Abstract
This research article’s goal and purpose are to find how healthcare quality factors (HQF) influence patient satisfaction (PS). The key objective of the research was to determine the crucial HQF, to assess the degree of influence these factors have on PS and the moderating role of patient experience (PE) on HQF and PS. The study also aimed to evaluate the impact of PE on PS. The study surveyed in-patients in private hospitals with an occupancy of 200 beds in Chennai, Tamil Nadu. The sample comprised 387 respondents. A developed questionnaire measuring PEs and PS, and an adapted questionnaire for HQF using a Likert scale, were used to collect data. The results obtained indicated that HQF influence PS, PE moderates PS, and PE influences PS.
Introduction
Providing quality care has turned into a vital perspective to improve services provided by hospitals, which in turn reflects in patient satisfaction (PS). Also, PS is used as an irreplaceable tool to evaluate service quality in hospitals to date (Ross & Rajagopalan, 2015). Previous research reveals that factors such as physical facilities (Sreenivas & Babu, 2012; Tam, 2007), diagnostic services (Merkouris et al., 2013), cleanliness (Ross & Rajagopalan, 2015; Ross, 2018; Sreenivas & Babu, 2012), food (Merkouris et al., 2013) and behaviour of doctors and nurses (Merkouris et al., 2013) greatly influence PS. PS is a subjective phenomenon, as it reflects the gap between expected and perceived quality of care, which inspires patients’ level of satisfaction (Rashid & Amina, 2014). The following research aims are the study’s major objectives: (a) to examine the present relationship between healthcare quality factors (HQF) and PS, (b) to analyse the moderating role of patient experience (PE) on HQF and PS and (c) to examine the connection between the PE and PS. The significance of this study is to promote quality in hospitals and to provide satisfactory services for patients. This study focuses on improving HQF that helps in achieving PS for hospital administrators.
Literature Review
Healthcare Quality
To upgrade proficiency and to increase a practical competitive position, empowering hospital administration with premium service quality is necessary (Carolyn, 2008). Service quality in healthcare is considered to be reasonably more imperative with the motive of satisfying and sustaining patients (Al-Majali & Al-Hashem, 2012; Arasli et al., 2008). Many health services administrators recognise service quality as a critical determinant for an organisation to succeed and service in the competitive environment of today. In this regard, many health service providers are doing their best in achieving service quality, as this is also used as a tool to measure PS (Aliman & Mohamad, 2016). New incentive structure and increasing competition have put pressure on healthcare providers to deliver quality effectively and efficiently (Raja et al., 2007).
Patient Satisfaction
Being a multidimensional concept, the main traits of providers correspond in addition to technical, functional, infrastructural, social climate and services (Elleuch, 2008; Zineldin, 2006). One important role PS plays is influencing patients’ trust (Alrubaiee & Alkaaida, 2011; Moliner, 2009), and improved hospital reputation leads to higher service usage and market share (Andaleeb et al., 2007). PS holds a vital role in determining the quality of healthcare service delivery (Chahal & Mehta, 2013). A satisfied patient prefers and refers hospitals based on their experience (Manzoor et al., 2019). If the customer is satisfied with comparing the service performance of hospitals and the desired expectation, it is PS (Lestariningsi et al., 2018).
Healthcare Quality and Patient Satisfaction
Patients view quality as two factors: (a) a marker of satisfaction depending on patients’ encounters with the services obtained and (b) a marker of general satisfaction during revisits after treatment (Shi & Singh, 2010). Satisfaction of patients also depends on three elemental issues, such as care quality, healthcare provider and relationship with healthcare services. High service quality can be achieved by improving the approach of administrators and managers towards patients in hospitals. Based on this, many hospitals have built up a High-Performance Work System (HPWS), which continuously monitors the relationship between HPWS and patient orientation. HPWS includes attributes, such as communication, behaviour of medical staff and diagnostic services (Ross & Rajagopalan, 2015; Scotti et al., 2007). A study conducted by the Agency for Healthcare Research and Quality revealed that physician relational abilities, clinical staff responses to patients, food, physical facilities and cleanliness were the factors favoured by patients (Ross, 2018).
Physical Facilities and Patient Satisfaction
On entering a hospital, patients evaluate the available facilities there and judge the hospital even before the start of a service experience. And then selects a course of action, whether to come back to the hospital based on the availability of physical facilities (Ross & Rajagopalan, 2015). PS judgement is more based on available physical facilities. Attractive physical facilities create a good impression of hospitals among patients. The better the appearance of physical facilities and hospital environment, the more noticeable PS will be (Andaleeb et al., 2007). From the above-mentioned literature, the study postulates the following hypothesis:
H1: Physical facilities positively influence PS.
Diagnostic Services and Patient Satisfaction
PS can also be measured by a provider’s efficiency in providing diagnostic facilities, which can meet patient expectations and needs (Thiedke, 2007). Earlier studies show that PS can be assessed with diagnostic services that include laboratory services and radiology services, as they are considered to be important departments in hospitals (Ejeta et al., 2015). As is well known, PS is an effective tool for assessing and improving quality; therefore, it is necessary to maintain quality standards in clinical laboratories and radiology services (Mekonnen et al., 2011). This has large effects on findings and treatment of diseases, as more than 80% of all diagnoses are made based on lab tests (Agarwal et al., 2012). Based on studies conducted earlier, the following hypothesis is postulated:
H2: Diagnostic services positively influence PS.
Cleanliness and Patient Satisfaction
In recent years, nosocomial infections have received major hospital-related considerations, with increased public awareness and media spotlight. This is also understandable from the connection between cleanliness models and the danger of contracting infection from hospitals, which has become a concern for people, while choosing hospitals that have high cleanliness metrics (Whitehead et al., 2007). Hospital cleanliness is viewed as an imperative and uncompromising issue by people, as the media plays a vital role in creating awareness among the public (Ranjeeta et al., 2009). Cleanliness is an indicator of quality that patients are expected to evaluate. Many studies reveal the dissatisfaction level of patients with cleanliness in toilets (Kulkarni et al., 2011). By maintaining quality standards on cleanliness, patients can be made satisfied and also infections among patients and visitors can be reduced (Ross, 2018). With research studies conducted earlier, the study proposes the following hypothesis:
H3: Cleanliness positively influences PS.
Food and Patient Satisfaction
Preparing hospital meals is a complicated process in hospitals as it remains diverse. Food can have a significant effect on the nutrition of hospitalised patients. An improper diet can lead to malnutrition (Mowe et al., 2006). Research has found that hospitals are changing their food services to be more patient-centred with a goal to improve satisfaction of patients and control costs (Buzalka, 2008). Quality food is a key indicator of PS, which is followed by a customised menu and staff who serve or deliver food to patients. The challenging task is to provide appropriate nutrition in hospital meals, as it has to cater to the different dietary needs of patients (Shreshtha & Vinti, 2014). Many researchers fail to give importance to the food service satisfaction of patients, as they think nursing and doctor quality are more famous in research. But the truth is, it is important to consider food and factors affecting its quality, as the way in which food is served impacts the satisfaction of patients in the hospital (Tranter et al., 2009). As evidenced in previous research works done by various researchers, the below-mentioned hypothesis was framed.
H4: Food positively influences PS.
Communication and Patient Satisfaction
Due to the demanding nature of patients, research on communication is gaining more importance (Wright et al., 2004). Quality communication influences PS, and communication between doctors and patients is always kept two-way, involving the exchange of information, including information giving and information seeking (Duffy et al., 2004). When a physician tries to have effective communication with a patient, it results in distinctive and effective involvement of patients in discussion and decision-making about the treatment process. It has also led them to a better comprehension of treatment and adherence to follow-ups (Brinkman et al., 2007). Based on the above research findings, the following hypothesis was postulated.
H5: Communication positively influences PS.
Behaviour of Doctors and Nurses and Patient Satisfaction
The healthcare industry is a people-driven industry. Besides the fact that patients consume services for their physical well-being and recovery, all procedures and medicines are administered by people. Hence, concentrating on the behaviour of doctors and nurses towards patients is very important to attain PS (Peltier et al., 2007). Since healthcare is more concerned with an individual’s health and their well-being, it requires high involvement of service involvement. The behaviour of medical personnel, such as doctors, nurses and other support staff, has a high impact on in-patient satisfaction in hospitals, as most procedures involve people. Healthcare providers should manage their behavioural quality through continuous processing and understanding the factors that are closely connected with PS (Sreenivas & Babu, 2012). Based on various literature, the study proposes the following hypothesis:
H6: Behaviour of doctors and nurses positively influences PS.
Patient Experience
Previous studies’ focus was on monitoring the progress of the healthcare experience of patients. Providing quality care to large numbers of people at an affordable price, centred on patients, can be achieved only through placing PE at the forefront (Lee et al., 2013). From the patients’ perspective, PE indicates the quality of care, and this has made people consider PE as an important data point to evaluate the quality of services rendered in hospitals. Considerably, direct feedback from in-patients is the best way to measure PE. Measuring PE has gained importance because providers are looking for opportunities to improve care, to monitor performance effectively, to meet patients’ expectations and documentations of benchmark for healthcare organisations (La Vela et al., 2014). From an administrator’s point of view, PE cannot be viewed as a single factor as it plays a vital role in quality and cost of healthcare (Lee et al., 2013). The literature review mentioned above leads us to the following hypotheses:
H7: PE moderates physical facilities and PS. H8: PE moderates diagnostic services and PS. H9: PE moderates cleanliness and PS. H10: PE moderates food and PS. H11: PE moderates communication and PS. H12: PE moderates the behaviour of doctors and nurses and PS.
Patient Experience and Patient Satisfaction
Patient forms an affective judgment predominantly, influenced by both external and internal factors, that results in PS (La Vela et al., 2014). The way a patient perceives treatment determines the evaluation of PE. Providers take many steps to define PE for their patients, but still, it can only influence patient perception by optimising actual provisions of service quality. Nowadays, providers have also started to accept the fact that commitment to PE improvement increases organisations’ benefits (Boodman, 2010). Patient-centred care can be attained by addressing PS through PE (DeCourcy et al., 2012). Various studies on PE and PS drive us to formulate the following hypothesis:
H13: PE positively influences PS.
Research Methodology
Problem Statement
Post-COVID-19 pandemic, the healthcare industry has undergone drastic changes. Especially, hospitals are overflowing with patients, and with precautions and restrictions, it has become hard for hospital administrators to satisfy patients’ needs without compromising on the quality of services provided. Not only the quality of services, but also the experience the patient had while receiving treatment plays a vital role in satisfaction, as it is also going to reflect the attitude and behaviour of workers in the hospital. Connection between healthcare quality factors, patient satisfaction and patient experience is represented in Figure 1.
Conceptual Framework Illustrating the Connection Between Healthcare Quality Factors, Patient Satisfaction and Patient Experience.
The Questionnaire for HQF was adopted from a previous study done by Ross (2018). A questionnaire for PS and PE was developed from a literature review. The questionnaire has two parts. The questionnaire starts with the first part consisting of demographic details, such as age, gender, mode of payment (Self or Insured), types of Patients (Standard or International) and duration of stay (less than 3 days, 3–7 days, 7–15 days, greater than 15 days). The second part of the questionnaire measures variables, which have one dependent variable (PS), six independent variables (HQFs) and one moderating variable (PE). A pilot study with 52 items was done to validate the questionnaire, with 42 samples. With the obtained results from the pilot study, the questionnaire was finalised with 46 items to measure the variables. Table 2 represents the study questionnaire.
Sample Size
The study has 387 valid responses. The responses were from patients of private hospitals in Chennai, the capital city of Tamil Nadu, located in the Southern part of India. The hospitals chosen for this study had a minimum 200-bed occupancy. Out of 500 responses approached, 387 responded. There were no disputed data, as all responded. Samples were recorded in person. The obtained responses were valid.
Measurement
Demographic characteristics as categorical data were measured in the first part. A 5-point Likert scale (1 as strongly disagree and 5 as strongly agree) was used to measure model variables in the second part. SPSS version 26.0 was used to analyse data.
Data Analysis and Results
The questionnaire that was used initially for conducting a pilot study gave a Cronbach’s alpha value that ranged from .82 to .96, and overall, α = .927, after testing 42 respondents. The value obtained was reliable, as per the studies done by Hair et al. (2018). Three items each were dropped from PS and PE. Out of 387 respondents, 54.6% were men, and the remaining 45.4% were women. All respondents were in-patients, as they can give a better view about the quality factors of hospitals compared to out-patients. Figure 2 shows the duration of stay of the respondents.
Duration of Stay of Respondents.
Multiple regression analysis was used to examine the connection between a single dependent variable (PS) and several independent variables (PF, DS, CL, FD, COM, BDN). To establish the moderating role of one variable (PE) on the dependent variable (HQF) and independent variables (PF, DS, CL, FD, COM, BDN), Hierarchical multiple regression analysis was used. Moderation diminishes or strengthens the effect between the independent and dependent variables. Also, to find the relationship between PE and PS, simple regression analysis was used.
Reliability and validity were used to assess the quality of the questionnaire, since it measures the constructs of the hypothetical model, as consistent results are produced by reliability and accurate results are produced by validity. As per the research done by Hair et al. (2018), the Cronbach’s alpha value of all constructs is above the threshold limit of .6, as represented in Table 1.
Reliability and Validity.
The Study Questionnaire.
Analysis and Findings
Multiple Regression Model
Healthcare Quality Factors and Patient Satisfaction
To analyse the significant relationship between HQF and PS, multiple regression analysis was performed.
HQF positively predict PS. Multiple regression analysis was done to find the relationship between all the variables of HQFs and PS. The obtained result displayed a significant positive relationship between HQFs and PS. The results support the hypotheses H1–H6.
The multiple regression analysis reflects a positive relationship between HQF (PF 0.432, DS 0.516, CL 0.522, FD 0.718, COM 0.857, BDN 0.736, p < .001) and PS.
From the values obtained in the analysis, it can be taken as proof of the significant relationship between HQF and PS. As seen in Table 3, the multiple regression model is stable and fit at F = 1.478 (PF), 278.174 (DS), 377.289 (CL), 356.172 (FD), 827.563 (COM), 673.484 (BDN), p < .001 for further data analysis. Since p < .001, all HQF are significant in this model, and so, all HQF also seem to independently reflect a statistically significant relationship with PS. On inferring from the obtained beta value, COM (0.857) is positively influencing and the strongest significant variable, while BDN (0.736) and FD (0.718) are positively influencing and moderately significant variables, CL (0.522) and DS (0.516) are positively influencing and significant variables, and PF (0.432) is positively influencing but still the weakest significant variable of HQFs. This provides proof for the positive relationship between HQF and PS.
Multiple Regression Analysis Between Healthcare Quality Factors and Patient Satisfaction.
A main effect is seen between HQF, PS and PE in step 1 of multiple hierarchical regression. Significance of F value, p and β coefficient for HQF and for PE indicate that the model is fit. Both HQF and PE are positively related to PS.
After examining step 2 for the moderating effects, R2 change for CL and COM shows that R2 has improved when the 2nd predictor is added. After the R2 change was tested with the F change, it was found that the F change is significant (p = .000), which indicates a significant improvement in adding the moderating variable in the prediction. The result supports that PE moderates the relationship between CL, COM and PS. For PF, DS, FD and BDN, there is no change in R2, and all factors of healthcare quality are positively related to PS. Therefore, it can be concluded that PE moderates the relationship between HQF and PS. Thus, the results support the hypotheses H7–H12.
On applying simple regression analysis, the relationship between PE and PS is found to be positively significant. The result supports the hypothesis H13.
From the values obtained and as seen in Table 5, the simple regression model is found to be fit at F = 652.187, p < .001. So, it can be concluded that there exists a significant positive relationship between PE and PS.
Hierarchical Multiple Regression Analysis of Employee Engagement on the Interaction Between Employee Motivational Factors and Work from Home.
Simple Regression Analysis Between Patient Experience and Patient Satisfaction.
Discussion
As presented in Table 6, the connection between HQF and PS, and also between PE and PS, is acceptable. The multiple hierarchical regression model also shows the moderation of PE between HQF and PS. Both the multiple regression model and simple regression model assured the positive influence of PF, DS, CL, FD, COM, BDN and PE on PS. From the beta value of the multiple regression model, it can be seen that COM has a strong influence on PS. Extant research and previous studies that examined the relationship between HQF and PS have solidly proved the important role of COM among other HQFs in influencing PS. A study made by Wong and Lee (2006) showcased the importance of communication, as it helps in improving the exchange of information between healthcare professionals and patients in hospitals. Also, Moller-Leimkuhler et al. (2002) found the imperative role of communication between hospitalised patients and doctors in achieving PS. Consonant with studies done earlier by Ammo et al. (2014), physical facilities influence PS. Physical facilities that include parking lots, trolleys and wheelchairs, beds and seating arrangements have an effect on PS. This current study also insists on the easy accessibility of these physical facilities to improve PS. A comparative study conducted by Mindaye and Taye (2012) shows that 80% of the population involved in the study were satisfied with diagnostic services. As we are aware, patients consider cleanliness to be the basic element in assessing care quality. Kulkarni et al. (2011) found through their study that patients are happy and satisfied when hospitals are clean. Bashir et al. (2011), from their study, insisted that accessibility of clean water and maintaining a hygienic atmosphere in hospital premises and restrooms are basic components of cleanliness. As obtained in the analysis, food influences PS. The result of this study is similar to the previous research done by Sheehan-Smith (2006), which showed a positive critical relationship between food quality and PS. Sweeney (2008) found the significance of doctors’ and nurses’ behaviour and its role in influence of PS, with measures of compassion, warmth and amicability.
Hypothesis Results.
PE on these factors, such as PF, DS, CL, FD, COM and BDN determine how much a patient is satisfied. When administrators work to improve PE, it increases PS. Wong et al. (2015) conducted a survey, which analysed PE and its role on PS. He concluded, saying that capturing PE and its effects on PS can be used as a tool for continuous improvement in hospitals. From the research mentioned above, which supports the outcomes, it can be assumed that PE moderates HQF and PS.
Previous research results would suggest that PE has a connection with PS. A study conducted by Jenkinson (2002) revealed a positive influence of PE on PS. It was also concluded in that research, PE has a major role among patients for willingness to recommend a hospital to others and in providing an optimistic picture about the hospital. With the results obtained from various studies done earlier, it can be concluded that HQFs influence PS, and PE also influences PS. Apart from this, when PE is added as a moderator, it furthermore strengthens the relationship between HQFs and PS.
With the obtained results to study HQF and PS, we can very well conclude that the behaviour of doctors and nurses plays a crucial role in determining the level of satisfaction among patients. Many patients admit to having a good experience with their doctors and nurses, hence enhancing their level of satisfaction. The behaviour of doctors is considered as one of the most important factors to determine the success of healthcare facilities, since patients mostly choose a hospital based on doctors. When we speak about the behaviour of doctors, it includes a doctor being a good listener. Patients feel relaxed and hopeful of recovering from their sickness when they are listened to by their doctors/physicians. After all, good listening skills go beyond simply being cordial with patients. It is also one of the most important medical abilities since it enables doctors to comprehend the stress of their patients and explain the diagnosis. While doctors hold the foremost place, nurses play a major role, as patients spend more time with them during their treatment period. When nurses are kind and compassionate towards patients, it inculcates trust in patients, hence influencing their satisfaction.
The results displayed in Table 4 are quite surprising when we use PE as a moderator to measure PS on HQFs. As seen, PE influences PS, the patient is very happy with the food facilities of the hospital. Previously, people used to complain about the food served to them, being bland and tasteless. But now, much importance is placed on food by customising it to the different nutritional needs of patients. In fact, this has given good experience to patients as they are delighted to have both nutritious and tasty food, thus making their satisfaction higher with their experience of food.
On considering only the experience of patients excluding the HQF, still PS is high. This reflects the general opinion and goodwill a patient has for the hospital they are visiting regularly. Unlike the older days, hospital administrators are more focused on finding each factor which might look important to the patient and trying to improve that factor’s quality. This attitude of management has given positive results, thus influencing PS through PE, either directly or indirectly.
Conclusion
Chances of passing on goodwill about the hospital are much higher with in-patients compared to out-patients. So, it is more imperative for the hospital administrators to focus on improving factors of care quality in order to fulfil patient needs and satisfy them. This study has practically proved the importance of HQFs, such as PF, DS, CL, FD, COM and BDN in achieving PS. Similarly, PE also impacts the role of HQFs in satisfying a patient. This study’s results show that there is always an open door for healthcare providers to improve quality and meet patient needs, which also becomes an advantage for healthcare administrators. Apparently, it can be concluded that PS with the service provided by the hospital carries a good image in the minds of customers and serves as a tool for quality improvement for hospital administrators.
Recommendations on Future Research
Observationally, this study was conducted on the patients of private hospitals in Chennai, Tamil Nadu, with more than 200-bed occupancy. Using different moderating variables will provide varied results. As Chennai is a metropolitan city in India, conducting the same study in hospitals located in other cities may yield different results.
Footnotes
Declaration of Conflicting Interests
The author declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Funding
The author received no financial support for the research, authorship and/or publication of this article.