-doctor) that 2
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Table 1 Results of the principle component analysis – identification of core service dimensions. Identified factor
Item description
Factor loading
Mean (SD)
Doctor communication (Cronbach alpha=0.79)
Frequency that doctors treated patient with courtesy and respect Frequency that doctors explained things in a way the patient could understand Frequency that doctors listened carefully to the patient
0.793 0.800 0.848
3.79 (0.51) 3.67 (0.65) 3.75 (0.57)
Nurse communication (Cronbach alpha=0.83)
Frequency Frequency Frequency Frequency
0.789 0.798 0.690 0.568
3.78 3.73 3.63 3.73
(0.53) (0.56) (0.68) (0.63)
Physical environment (Cronbach alpha=0.72) Discharge Information (Cronbach alpha=0.60)
Frequency that the patient's room and bathroom were kept clean Frequency that the area around patient's room was quiet at night? Hospital staff talked with patient about the availability of necessary help when leaving the hospital The patient got information in writing about what symptoms or health problems to look out for after leaving the hospital
0.773 0.736 0.813 0.830
3.67 3.41 0.28 0.24
(0.65) (0.79) (0.44) (0.42)
that that that that
nurses treated the patient with courtesy and respect nurses listened carefully to the patient nurses explained things in a way the patient could understand patient got help immediately after pressing the call button
accounts for 11.59% of the variance, nurse communication (F-nurse) that accounts for 40.56% of the variance, physical environment (Fenvironment) that accounts for 7.62% of the variance, and information about discharge (F-information) that accounts for 9.30% of the variance. The internal consistency of the questionnaire was measured using Cronbach-alpha coefficient. The value of Cronbach-alpha for the total sample was 0.77, verifying the instrument's scaling is reliable since it exceeds the minimum accepted value of 0.7 (De Vaus, 2002), even though the low level of alpha is often associated with multidimensional data and in specific situations such as social sciences some researchers use smaller levels. The factor-wise internal consistency was 0.79 for doctor communication, 0.83 for nurse communication, 0.72 for physical environment and 0.60 for discharge information.
Table 2 Descriptive data for inpatients. Variable
Percentage
Overall satisfaction (scale 1–10) Health status (scale 1–5) Age, % (> 45) Gender, % female Nationality, % native
Mean (SD) 8.07 (2.30) 2.96 (1.02)
66 53 95
secondary care hospitals are offering all ranges of secondary health care. The tertiary care hospitals are equipped with advanced technology to offer highly specialised services. Finally, the specialised hospitals are dealing with specific medical needs such as psychiatric problems and certain disease categories. The academic status was a dummy variable to indicate the hospital's involvement in medical education with university hospitals being the reference category. Finally, hospitals were classified by location, in order to attribute the differences on policies implemented at the regional level. More specifically, the Greek national health system has a regional structure, allowing local administrations to play an important role in determining the responsibilities and formulating proposals to better address local needs. The location variable encapsulates the 6 health administrative regions of Greece, namely 1) Attica, 2) Aegean 3) Epirus & West Macedonia, 4) East Macedonia & Thrace, 5) Thessaly, 6) Peloponnese & West Greece. Table 3 presents the descriptive statistics of the institutional characteristics of the 42 hospitals included in the survey. As a final point in the description of the prediction variables, it should be mentioned that for all the categorical predictor variables, the largest group in our sample was selected as the reference group. The Clog-log link function was employed in the ordinal regression model. First of all, the appropriate choice of the link function had to be
4. Regression analysis An ordinal regression analysis was employed to identify the determinants that have the most significant impact on inpatient satisfaction. The survey asked from impatiens to rate their general degrees of satisfaction or otherwise from their hospital services on a 10point scale from very low to very high. Accordingly, the single item of the questionnaire that measures the overall patient satisfaction is used as a dependent variable in the regression procedure. The independent variables of the study are classified into the following three main groups. The first group of variables consists of the four factors identified in the previous section, namely the doctor communication, the nurse communication, the physical environment and the information about discharge, which capture the quality of services provided within the hospital. The second group of variables refers to the demographic characteristics of the inpatients: gender, age, nationality and the self-reported health status. More specifically, gender was a dummy variable indicating whether inpatients were female or male. Age was transformed into the two categories, indicating whether the respondent belonged to a younger (≤45 years) or to an older inpatient group (> 45 years). Nationality was also a dummy variable indicating native (Greek) or non-native inpatients. Health status was measured by the relevant single item of the HCAHPS questionnaire, which asks patients to rate their health status on a five-point scale from poor (1) to excellent (5). Table 2, presents the descriptive statistics for the demographic characteristics of inpatients that participate in the survey. The third group of variables pertains to the institutional characteristics of hospitals comprising their type, location and academic status. Particularly, the type of hospital is specified as primary, secondary, tertiary and specialised. The primary care hospitals are known as hospital-health centres offering mainly primary health care and dealing with rather trivial treatments of the secondary health care. The
Table 3 Descriptive data for hospitals.
3
Variable
Category
Frequencies (%)
Hospital type
Primary Secondary Tertiary Specialized
4 (10) 29 (69) 6 (14) 3 (7)
Academic status
Non university University
35 (83) 7 (17)
Health region
Attica Aegean Epirus & West Macedonia East Macedonia & Thrace Thessaly Peloponnese & West Greece
7 (17) 10 (23) 5 (12) 8 (19) 5 (12) 7 (17)
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addition, hospitals located in the health regions of Epirus & West Macedonia (OR 1.71), East Macedonia & Thrace (OR 1.21), and Thessaly (OR 1.27), had significantly higher satisfaction scores than did hospitals in the Attica region.
Table 4 Results of the ordinal regression model: determinants of overall inpatient satisfaction. Predictors (reference group)
Service quality F- nurse F- doctor F- information F- environment
Odds Ratio (95% Confidence interval)
p-value
1.46 1.43 1.26 1.40
< 0.001 < 0.001 < 0.001 < 0.001
5. Discussion (1.41–1.52) (1.38–1.49) (1.21–1.31) (1.35–1.46)
The communication with nurses was found to be the most salient predictor of overall satisfaction, followed by communication with doctors. These results are consistent with prior research which highlighted the importance of communication between patients and hospital staff. The major impact of nursing care on patient satisfaction and its greater meaning in comparison to physicians’ care is in agreement with the results of Elliott et al. (2009a), who also found that communication with nurses and nursing care to be more important to patients. One possible explanation is that inpatients during their stay, interact most with nurses than doctors because nurses are the first responders to patients when they have concerns or feel discomfort (Schoenfelder, 2011). The physical environment emerged as the next most important factor with respect to patients’ satisfaction. Several studies have shown that physical environment displays a strong positive correlation with patient satisfaction (Coulter and Cleary, 2001). Cleanliness is considered as an important issue, not only as a primary measure to control the infection risk, but as well as an indicator of the commitment of the hospital staff and the hospital's attention as a whole (Sofaer et al., 2005). Quietness is also important because it is directly related to the inpatient's needs to rest or sleep. The factor that the inpatients considered as less important was the information about discharge. This result is consistent with Elliott et al. (2009a), who also found discharge information to be of less importance to patients. The patient characteristics that were significantly related to overall patient satisfaction were both age and self-reported health status. Consistent with the literature, our study showed that the elderly patients tended to report higher satisfaction scores with the received services than the younger ones (Nerney et al., 2001; Gnardellis and Niakas, 2005). One possible explanation for the lower satisfaction rating of younger patients could be that they may be treated differently (e.g. less gently than older ones) or, that they have unrealistic expectations due to their lack of knowledge about hospital care (Young et al., 2000). As in previous studies (Nguyen Thi et al., 2002; Xiao and Barber, 2008), we showed that people who perceived themselves as being healthy were more likely to be more satisfied with hospital care. A possible explanation is that healthier people may be more satisfied with life generally, and this attitude stimulates their ultimate satisfaction with hospital care (Young et al., 2000). Regarding gender and nationality, both of them were not significant predictors of inpatient satisfaction. The study results are consistent with most prior research that found similar satisfaction scores between male and female inpatients (Niakas et al., 2004; Nguyen Thi et al., 2002). Nationality was unrelated with overall satisfaction showing that patients are treated in Greek hospitals without ethnic disparities. The institutional characteristics that were significantly related to overall patient satisfaction were both the location and type of hospitals. There were high regional variations in patients’ satisfaction with Epirus & West Macedonia, Thessaly, and East Macedonia & Thrace performing better than the other health regions. The patients hospitalised in the Attica region were the least satisfied. Considering that most of the largest hospitals are located in Attica since it is the biggest urban area of Greece, a possible explanation of this lower satisfaction is that the patients perceive larger hospitals as impersonal and intimidating (Young et al., 2000). Furthermore, we found that the inpatients treated in specialised hospitals were more satisfied than the others. This may be attributed to the fact that the staff and the hospital environment in specialised hospitals are more focused on patients and their specific needs, providing better attentiveness, personal care and information
Patient characteristics Gender (female) male
0.99 (0.91.1.07)
0.818
Age (> 45 years) ≤45 years
0.77 (0.70–0.85)
< 0.001
Nationality (natives) Non natives Self-reported health status
1.03 (0.86–1.23) 1.09 (1.05–1.13)
0.722 < 0.001
Type (secondary) Primary Tertiary Specialized
1.19 (0.95–1.48) 0.89 (0.66–1.18) 1.40 (1.11–1.75)
0.112 0.436 0.004
Academic status (non university) University
1.23 (0.93–1.63)
0.140
Location (Attica) Aegean Epirus & West Macedonia East Macedonia & Thrace Thessaly Peloponnese & West Greece
1.13 1.71 1.21 1.27 1.15
0.123 < 0.001 0.006 0.001 0.056
Institutional characteristics
(0.97–1.31) (1.44–2.01) (1.05–1.38) (1.09–1.47) (0.99–1.33)
made since the categories were ordered (O'Connell, 2000). Given that patients tend to report high levels of satisfaction with health care, the Clog-log link function exhibits a better fit in the regression model since it is more suitable for analysing the ordered categorical data when the higher categories are more probable among the other categories. The validity of the estimated model was then explored with the test of parallel lines. The significance of this test p=0.991 > 0.05 indicated that regression coefficients were the same across the response categories, suggesting that the model assumption of parallel lines was not violated in the model. Finally, the overall model goodness-of-fit explaining patient satisfaction was assessed by the pseudomultiple correlation squared values for Nagelkerke-R2, which was found to be 0.32.
4.1. Determinants of inpatient satisfaction Table 4 presents estimates of odds ratios (OR) for inpatients with respect to their overall satisfaction with hospital's performance. We observe that ten variables were significantly related to inpatient satisfaction (p < 0.05). It is evident that all of the four service dimensions were found significant for describing and explaining satisfaction. The most influential determinants were the communication with nurses (OR 1.46) and doctors (OR 1.43) followed by the physical environment (OR 1.40) and information at discharge (OR 1.26). Regarding the patient characteristics both older age and better health status were significantly associated with higher satisfaction. Age was a stronger determinant (OR 0.77) than the self-reported health status (OR 1.09). In contrast, gender and nationality were not significantly associated with satisfaction. Among the institutional characteristics, both the hospital type and location were significantly associated with overall satisfaction. In particular, the specialised hospitals exhibited significantly higher satisfaction score than did the other types of hospitals (OR 1.40). In 4
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almost two-thirds of public hospitals operating in the national health system failed to provide such data claiming that they have a shortage of the necessary budget and time. Moreover, there is no information available about the eligible patients that inclined to participate in the survey. However, because of the relatively large size of the sample (around 5500 patients) emanated from all the Health Regions and hospital types, it may be assumed that the nonresponse bias has a minor on research results. Moreover, the study sample consists solely of patients of public hospitals, so the study should be extended to private health providers. Finally, our data come from a single survey, thus, they provide a ‘snapshot’ of patients’ perceptions. Therefore, it would be rather important to conduct such surveys on a regular basis to understand the ways in which patients’ satisfaction changes over time as well as the importance of its determinants factors, in order to launch and implement more useful health improvement plans in care delivery and services. References Aletras, V., Papadopoulos, E., Niakas, D., 2006. Development and preliminary validation of a Greek-language outpatient satisfaction questionnaire with principal components and multi-trait analyses. BMC Health Serv. Res. 6, 6–66. Aletras, V., Zacharakis, F., Niakas, D., 2007. Questionnaire for the measurement of outpatient satisfaction in the ophthalmology clinic of a Greek public hospital. Arch. Hell. Med. 24 (1), 89–96. Aletras, V., Basiouri, F.N., Kontodimopoulos, N., Ioannidou, D.M., Niakas, D. Α, 2009. Development and psychometric assessment of a Greek-language inpatient satisfaction questionnaire. Arch. Hell. Med. 26 (1), 79–89. Al-Refaie, A., 2011. A structural model to investigate factors affect patient satisfaction and revisit intention in Jordanian hospitals. Int. J. Artif. Life Res. 2 (4), 43–56. Bleich, S.N., Özaltin, E., Murray, C.J.L., 2009. How does satisfaction with the health-care system relate to patient experience? Bull. World Health Organ. 87 (4), 271–278. Chandrinou, A., Gaitanou, K., Exarchos, K., Antoniadou, D., Tsorbanaki, C., Bissias, C., Malliarou, M., 2013. Rating of patient satisfaction factors in a clinical hyperbaric centre of a Greek navy hospital. Int. J. Caring Sci. 6 (1), 69–77. CMS, 2014. Centers for Medicare and Medicaid Services. HCAHPS questionnaire 2014. Retrieved: November 2015, from 〈http://www.hcahpsonline.org/〉. Coulter, A., Cleary, P.D., 2001. Patients' experience with hospital care in five countries. Health Aff. 20, 244–252. De Vaus, D., 2002. Analyzing Social Science Data. Sage, London. Dempsey, C., McConville, E., Wojciechowski, S., Drain, M., 2014. Reducing patient suffering through compassionate connected care. J. Nurs. Adm. 44 (10), 517–524. Elliott, M.N., Kanouse, D.E., Edwards, C.A., Hilborne, L.H., 2009a. Components of care vary in importance for overall patient-reported experience by type of hospitalization. Med. Care 47 (8), 842–849. Elliott, M.N., Zaslavsky, A.M., Goldstein, E., Lehrman, W., Hambarsoomians, K., Beckett, M.K., Giordano, L., 2009b. Effects of survey mode, patient mix, and nonresponse on CAHPS® hospital survey scores. Health Serv. Res. 44 (2p1), 501–518. Giordano, L.A., Elliott, M.N., Goldstein, E., Lehrman, W.G., Spencer, P.A., 2010. Development, implementation, and public reporting of the HCAHPS survey. Med. Care Res. Rev. 67 (1), 27–37. Gnardellis, C., Niakas, D., 2005. Factors influencing impatient satisfaction. An analysis based on the Greek National System. Int. J. Healthc. Technol. Manag. 6 (3), 307–320. Huang, J.-A., Lai, C.-S., Tsai, W.-C., Hu, W.-H., Yang, D.-W., 2004. Determining factors of patient satisfaction for frequent users of emergency services in a medical center. J. Chin. Med. Assoc. 67 (8), 403–410. Jha, A.K., Orav, E.J., Zheng, J., Epstein, A.M., 2008. Patients' perception of hospital care in the United States. New Engl. J. Med. 359, 1921–1931. Kaiser, H.F., 1974. An index of factorial simplicity. Psychometrika 39 (1), 31–36. Karanikolos, M., Mladovsky, P., Cylus, J., Thomson, S., Basu, S., Stuckler, D., McKee, M., 2013. Financial crisis, austerity and health in Europe. Lancet 381 (9874), 1323–1331. Kentikelenis, A., Karinikolos, M., Papanicolas, I., Basu, S., McKee, M., Stuckler, D., 2011. Health effects of financial crisis: omens of a Greek tragedy. Lancet 2011 (378), 1457–1458. Kleefstra, S.M., Zandbelt, L.C., de Haus, H.J., Kool, R.B., 2015. Trends in patient satisfaction in Dutch university medical centers: room for improvement for all. BMC Health Serv. Res. 15 (1), 112. Labiris, G., Niakas, D., 2005. Patient satisfaction surveys as a marketing tool for Greek NHS Hospitals. J. Med. Mark.: Device, Diagn. Pharm. Mark. 5, 324–330. Matis, G.K., Birbilis, T.A., Chrysou, O., 2009. Patient satisfaction questionnaire and quality achievement in hospital care: the case of a Greek public university hospital. Health Serv. Manag. Res. 22 (4), 191–196. Merkouris, A., Andreadou, A., Athini, E., Hatzimbalasi, M., Rovithis, M., Papastavrou, E., 2013. Assessment of patient satisfaction in public hospitals in Cyprus: a descriptive study. Health Sci. J. 7 (1), 28–40. Meterko, M., Mohr, D.C., Young, G.J., 2004. Teamwork culture and patient satisfaction in hospitals. Med. Care 42, 492–498. Nembhard, I.M., Alexander, J.A., Hoff, T., Ramanujam, R., 2009. Why does health care continue to lag? Insights from management research. Acad. Manag. Perspect. 23 (1), 24–42.
Fig. 1. Determinants of patients' satisfaction in Greek public hospitals.
than the other types of hospitals. The academic status was not significantly related with satisfaction. This result is consistent with the previous studies (Meterko et al., 2004; Jha et al., 2008) which argued that university hospitals might emphasise more on the technical aspects of quality than on improving the inpatients’ experiences. Fig. 1 summarises the conceptual framework of the study and depicts the final outcome with the statistically significant determinants of the patient satisfaction. 6. Conclusions This study aimed to investigate the factors determining the inpatient satisfaction in Greek public hospitals by utilising the data collected from a nationwide HCAHPS questionnaire survey conducted by the Greek Ministry of Health in 2011 after the outbreak of the financial crisis. The research findings from the factor and the ordinal regression analyses conducted are consistent with prior research which stressed the importance of communication between patients and hospital staff, as the communication with nurses was found to be the most salient predictor of overall satisfaction followed by the communication with doctors. Although, to a less extent, both the physical environment and the information about discharge were also found to play a significant role in patients' perceived satisfaction. Consequently, future quality improvement activities should primarily focus on the improvement of health professionals' behaviour, especially of nurses' since they assume most of the heavy load of treatment implementation and communication with patients. The study, in line with prior research, also revealed that certain patients', as well as hospitals' institutional, characteristics are significantly related to patients' perceived overall satisfaction. Therefore, the healthcare providers/managers should utilise the findings from patient satisfaction surveys in order to better understand their patient population and to adapt their quality improvement activities to the special needs of the patient groups at risk of having bad experiences in the hospital. Such an approach would contribute to the successful implementation of health reform plans by fulfilling consumer needs and preferences more effectively. Like similar surveys on patients' satisfaction, our study has some limitations. Although, the study utilised the HCAHPS data from a nationwide survey administered by the Greek Ministry of Health, 5
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Schoenfelder, T., Klewer, J., Kugler, J., 2011. Determinants of patient satisfaction: a study among 39 hospitals in an in-patient setting in Germany. Int. J. Qual. Health Care 23, 503–509. Sofaer, S., Firminger, K., 2005. Patient perceptions of the quality of health services. Annu. Rev. Public Health 26, 513–559. Sofaer, S., Crofton, C., Goldstein, E., Hoy, E., Crabb, J., 2005. What do consumers want to know about the quality of care in hospitals? Health Serv. Res. 40, 2018–2036. Squires, A., Bruyneel, L., Aiken, L., van den Heede, K., Brzostek, T., Busse, R., Ensio, A., Schubert, M., Zikos, D., Sermeus, W., 2012. Cross-cultural evaluation of the relevance of the HCAHPS survey in five European countries. Int. J. Qual. Health Care 24 (5), 470–475. Toundas, Y., Lopatatzidis, A., Chouliara, L., 2003. Degree of satisfaction among IKA beneficiaries concerning primary health care services offered. Arch. Hell. Med. 20 (5), 497–503. Vogus, T., McClelland, L., 2016. When the customer is the patient: lessons from healthcare research on patient satisfaction and service quality ratings. Hum. Resour. Manag. Rev. 26 (1), 37–49. Xesfingi S., Karamanis D., 2015. In- and Out-patient satisfaction assessment: the case of a Greek General Hospital. MPRA Paper No. 66672. Online at 〈https://mpra.ub.unimuenchen.de/66672/〉. Xiao, H., Barber, J.P., 2008. The effect of perceived health status on patient satisfaction. Value Health 11 (4), 719–725. Young, G., Materko, M., Desai, K., 2000. Patient satisfaction with hospital care. Med. Care 38, 325–334. Zavras, D., Tsiantou, V., Pavi, E., Mylona, K., Kyriopoulos, J., 2012. Impact of economic crisis and other demographic and socio-economic factors on self-rated health in Greece. Eur. J. Public Health 2012. http://dx.doi.org/10.1093/eurpub/cks143.
Nerney, M.P., Chin, M.H., Jin, L., 2001. Factors associated with older patients’ satisfaction with care in an innercity emergency department. Ann. Emerg. Med. 38, 140–145. Nguyen Thi, P.L., Briancon, S., Empereur, F., Guillemin, F., 2002. Factors determining inpatient satisfaction with care. Soc. Sci. Med. 54, 493–504. Niakas, D., Gnardellis, C., Theodorou, M., 2004. Is there a problem with quality in the Greek hospital sector? Preliminary results from a patient satisfaction survey. Health Serv. Manag. Res. 17 (1), 62–69. O'Connell, A.A., 2000. Methods for modeling ordinal outcome variables. Meas. Eval. Couns. Dev. 170–193. Panteli, V., Patistea, E., 2007. Assessing patients' satisfaction and intensity of pain as outcomes in the management of cancer-related pain. Eur. J. Oncol. Nurs. 11, 424–433. Pantouvakis, A., Bouranta, N., 2014. Quality and price – impact on patient satisfaction. Int. J. Health Care Qual. Assur. 27 (8), 684–696. Papanikolaou, V., Ntani, S., 2008. Addressing the paradoxes of satisfaction with hospital care. Int. J. Health Care Qual. Assur. 21 (6), 548–561. Pascoe, G.C., 1983. Patient satisfaction in primary health care: a literature review and analysis. Eval. Program Plan. 6 (3–4), 185–210. Pini, A., Sarafis, P., Malliarou, M., Tsounis, A., Igoumenidis, M., Bamidis, P., Niakas, D., 2014. Assessment of patient satisfaction of the quality of health care provided by outpatient services of an oncology hospital. Glob. J. Health Sci. 6 (5), 196–203. Polyzos, N., Mpartzokas, D., Mylonakis, J., Yfantopoulos, J., Mougia, V., 2005. Factors affecting outpatient and inpatient hospital satisfaction. Eur. J. Sci. Res. 11 (2), 131–144. Priporas, C.V., Laspa, C., Kamenidou, I., 2008. Patient satisfaction measurement for inhospital services: a pilot study in Greece. J. Med. Mark. 8 (4), 325–340.
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