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Keywords: Health services compared to the most of other sectors' customer services present some special traits, such as
Patients' satisfaction extreme complexity, co-production, and intangibility, while nancial and human consequences of low quality
HCAHPS are high. This study reports on the ndings of a nationwide HCAHPS questionnaire survey conducted in Greece
Nationwide survey after the implementation of the health system reform due to the nancial crisis regarding the factors determining
Greece
inpatient satisfaction in public hospitals. HCAHPS data were initially analysed by factor analysis followed by an
Public hospital
ordinal regression analysis, which aimed to identify the determinants with signicant 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 signicantly to patients perceived overall satisfaction. Hence, health quality improvement
activities should consider the critical dierences among patient subgroups and hospital types in order to full
consumer needs and preferences more eectively.
Corresponding author.
E-mail addresses: pmitro@upatras.gr (P. Mitropoulos), vasileiou@teiwest.gr (K. Vasileiou), mitro@teiwest.gr (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
P. Mitropoulos et al. Journal of Retailing and Consumer Services xxx (xxxx) xxxxxx
Most of these instruments are specic to a country's health system or tion of the health system reform due to the nancial crisis, utilising the
type of the hospital rendering comparisons between countries and over data of the nationwide HCAHPS questionnaire survey conducted by the
time practically rather dicult, if not unattainable. Greek Ministry of Health during the period of May 2011 to November
The Hospital Consumer Assessment of Healthcare Providers and 2011. Moreover, the impact of the demographic characteristics of the
Systems (HCAHPS) survey, developed for use in the USA by the Centres patients and the institutional characteristics of hospitals on patients
for Medicare and Medicaid Services (CMS) with the collaboration of the satisfaction was also investigated.
Agency for Healthcare Quality Research (AHRQ) (Elliott et al., 2009a, In this light, the next section presents the methodology and the
2009b; Giordano et al., 2010), has been the most known standardized, sample of the study, followed by our research results. The paper
and unbiased set of measures of patient experience so far (Vogus and concludes with a discussion of our ndings, limitations of our work
McClelland, 2016). The HCAHPS survey has been endorsed by the and recommendations.
National Quality Forum (NQF) in the USA and it was also selected for
the purposes of the European Commission RN4CAST project, which 2. Study sample
involved 12 countries (Belgium, England, Finland, Germany, Greece,
Ireland, The Netherlands, Norway, Poland, Spain, Sweden and Switzer- The survey was administered by the Greek Ministry of Health
land) because of its potentiality to yield comparable results that would (MOH) with the aim to include all the 131 public hospitals operating
allow to obtain objective and meaningful comparisons across health in the national health system. However, 89 hospitals denied participa-
systems on domains that are important to consumers among the tion, claiming that there was a lack of the necessary budget and time.
participating European countries and the USA (Squires et al., 2012). Thus, data was selected by 42 hospitals, which are a fairly representa-
The content validity of the Greek translation of the HCAHPS survey has tive sample of hospitals to mirror the general structure of the national
already been examined by Squires et al. (2012) and achieved an health system.
'excellent' rating. The data were collected by the hospitals' Quality Oce that has the
The HCAHPS survey measures discharged inpatients experiences of responsibility to run the patient satisfaction survey on a yearly basis.
the hospital care, employing 25 patient rating items with respect to Using the simple random sampling technique, the patients received the
communication with nurses and doctors, the responsiveness of hospital corresponding questionnaire the previous day before being discharged
sta, the cleanliness and quietness of the hospital environment, pain and returned it to a secured drop box at the reception before leaving the
management, communication about medicines, discharge information, hospital. Then, at a centralised level, the sample was collected and
overall rating of hospital, and would they recommend the hospital, as validated by the Quality and Eciency Department of the MOH to
well as questions regarding patients demographics (CMS, 2014). ensure that it was representative of each hospital. The sample that was
The interest in evaluating the patients expectations and demands nally selected in the survey contains 5467 inpatients stratied
from the public health system is considerably rising during crisis according to the population of patients that each hospital served.
periods, where all involved stakeholders strive to optimise the e-
ciency and, especially, the eectiveness of the scarce public resources 3. Factor structure of service quality
dedicated to health care (Pantouvakis and Bouranta, 2014; Karanikolos
et al., 2013). Greece has indeed experienced a thrilling transition in the Exploratory factor analysis was conducted to explore latent factors
legislative, political and economic environment since early 2010 with within the questionnaire items and to verify the reliability and validity
enormous consequences on the health care system, given that the cuts of the service dimensions. Factor analysis can identify a more reduced
to hospital budgets exceed 40% and the shortages of personnel and set of variables without interrelationships in order to explain, in the
medical supplies dramatically raised. Kentikelenis et al. (2011) and highest possible degree, the variability found in the answers to the
Zavras et al. (2012) reported that Greeks health status self-evaluation questionnaire. The Principal Component Analysis method and ortho-
has worsened since the outbreak of the nancial crisis while the gonal (varimax) rotation were employed to extract the factors that
proportion of citizens that appreciate that they have limited access to would improve the interpretation of the participants answers with
medical care is steadily increasing. respect to the core part of the questionnaire which contains 11 services
Although, the investigation of patients' satisfaction with the medical attributes. In particular, we used 9 questions rated on a 4-point Likert
care provided by the Greek public hospitals is crucial for developing scale (Never, Sometimes, Usually, Always) covering 3 specic hospital
and implementing quality improvement strategies and activities, most practices: Communication with doctors (3 items), Communication with
of the published studies report on the patients' perceptions before the nurses (4 items) and the physical environment (2 items). The remaining
emergence of the nancial crisis (Niakas et al., 2004; Gnardellis and two items, rated on a dichotomous scale (No/Yes), cover the informa-
Niakas, 2005; Priporas et al., 2008; Matis et al., 2009; Aletras et al., tion about discharge.
2006, 2007, 2009; Panteli and Patistea, 2007; Labiris and Niakas, 2005; The analysis identied four factors with eigenvalues greater than 1.
Papanikolaou and Ntani, 2008; Polyzos et al., 2005; Toundas et al., The Kaiser-Meyer-Olkin statistic is 0.87, indicating strong correlations
2003; Pantouvakis and Bouranta, 2014; Pini et al., 2014; Chandrinou among items and conrms that factor analysis is an appropriate analysis
et al., 2013). Thus, the results from the aforementioned studies cannot of the sample as it exceeds the 0.5 acceptable limit (Kaiser, 1974). In
provide a solid basis for decision making in the contemporary Greek addition, the Bartlett's Test of Sphericity shows that the suitability of
Hospitals conditions, taking also into consideration that their sample the intercorrelation matrix of the 11 variables for factor analysis is
emanated from either a single or a limited number of hospitals and that signicant at the 0.001 level.
they did not follow international procedures and protocols for survey- Factors and items of the questionnaire are described in Table 1. This
ing data from General Hospitals (e.g. HCAHPS). There is only one table also presents the mean and standard deviation of the items, their
reported study on patients satisfaction assessment regarding their factor loadings and the Cronbach's alpha reliability index for each
experience of a Greek general hospital since the outbreak of the principal component. The results indicate strong relationships of the
nancial crisis (Xesngi and Karamanis, 2015). However, their study items within each factor that are independent of those of other factors.
sample concerns only a single general hospital in the capital Athens, The four factors identied, conrmed the four dimensions under
therefore, it is not possible to draw rm conclusions about the whole consideration of the HCAHPS questionnaire. Since all items load as
population of Greek patients. expected, it is evidence that the questionnaire exhibits strong con-
This paper aims to ll the gap in the literature by providing vergent validity.
evidence about the patients satisfaction regarding the medical care Then, we dened the four distinct factors which explain 69.08% of
they experienced from the Greek public hospitals after the implementa- total variance as follows: doctor communication (F-doctor) that
2
P. Mitropoulos et al. Journal of Retailing and Consumer Services xxx (xxxx) xxxxxx
Table 1
Results of the principle component analysis identication of core service dimensions.
Doctor communication Frequency that doctors treated patient with courtesy and respect 0.793 3.79 (0.51)
(Cronbach alpha=0.79) Frequency that doctors explained things in a way the patient could understand 0.800 3.67 (0.65)
Frequency that doctors listened carefully to the patient 0.848 3.75 (0.57)
Nurse communication Frequency that nurses treated the patient with courtesy and respect 0.789 3.78 (0.53)
(Cronbach alpha=0.83) Frequency that nurses listened carefully to the patient 0.798 3.73 (0.56)
Frequency that nurses explained things in a way the patient could understand 0.690 3.63 (0.68)
Frequency that patient got help immediately after pressing the call button 0.568 3.73 (0.63)
Physical environment Frequency that the patient's room and bathroom were kept clean 0.773 3.67 (0.65)
(Cronbach alpha=0.72) Frequency that the area around patient's room was quiet at night? 0.736 3.41 (0.79)
Discharge Information Hospital sta talked with patient about the availability of necessary help when leaving the hospital 0.813 0.28 (0.44)
(Cronbach alpha=0.60) The patient got information in writing about what symptoms or health problems to look out for after leaving the 0.830 0.24 (0.42)
hospital
3
P. Mitropoulos et al. Journal of Retailing and Consumer Services xxx (xxxx) xxxxxx
Table 4 addition, hospitals located in the health regions of Epirus & West
Results of the ordinal regression model: determinants of overall inpatient satisfaction. Macedonia (OR 1.71), East Macedonia & Thrace (OR 1.21), and
Thessaly (OR 1.27), had signicantly higher satisfaction scores than
Predictors (reference group) Odds Ratio (95% Condence p-value
interval) did hospitals in the Attica region.
4
P. Mitropoulos et al. Journal of Retailing and Consumer Services xxx (xxxx) xxxxxx
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