Exposé

Title of the Thesis

Patient Satisfaction: A Literature Review

Supervisor: Dipl.-Kffr. Jana Rosenbusch

(Institute of Human Resource Management and Organizations,
Hamburg University of Technology, Germany)

Caglar Bozkurt
International Production Management
Hamburg University of Technology
E-mail: caglar.bozkurt@tuhh.de
SUPERVISOR: DIPL.-KFFR. JANA ROSENBUSCH ...................................................................... 1
1.Research Topic ............................................................................................................ 1
1.1. Understanding the Problem ............................................................................... 1
1.2. Research Questions ............................................................................................. 4
1.3. Research Objectives ............................................................................................ 4
2. Methodology ............................................................................................................... 4
3. Timeline and Status of the Research........................................................................... 5
LITERATURE ................................................................................................................................. 7

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1. Research Topic

In healthcare industry, patient satisfaction has been one of the most popular research topics since
1960s due to its theoretical importance for the all parties in the industry; especially health care
providers, patients themselves as well as stakeholders. Regarding medical care providers, Drain (2001)
highlights an increasing pressure to improve service delivery focus and quality to meet increasing
demands of consumers. Therefore they begin undertaking research projects to find new and better
ways of keeping up-to-date with these changing demands as well as how best to efficiently fulfill them
(Ofili 2014). As a matter of fact, when the literature reviewed, it can be seen that there are numerous
reasons for medical care providers to conduct patient satisfaction research. As Gill and White (2009)
point out this could be because of the organization’s strategy or desire to make its processes better
which can be an outcome of its motivation to either reduce costs by improving the processes or
continue having old customers as well as attracting new ones by the improvement of patient
satisfaction (Nelson et al. 1992). Other than organizational reasons, the need to conduct patient
satisfaction research could also be a result of industry requirements such as regulations (Friesner et al.
2008). For instance, since 1998 patient satisfaction assessment has been mandatory for hospitals in
France. However this practice is being used for the improvement of the hospital environment, patient
facilities and amenities in a consumerist sense, but not necessarily the improvement of care (Boyer et
al., 2006). Also, national and international organizations for evaluations of health service place patient
satisfaction as one of the key indicators for the control of health service outcomes and reimbursement
of hospitals (Batbaatar et al. 2015). Furthermore, a simultaneous attention to consumerism and the
health service accountability is putting further pressure on the healthcare industry, pushing medical
care organizations to address the satisfaction levels of their patients (Turris 2005).

1.1. Understanding the Problem

By implication, in appearance patient satisfaction both a practical and politically important issue,
however it is an under-theorized concept, yet frequently measured (Turris 2005). The patient
satisfaction terminology is ambiguous and there is a significant divergence in the literature (Batbaatar
et al. 2015).
In logical sense, theoretical research should precede the measurement of any correlating concept
(Batbaatar et al. 2015). However in research of service satisfaction, including health services, the
opposite has been the case (Sitzia and Wood 1997; Batbaatar et al. 2015). Thus, there are only a
handful of original theories regarding patient satisfaction in the health care literature, which can be
summarized as follows (Hawthorne 2006; Gill and White 2009; Ofili 2014):

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1. Discrepancy and transgression theories of Fox and Storms (1981) advocate that patient
satisfaction is obtainable if there is an alignment between healthcare orientations of the patient
and the medical provider’s conditions of care.

2. Expectancy-value theory of Linder-Pelz (1982) claims that personal beliefs and values as well as
prior expectations about care have a mediating effect on patient satisfaction. Upon identifying the
relationship between expectations and variance in satisfaction ratings, Linder-Pelz defined patient
satisfaction as “positive evaluations of distinct dimensions of healthcare” (p.578). The Linder-Pelz
model was developed by Pascoe (1983) to take into account the influence of expectations on
satisfaction and then further developed by Aharony and Strasser (1993) to create a six factor
psychological model: cognitive and affective perception formation; multidimensional construct;
dynamic process; attitudinal response; iterative; and ameliorated by individual difference.

3. Determinants and components theory of Ware et al. (1983) suggest that patient healthcare
satisfaction is a function of patients’ personal preferences and expectations regarding their
healthcare service.

4. Multiple models theory of Fitzpatrick and Hopkins (1983) argue that patients’ satisfaction is
mediated by their individual social environment, reflecting their health goals and the perceived
comfort or discomfort they feel in regard to the healthcare services.

5. Healthcare quality theory of Donabedian (1980) proposes that interpersonal process of care plays
a key role in the determination of patient satisfaction regarding health care. He argues that for a
patient to have a high level of satisfaction regarding the health care delivery, he/she needs to have
a positive judgment towards the quality of care in all its aspects, but especially its interpersonal
side.

To reach an appropriate conceptualization of patient satisfaction, one first needs to have an accurate
concept of satisfaction. However, after a detailed review of the literature, it can be said that regardless
of the field it is studied in, the concept of satisfaction is complicated (Heidegger et al., 2006; Gill and
White 2009). As for the field of healthcare, Crowe et al. (2002) points out that the measurement of
patient satisfaction is “probably a hopeless quest” due to the concept’s subjective affective element.
This statement is argued in a more detailed manner in other studies as well (Vuori 1987; Aharony and
Strasser 1992):
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1. Patients do not have the necessary expert knowledge for the accurate assessment of the medical
personnel’s technical competence. Furthermore, their physical or emotional status can easily
prevent them from reaching an accurate judgment.

2. “Non-medical factors” such as the provider’s interpersonal skills can affect patient’s judgment
regarding his/her satisfaction over the received care. For example, lack of technical quality can
easily be covered up by a simple pleasant bedside manner.

3. Patients are often unwilling to share their real thoughts due to their perception of dependency or
prior patient-physician communication failures. Patients might also fear retribution from the
provider if they voice discontent.

4. Patients cannot accurately recall aspects of the delivery process. Furthermore, patient surveys or
even face-to-face interviews are imperfect means for measuring highly subjective phenomena.

On the other hand, there are several studies which advocate counter arguments to these factors
(Aharony and Strasser 1992):

1. Cleary and McNeil (1988) argue that by determining what values should be associated with
different outcomes patients can play a key role in defining quality care. While they may not have
the necessary knowledge to accurately assess the technical quality of care they receive, patients
certainly appreciate its importance.

2. Studies have found that the quality of physicians' interpersonal skills influences patient outcomes
more than the quantity of teaching and instruction given to the patient. Also, it has been
suggested that the effects of physician communication skills on the patient's adherence to medical
regimes are mediated by patient satisfaction and recall (Bartlett, Grayson, Barker, et al. 1984).

3. Sometimes actual healing may occur because of patient perceptions of the medical interaction.
This placebo effect may contribute up to one-third of the actual healing process (Press, Ganey, and
Malone 1990).

4. "Nonmedical factors," such as attitudes toward patients, interpersonal aspects of care, and
physician-patient communication, can cause reduced use of pain medication, shorter lengths of
stay, and improved patient compliance (Press, Ganey, and Malone 1990).

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In summary, while healthcare satisfaction research has not yet found a simple, direct connection
between the satisfaction of patients and improved outcome, satisfied patients appear to be more
prone to follow their treatment (Aharony and Strasser 1992) which can be considered as the main
motivator to continue doing research on patient satisfaction for some researchers.

1.2. Research Questions

Which patient satisfaction concepts are valid under certain conditions and what factors they consist
of?
-what are the main accurate customer satisfaction models in the service quality literature?
-what are the main satisfaction models that are studied under the healthcare service research?
-what are the main patient satisfaction dimensions and the factors affecting them?

1.3. Research Objectives

- To define the patient satisfaction concept and identify its major dimensions
- To evaluate the current patient satisfaction measurement methods, focusing especially on their
reliability and validity under certain conditions (e.g. inpatient-outpatient, emergency department,
oncology etc.)
- To evaluate the usefulness of the concept of patient satisfaction as an independent and
dependent variable

2. Methodology

This study will be aimed to evaluate the dynamics of patient satisfaction using a systematic review
approach. Articles will be searched in 3 databases, CINAHL, MEDLINE, EMBASE, and EBSCO using the
following main key words:

‘patient satisfaction’ AND ‘concepts’, or ‘patient satisfaction’ AND ‘models’, or ‘patient satisfaction’
AND ‘theory’, or ‘meaning’ AND ‘patient satisfaction’, or ‘patient satisfaction’ AND ‘conceptualization’,
or ‘exploring’ AND ‘patient satisfaction’, or ‘patient satisfaction’ AND ‘factors’, or ‘patient satisfaction’
AND ‘measure’ or ‘patient satisfaction’ AND ‘method’ or ‘satisfaction concepts’ AND ‘service’, or
‘service quality’ AND ‘satisfaction’, or ‘service quality’ AND ‘theory’

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Other factors considered in the selection process of the articles:

-Earliest publication year for articles: 1980

-Articles fully available in the database they’re found
-Main discussion areas of the article are related to satisfaction models in service industry or patient
satisfaction, or factors affecting patient satisfaction
-Articles are in English

3. Timeline and Status of the Research

Work Package Status Start Date End Date

WP 1 Article Screening ongoing 07.01.2016 20.02.2016
WP 2 Customer Satisfaction not started 20.02.2016 20.03.2016
WP 3 Patient Satisfaction not started 20.03.2016 01.05.2016
WP 4 Implications of Research not started 01.05.2016 01.06.2016
WP 5 Finalizing not started 01.06.2016 01.07.2016
Table 1: Timeline and status of work packages

WP 1: Article Screening
Firstly, the chosen databases will be searched using the predefined key words. Subsequently, after the
removal of duplicated and irrelevant articles considering other selection factors, abstracts of the
remaining articles will be read and a second elimination process will be conducted considering the
relevance of the articles’ abstracts to satisfaction models, patient satisfaction, and factors affecting
patient satisfaction. Following, using Critical Appraisal Skills Programme (CASP) checklist for systematic
review a final screening of the articles will be conducted.

WP 2: Customer Satisfaction
The articles that are found regarding the customer satisfaction will be analyzed and the corresponding
definitions, models and methodologies will be examined and categorized.

WP 3: Patient Satisfaction
The articles that are found regarding the patient satisfaction will be analyzed and the corresponding
definitions, models, dimensions, and factors as well as methodologies will be examined and
categorized. Following, these findings will be compared with the corresponding findings of customer
satisfaction studies and statements will be made as a result.

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WP 4: Implications of Research
During this period, implications of the reviewed articles will be examined and their validities will be
categorized regarding certain situations (i.e. which concepts are valid under which conditions). For
instance, there is a significant difference between the dynamics of patient satisfaction regarding
emergency departments and medical clinics.

WP 5: Finalizing
Lastly, the thesis will be finalized by arriving to conclusions in regard to the research findings.

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Literature

Aharony, L., & Strasser, S. (1993). Patient satisfaction: what we know about and what we still need to
explore. Medical care review.

Bartlett, E. E., Grayson, M., Barker, R., Levine, D. M., Golden, A., & Libber, S. (1984). The effects of
physician communications skills on patient satisfaction; recall, and adherence. Journal of chronic
diseases, 37(9), 755-764.

Batbaatar, E., Dorjdagva, J., Luvsannyam, A., & Amenta, P. (2015). Conceptualisation of patient
satisfaction: a systematic narrative literature review. Perspectives in public health, 135(5), 243-250.

Boyer, L., Francois, P., Doutre, E., Weil, G., & Labarere, J. (2006). Perception and use of the results of
patient satisfaction surveys by care providers in a French teaching hospital. International Journal for
Quality in Health Care, 18(5), 359-364.

Cleary, P. D., & McNeil, B. J. (1988). Patient satisfaction as an indicator of quality care. Inquiry, 25-36.

Crowe, R., Gage, H., Hampson, S., Hart, J., Kimber, A., Storey, L. and Thomas, H. (2002), The
measurement of satisfaction with healthcare: implications for practice from a systematic review of the
literature, Health Technology Assessment, Vol. 6 No. 32, pp. 1-244.

Donabedian, A. (1980). The definition of quality and approaches to its assessment, Explorations in
Quality Assessment and Monitoring, Vol. 1, Health Administration Press, Ann Arbor, MI.

Drain, M. (2001). Quality improvement in primary care and the importance of patient perceptions. The
Journal of ambulatory care management, 24(2), 30-46.

Fitzpatrick, R., & Hopkins, A. (1983). Problems in the conceptual framework of patient satisfaction
research: an empirical exploration. Sociology of health & illness, 5(3), 297-311.

Fox, J. G., & Storms, D. M. (1981). A different approach to sociodemographic predictors of satisfaction
with health care. Social Science & Medicine. Part A: Medical Psychology & Medical Sociology, 15(5),
557-564.

Friesner, D., & Scott, D. M. (2008). Exploring the formation of patient satisfaction in rural community
telepharmacies. Journal of the American Pharmacists Association: JAPhA, 49(4), 509-518.

Gill, L., & White, L. (2009). A critical review of patient satisfaction. Leadership in Health Services, 22(1),
8-19.

Hawthorne, G. (2006). Review of Patient Satisfaction Measures, Australian Government Department

of Health and Ageing, Canberra.

Heidegger, T., Saal, D., & Nuebling, M. (2006). Patient satisfaction with anesthesia care: what is patient
satisfaction, how should it be measured, and what is the evidence for assuring high patient
satisfaction?. Best Practice & Research Clinical Anesthesiology, 20(2), 331-346.

Linder-Pelz, S. (1982). Toward a theory of patient satisfaction. Social science & medicine, 16(5), 577-
582.

Nelson, E. C., Rust, R. T., Zahorik, A., & Rose, R. L. (1992). Do patient perceptions of quality relate to
hospital financial performance?. Marketing Health Services, 12(4), 6.
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Ofili, O. U. (2014). Patient satisfaction in healthcare delivery–a review of current approaches and
methods. European Scientific Journal, 10(25).

Pascoe, G. C. (1983). Patient satisfaction in primary health care: a literature review and analysis.
Evaluation and program planning, 6(3), 185-210.

Press, I., R. Ganey, and M. P. Malone (1990). Satisfied Patients Can Spell Financial Well-Being.
Healthcare Financial Management 45, no. 2: 34-36, 38, 42.

Sitzia, J., & Wood, N. (1997). Patient satisfaction: a review of issues and concepts. Social science &
medicine, 45(12), 1829-1843.

Turris, S. A. (2005). Unpacking the concept of patient satisfaction: a feminist analysis. Journal of
Advanced Nursing, 50(3), 293-298.

Ware, J. E., Snyder, M. K., Wright, W. R., & Davies, A. R. (1983). Defining and measuring patient
satisfaction with medical care. Evaluation and program planning, 6(3), 247-263.

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