International Journal of Health Care Quality Assurance Developing a Persian inpatient satisfaction questionnaire Mohammad Arab Arash Rashidian Abolghasem Pourreza Maryam Tajvar Roghayeh Khabiri Nemati Ali Akbari Sari Abbas Rahimi Forooshani
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Article information: To cite this document: Mohammad Arab Arash Rashidian Abolghasem Pourreza Maryam Tajvar Roghayeh Khabiri Nemati Ali Akbari Sari Abbas Rahimi Forooshani , (2014),"Developing a Persian inpatient satisfaction questionnaire", International Journal of Health Care Quality Assurance, Vol. 27 Iss 1 pp. 4 - 14 Permanent link to this document: http://dx.doi.org/10.1108/IJHCQA-10-2011-0059 Downloaded on: 30 January 2016, At: 10:07 (PT) References: this document contains references to 25 other documents. To copy this document: [email protected] The fulltext of this document has been downloaded 629 times since 2014*
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IJHCQA 27,1
Developing a Persian inpatient satisfaction questionnaire Mohammad Arab
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4 Received 18 October 2011 Revised 17 January 2012 28 May 2012 27 August 2012 16 December 2012 Accepted 16 December 2012
Department of Health Management & Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
Arash Rashidian Department of Health Management & Economics, Knowledge Utilization Research Center, Tehran University of Medical Sciences, Tehran, Iran
Abolghasem Pourreza, Maryam Tajvar, Roghayeh Khabiri Nemati and Ali Akbari Sari Department of Health Management & Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran, and
Abbas Rahimi Forooshani Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran Abstract Purpose – Valid and reliable measures are required for assessing patient satisfaction meaningfully. The purpose of this paper was to develop and validate a Persian-language in-patient satisfaction questionnaire for patients discharged from Iranian medical and surgical services. Design/methodology/approach – The cross-sectional survey included 400 patients randomly selected from six Tehran hospitals. A total of 405 patients responded to the questionnaire (76.3 percent response). To assess inter-item reliability and construct validity, factor analysis was carried out. Items belonging to each factor and their Cronbach’s alpha coefficient were calculated. Findings – A total of seven dimensions were identified: doctor-patient communication; nursing care; convenience; visitors; cleanliness; costs; and general satisfaction. Together, these dimensions explained 60 percent of the variance. All items, except three, revealed loadings above 0.4, while Cronbach’s alpha exceeded 0.8 for all dimensions, except visitors (0.66). Patient satisfaction levels were relatively high. Practical implications – Results must be interpreted cautiously owing to high satisfaction, which should not be considered as comprehensive evidence of high performance without important additional service-performance information. Qualitative studies are recommended to complement the authors’ quantitative satisfaction study. Originality/value – The patient satisfaction questionnaire strives to be a valid and reliable instrument for assessing in-patient satisfaction with hospital services in Iran.
International Journal of Health Care Quality Assurance Vol. 27 No. 1, 2014 pp. 4-14 q Emerald Group Publishing Limited 0952-6862 DOI 10.1108/IJHCQA-10-2011-0059
Keywords Reliability, Validity, Inpatient satisfaction, Questionnaire Paper type Research paper
This study was funded and supported by research council of Tehran University of Medical Sciences (TUMS); Grant no: 87.04.27.6813. The authors are thankful to Zahra Negahban and Elham Movahed for their valuable assistance in data collection.
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Introduction Patient satisfaction is among the most widely used outcome measures in health services research, demonstrated by the growing tools created to assess patient satisfaction in recent years. Some authors consider patient satisfaction to be the primary healthcare outcome (Donabedian, 1966; Gonzalez et al., 2005). Hospitals managers are increasingly implementing programs to improve patient satisfaction. Three fundamental realities appear to be driving this momentum. First, patient satisfaction can significantly affect staff reputation. Second, patient satisfaction has been accepted as an important service-quality measure (Kenagy et al., 1999). Third, physicians are paying greater attention to patient satisfaction because it is associated with patient compliance (Aragon et al., 2003), clinical outcomes (Pichert et al., 1998) and more recently the patient’s tendency to take legal action against clinicians (Aragon et al., 2003; Hickson et al., 2002). Existing research shows that satisfied patients are more likely to follow treatment instructions and medical advice, probably because they are more likely to believe that treatment will be effective (Hardy et al., 1996; Grogan et al., 2000). Several challenges are relevant to measuring patient satisfaction, including what to measure, how to measure and how valid the measurement is (Kenagy et al., 1999; Pichert et al., 1998). Nevertheless, several researchers have attempted to develop well-grounded instruments for measuring patient satisfaction (Hendriks et al., 2001; Salomon et al., 1999; Labarere et al., 2001; Gonzalez et al., 2005). However, those questionnaires are largely developed in countries that are culturally and socially different from Iran. Because of such explicit differences, any questionnaire’s applicability to Iran’s context may be challenged. Apart from patient satisfaction instruments developed outside Iran, there are a few locally-developed instruments. However, these tools have not been validated systematically. Therefore, we attempted to develop a new questionnaire by: reviewing existing national and international in-patient satisfaction questionnaires; using existing tools to develop a revised questionnaire; and assessing the questionnaire’s validity. The theoretical foundation of developing the patient satisfaction instrument in this research is the Williams (1994, p. 510) definition: “evaluation based on the fulfilment of expectations”. If this broad definition is accepted then it is possible to examine instrument validity: is it properly measuring what it intends to measure, i.e. service-evaluation by the patient? This would be the first reliable and valid inpatient satisfaction measure in Iran, which could also be adapted culturally to other Persian-speaking countries and used by staff in several general hospitals. Research question and method Developing the questionnaire We looked at several sources and the methods that researchers employed to determine the questions included in the questionnaire. Initially, an electronic search using Ovid Medline identified the instruments developed up to April 2009 to evaluate in-patient satisfaction at national and international levels. Keywords included “inpatient satisfaction questionnaire”, “hospital care”, “validity” and “reliability”. Two independent, experienced reviewers screened the article titles and abstracts to determine their eligibility. We then extracted relevant information from eligible articles sequentially. Discrepancies were resolved by consensus between the two reviewers after discussion. The first, draft questionnaire was drawn from reviewing existing in-patient satisfaction questionnaires and selecting relevant questions. This draft
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contained 46 questions. Then, interviews were carried out with hospitalized patients to elicit their comments about the positive and negative care-aspects they received during hospitalization. Further interviews were conducted with healthcare professionals to explore their opinions about the questionnaire. The interviews resulted in changes to question wording and seven more questions were added (including satisfaction with service costs and payment processes). This questionnaire was subsequently evaluated in a pilot study. We assessed questionnaire face validity by presenting it to 15 patients with different educational levels and evaluated item clarity and instrument features. Content validity was evaluated using six experts’ (university lecturers and healthcare professionals) opinions. They checked whether satisfaction was comprehensively covered in the questionnaire. Content validity was further enriched using relevant textbooks and academic sources. A pilot study led to further changes in the questionnaire, including rewording or removing some items. These changes were applied to questions that received low response rate, or where more than one option was selected by some patients. The final questionnaire contained two parts: socio-demographic variables including age, gender, educational level, marital status, employment status and medical insurance; and 52 questions representing all steps that a patient follows in a chronological order from hospital admission to discharge. These questions aimed to evaluate patient satisfaction within seven dimensions including: (1) doctor communication (13 items); (2) nursing care (six items); (3) convenience (17 items); (4) visitors (two items); (5) cleanliness (five items); (6) hospital expenditure (three items); and (7) general satisfaction (six items). The items were scored using a five-point Likert-type scale, ranging from strongly agree (1) to strongly disagree (5). Implementation We used the questionnaire in a survey to measure inpatient satisfaction. Six general teaching hospitals affiliated to the Tehran University of Medical Sciences (TUMS) were selected after the hospital chief and administrator agreed to this research. A total of 400 patients were selected using a proportional stratified random sampling approach. Our sampling frame was patients discharged from each hospital between November and December 2009. We used random number tables to select patients. Deciding sample sizes for each hospital was proportionate to their bed number to ensure adequate representation in the overall sample. Patients were included in the study if they had been in the hospitals for longer than 48 hours and were aged 15 years, and above. Surgical and medical ward patients were included, although patients with serious health conditions, such as terminal diseases or psychoses, identified as unable to complete the questionnaire, were excluded. The questionnaires were completed via face-to-face interviews at discharge from hospital by three fieldworkers who were selected based on their previous experience,
training and performance during training. Additionally, we attempted to ensure that interviewer characteristics, e.g. age and education, were as homogenous as possible to minimize interviewer bias. One check for interviewer bias during the fieldwork was that some interviews were repeated by a different fieldworker to check for consistency between the answers. However, interviewer bias can never be completely ruled-out owing to possible inconsistencies in the way questions are asked.
Persian satisfaction questionnaire
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7 Statistical analyses We used principal component, exploratory factor analysis (EFA) rather than confirmatory factor analysis (CFA) with Varimax rotation to assess construct validity and to determine the dimensions and items included within each dimension. We applied EFA rather than CFA because we had no a priori hypothesis to test whether construct measures are consistent with our understanding of the construct’s nature. If the EFA loadings were greater than 0.4 (Hair, 2009) then the factor loadings, communalities at the item level, Eigenvalues and explained variance at the scale level were calculated. Once each dimension was recognized, scores were calculated by adding the values attributed to the answers to all items in each dimension. The scoring scale for each dimension was set between 0 and 100, in which 100 indicated highest satisfaction. Domain reliability was evaluated using internal consistency. The t-test and one way ANOVA were used to assess relationships between patient demographics and their satisfaction with hospital services. Ethics Ethical approval came from the Tehran University of Medical Sciences (TUMS) Ethics Committee. The patients were informed about the study’s purpose and what was expected from them. The patients were assured about their rights to withdraw at any stage. Anonymity and confidentially were guaranteed. Findings Sample response Out of 400 patients, 305 responded (response rate ¼ 76.3 percent). No socio-demographic difference was observed between those who answered the questionnaire and those who did not. However, there was a difference in the hospital services; with a higher percentage admitted for surgery. Findings revealed that 64.3 percent of non-respondents were female (average age 42 þ 11). Most non-respondents were married (66 percent). Sample characteristics Most participants (68.5 percent) were female, married (69 percent) and held a degree ranging from high school education to diploma (34.4 percent). Housewives constituted the highest frequency (48.5 percent). Most participants had medical insurance (76 percent) and were referred by a physician (38.4 percent). Internal consistency Factor analysis loadings and internal consistencies in each domain are exhibited in Table I. Component coefficients matrix was used to evaluate each item’s importance and weight in assessing satisfaction. The findings proved that all 52 items studied can
Table I. Factor loadings and internal consistency results 0.75 0.70 0.69 0.68 0.67 0.67 0.66 0.61 0.52 0.46 0.45 0.38 0.64 0.62 0.60 0.58 0.57 0.52
Factor 2 Nursing care
0.64 0.63 0.62 0.60 0.59 0.58 0.58 0.56 0.53 0.52 0.52 0.48 0.48 0.47
Factor 3 Convenience
Factor 4 Visitors
Factor 5 Cleanliness
Factor 6 Costs
8
Doctors do their best Access to doctors Doctors’ explanation of the disease and treatment Doctors’ deal with patient Doctors’ use of simple and understandable words Doctors’ interest in patients’ questions Doctors’ experience and skills Education at discharge Doctors’ explanation of regime Killing time Patients’ opinion of visits by different doctors Patients’ opinion of visits by medical students Nurses’ education at discharge Nurses’ explanations are understandable Nurses’ interest in patients’ questions Nurses’ experience and skills Nurses’ care of patients Nurses’ empathy Patients’ clothes Space for religious acts Condition of the room Privacy during examination or tests Global assessment of the physical conditions Admission staff’s deal with patient Space for property of patient Para clinic staff’s deal with patient Sleep disturbance due to environmental conditions Diagnostic tests Visitors disturbed by staff Transfer to wards Quality of the food Global assessment of the physical
Factor 1 Doctor’s communication
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(continued)
Factor 7 General satisfaction
IJHCQA 27,1
Note: n ¼ 305
Delay in admission Complaint’s system Difficulty in hospitalization Visitors disturbed by staff Visiting hours, time the visitors spent in the room, and quantity of visitors Number of toilets and baths Bath cleanliness Toilet cleanliness Room cleanliness Patient clothes cleanliness Logical cost of services Cost-effective services Unaffordable services General satisfaction of the hospital General satisfaction of the wards Recommending the hospital to the others Interest in readmitting to the hospital Thinking about switching hospitals Satisfaction of treatment’s result
Factor 1 Doctor’s communication Factor 2 Nursing care 0.45 0.41 0.36
Factor 3 Convenience
0.36
0.37
Factor 4 Visitors
0.63 0.63 0.62 0.60 0.57
Factor 5 Cleanliness
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0.61 0.60 0.36
Factor 6 Costs
0.79 0.78 0.73 0.70 0.64 0.63
Factor 7 General satisfaction
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Table I.
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measure patient satisfaction in TUMS hospitals based on the 0.4 cut-off value. Only three items had slightly lower loadings. However, as we found them conceptually important, they were kept in the questionnaire. In Table I, the highest weight belongs to items 51 and 52 and the least importance and weight in items 37 and 13. Regarding internal consistency, Cronbach’s alpha coefficients were 0.8 for all domains except “visitors” (0.66), indicating good reliability (Table II), (Hair, 2009).
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10 Patients’ demographic characteristics and their overall satisfaction Table III demonstrates the relationship between patient demographics and their overall satisfaction with hospital services. A significant relationship was established between gender, educational level, age, employment status and hospital (general or specialty) from where patients were discharged and with their satisfaction level ( p , 0.01). There was no significant relationship between marital status, insurance and referral type, and satisfaction ( p . 0.05). Discussion Various methods were employed to develop the questions, including electronic medical searches, reviewing related literature, interviews with hospitalized patients and healthcare professionals; all somehow suggest the questionnaire is valid. Additionally, the instrument’s particular scope was in line with others (Rubin, 1990; Hendriks et al., Doctor-patient Nursing General communication care Convenience Visiting Cleanliness Costs satisfaction
Table II. Internal consistency coefficients and intra- and inter-scale correlations
Doctor’s communication Nursing care Convenience Visiting Cleanliness Costs General satisfaction
0.91 0.30 0.38 0.49 0.45
0.87 0.26 0.32 0.28
0.66 0.38 0.30
0.92 0.51
0.81
0.42
0.49
0.32
0.42
0.53
0.52
0.91
Note: Italicized numbers represent the Cronbach’s alpha coefficient
Variable
Table III. Relationship between demographic variables and overall satisfaction
0.88 0.35 0.29 0.30 0.35 0.33
Gender Various hospitals Marriage status Education Insurance type Referral type Age Employment status
Tests
p-value
t ¼ 0.165 F ¼ 13.93 t ¼ 1.05 F ¼ 7.73 F ¼ 1.35 F ¼ 2.42 F ¼ 5.96 F ¼ 4.14
0.02 , 0.001 0.056 , 0.001 0.23 0.06 0.001 0.003
Note: Analysis of variance (ANOVA) and Tukey’s test for multiple comparisons were used
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2001) indicating our questionnaire’s construct validity. The Crohnbach alphas were acceptable and the results were supported by what was obtained in other patient satisfaction questionnaires (Labarere et al., 2001; Carey and Seibert, 1993; Gonzalez et al., 2005). We explored patient satisfaction in TUMS hospitals. Cronbach alpha coefficients in all areas were high, except for visitors (0.66), despite only two items, which suggested a high consistency between items (Table II). These results are largely consistent with other studies (e.g. Gonzalez et al., 2005) confirming the study’s internal reliability. Nevertheless, the results show that some questions and domains still merit improvement and thus some other psychometric properties have to be checked. Two domains (i.e. visitors and cleanliness) had high ceiling effects and low Cronbach’s alpha, so both need further study to improve their psychometric properties. Perhaps one reason for a relatively lower coefficient for the visitor domain was that, according to the authors’ experiences, public hospital staff do not deal well with visitors. Since doctor-patient communication and nursing care play central roles in improving and restoring patients’ health, these domains attract patients’ attention. Findings showed that satisfaction with these domains was considerable. Dissatisfaction with ward facilities and cleanliness was extensive. Since satisfaction with nutrition and laundry services can affect hospital accreditation, hospital managers should take effective steps to improve these services, which may lead to more satisfied customers and improve hospital staff reputation. Several studies have been carried out dealing with inpatient satisfaction measurement. But the first question is whether patient satisfaction is a valid concept? In other words, whether high patient satisfaction signifies high-quality services (Williams, 1994). When a patient is referred to a health service, he/she has expectations. While at the center, patients are likely to evaluate all workers and their behavior and might ultimately announce their satisfaction or dissatisfaction with them. But the Zastowny et al. (1998) study showed that patients’ expectations only justified around 10 percent of the variance in their satisfaction, so the satisfaction seemed not to be affected by expectations; there are many other factors, not all known, which might influence patient satisfaction. These observations, therefore, point to the difficulty interpreting questionnaire-based satisfaction studies. Studies indicate that quantitative questionnaire results show greater satisfaction compared to qualitative ones. Hopkins et al. cited in Williams, 1994) argue that people mostly tend to show their dissatisfaction in a qualitative form and are reluctant to describe that in a scale format such as quite satisfied, some satisfied, I have no idea, quite unsatisfied, etc. Despite these limitations, Ware (1995) reviewed 45 articles and concluded that patient satisfaction was a suitable indicator for estimating service quality. Satisfaction studies usually focus on a specific healthcare setting such as a hospital and consider both medical and non-medical aspects. As such, these studies may reflect complex, perceived needs, expectations and experience (Kavosi et al., 2011). When patients express their satisfaction, it might indicate three different statuses (Williams, 1994): (1) I evaluated this service aspect and it fully conformed to my demands. (2) I do not think that I have the ability to evaluate the services. But I have full confidence in medical staff.
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(3) Healthcare delivery did not meet my expectations, but I do not want to criticize them because I think they are doing their best. As such, satisfaction studies should be interpreted with care. In Table III, there were significant relationships between gender, hospital, educational level, age and employment status with patient satisfaction ( p , 0.01). These findings are seemingly consistent with similar studies conducted in this area (e.g. Quintana et al., 2006; McKinley, 2001). In fact, more experienced, better informed and educated patients often expressed less satisfaction. This is not always significant and involves some interfering variables such as expectations and entitlement, and might also interact with ethnicity as a demographic variable (Lewis, 1994). Similarly, a study conducted by Garroute et al. (2004) that evaluated hospital satisfaction among American Indian patients found a significant relationship between satisfaction and the patient’s character. The current study suggests that dissatisfaction is low, e.g. dissatisfaction with doctors and nurses were about 14.9 percent and 10.3 percent, respectively. The results somehow imply that patients are satisfied with hospital services. This finding should be interpreted with care. Given the patients’ social and cultural background, their satisfaction might be at least in part due to information asymmetry and poor knowledge about the patients’ rights charter. These may lead to lower expectations among patients. Therefore, it could be argued that some educational intervention to notify patients of their rights and raising their expectations might lead to different results in user dissatisfaction with hospital services studies. As an example, Griffin Hospital staff in the USA performed an educational intervention to raise patients’ expectations and make them familiar with the Charter of Rights (GHO, 2004). They observed that dissatisfaction increased after the educational intervention. Two further reasons might explain patient satisfaction. First, it may be due to social desirability bias, which is explained by individuals responding in a way which they think is socially acceptable. This bias may cause individuals to over-report their satisfaction levels (Sjostrom and Holst, 2002). Second, courtesy, which is related to social desirability, implies that patients and other social groups have a tendency to give answers that they believe the interviewer wants to hear, rather than what they really feel (Glick, 2009). After all, high-quality service should be present in hospitals, which could improve clinical outcomes and patient satisfaction while reducing cost, and ultimately create competitive advantage for staff (Kenagy et al., 1999). The current study has some limitations. One was related to the data-collection time period. Seasonal factors or vacation periods could determine the pathologies presented in the hospitals and consequently the workload for hospital workers. This might affect patients’ assessments. It might be advisable, therefore, to carry out satisfaction surveys at different times of a year. Future studies should aim to identify other variables that might improve the questionnaire in capturing patient satisfaction. We recommend that this scale should be further evaluated in studies involving larger sample sizes comprising people from other Iranian regions. Implications for research and practice Our questionnaire, designed to measure patient satisfaction, has shown statistically acceptable reliability and validity, making it a strong tool to be used in similar studies
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in similar contexts. Evaluating inpatient satisfaction in healthcare organizations, using this multi-dimensional questionnaire appears to improve healthcare. However, the results must be interpreted with caution owing to our high satisfaction scores and should not be considered as a comprehensive evidence of high service performance. It is advisable to use a qualitative study to complement such studies. Given that the current questionnaire was developed using Iranian patient and experts’ opinions, questionnaire items are culturally important. This is because the items that are culturally important and appropriate were emphasized by patients and experts in the interviews. However, different regions may have different cultural and social norms and patients discharged from Tehran hospitals may not fully represent those discharged from hospitals in other cities. This questionnaire should be further scrutinized by researchers to improve its applicability as a standard tool for measuring patient satisfaction in Iran hospitals. References Aragon, S.J. and Gesell, S.B. (2003), “Patient satisfaction theory and robustness across gender in emergency departments”, American Journal of Medical Quality, Vol. 18 No. 6, pp. 229-241. Carey, R.G. and Seibert, J.H. (1993), “A patient survey system to measure quality improvement: questionnaire reliability and validity”, Medical Care, Vol. 31 No. 9, pp. 834-845. Donabedian, A. (1966), “Evaluating the quality of medical care”, Milbank Memorial Fund Quarterly Journal, Vol. 44 No. 3, pp. 166-203. Garroute, E. and Robert, M. (2004), “Patient satisfaction and ethane identity about American Indian older adults”, American Journal of Psychiatry, Vol. 59 No. 3, pp. 1-3. GHO (2004), available at: www.griffinhealth.org/PatientVisitor/Default.aspx (accessed October 2010). Glick, P. (2009), “How reliable are surveys of client satisfaction with healthcare services? Evidence from matched facility and household data in Madagascar”, Social Science and Medicine, Vol. 68 No. 2, pp. 368-379. Gonzalez, N., Quintavna, J.M., Bilbao, A., Escobar, A. and Aizpuru, F. (2005), “Development and validation of an in-patient satisfaction questionnaire”, Quality in Health Care, Vol. 17 No. 6, pp. 465-472. Grogan, S., Conner, M., Norman, P., Willits, D. and Porter, I. (2000), “Validation of a questionnaire measuring patient satisfaction with general practitioner services”, Quality in Health Care, Vol. 9 No. 4, pp. 210-215. Hair, G.F., Black, B., Babin, B., Anderson, R.E. and Tatham, R.L. (2009), Multivariate Data Analysis, 6th ed., Pearson, Upper Saddle River, NJ. Hardy, G.E., West, M.A. and Hill, F. (1996), “Components and predictors of patient satisfaction”, British Journal of Health Psychology, Vol. 1, pp. 65-85. Hendriks, A.A., Vrielink, M.R., Smets, E.M., van Es, S.Q. and De Haes, J.C. (2001), “Improving the assessment of (in) patients’ satisfaction with hospital care”, Medical Care, Vol. 39 No. 3, pp. 270-283. Hickson, G.B., Federspiel, C.F. and Pichert, J.W. (2002), “Patient complaints and malpractice risk”, Journal of the American Medical Association, Vol. 287 No. 22, pp. 2951-2957. Kavosi, Z., Rashidian, A., Majdzadeh, R., Pourmalek, F., Pourreza, A., Arab, M. and Mohammad, K. (2011), “Assessing health system responsiveness: a household survey in 17th district of Tehran”, Iranian Red Crescent Medical Journal, Vol. 13 No. 5, pp. 302-308.
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Kenagy, J.W., Berwick, D.M. and Shore, M.F. (1999), “Service quality in health care”, Journal of the American Medical Association, Vol. 281 No. 7, pp. 661-665. Labarere, J., Francois, P., Auquier, P., Robert, C. and Fourny, M. (2001), “Development of a French inpatient satisfaction questionnaire”, Quality in Health Care, Vol. 13 No. 2, pp. 99-108. Lewis, J.R. (1994), “Patient views on quality care in general practice: literature review”, Social Science and Medicine, Vol. 39 No. 5, pp. 655-670. McKinley, R. and Roberts, C. (2001), “Patient satisfaction with out of hours primary medical care”, Quality in Health Care, Vol. 10 No. 1, pp. 23-28. Pichert, J.W., Miller, C.S. and Hollo, A.H. (1998), “What health professionals can do to identify and resolve patient dissatisfaction”, Joint Community Journal of Quality Improvement, Vol. 24 No. 6, pp. 303-312. Quintana, J.M., Gonzalez, N., Bilbao, A. and Aizpuru, F. (2006), “Predictors of patient satisfaction with hospital health care”, BMC Health Services Research, Vol. 6 No. 102, pp. 1-9. Rubin, H.R. (1990), “Can patients evaluate the quality of hospital care?”, Medical Care Review, Vol. 47 No. 3, pp. 267-326. Salomon, L., Gasquet, I., Mesbah, M. and Ravaud, P. (1999), “Construction of a scale measuring inpatients’ opinion on quality of care”, Quality in Health Care, Vol. 11 No. 6, pp. 507-516. Sjostrom, O. and Holst, D. (2002), “Validity of a questionnaire survey: response patterns in different subgroups and the effect of social desirability”, Acta Odontologica Scandinavica, Vol. 60 No. 3, pp. 136-140. Ware, J.E. (1995), “What information do consumers want and how will they use it?”, Medical Care, Vol. 33 No. 1, pp. 25-30. Williams, B. (1994), “Patient satisfaction: a valid concept?”, Social Science and Medicine, Vol. 38 No. 4, pp. 509-516. Zastony, T.R., Roghmann, K.J. and Cafferata, G.L. (1998), “Patient satisfaction and health services”, Medical Care, Vol. 27 No. 5, pp. 522-534. Corresponding author Roghayeh Khabiri Nemati can be contacted at: [email protected]
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Article information: To cite this document: Mohammad Arab Arash Rashidian Abolghasem Pourreza Maryam Tajvar Roghayeh Khabiri Nemati Ali Akbari Sari Abbas Rahimi Forooshani , (2014),"Developing a Persian inpatient satisfaction questionnaire", International Journal of Health Care Quality Assurance, Vol. 27 Iss 1 pp. 4 - 14 Permanent link to this document: http://dx.doi.org/10.1108/IJHCQA-10-2011-0059 Downloaded on: 30 January 2016, At: 10:07 (PT) References: this document contains references to 25 other documents. To copy this document: [email protected] The fulltext of this document has been downloaded 629 times since 2014*
Users who downloaded this article also downloaded: Jenny Rowley, (2014),"Designing and using research questionnaires", Management Research Review, Vol. 37 Iss 3 pp. 308-330 http://dx.doi.org/10.1108/MRR-02-2013-0027 Nicolaos E. Synodinos, (2003),"The “art” of questionnaire construction: some important considerations for manufacturing studies", Integrated Manufacturing Systems, Vol. 14 Iss 3 pp. 221-237 http://dx.doi.org/10.1108/09576060310463172 Simon C.H. Chan, Wai-ming Mak, (2010),"The use of Learning Styles Questionnaire in Macao", Industrial and Commercial Training, Vol. 42 Iss 1 pp. 41-46 http://dx.doi.org/10.1108/00197851011013706
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About Emerald www.emeraldinsight.com Emerald is a global publisher linking research and practice to the benefit of society. The company manages a portfolio of more than 290 journals and over 2,350 books and book series volumes, as well as providing an extensive range of online products and additional customer resources and services. Emerald is both COUNTER 4 and TRANSFER compliant. The organization is a partner of the Committee on Publication Ethics (COPE) and also works with Portico and the LOCKSS initiative for digital archive preservation. *Related content and download information correct at time of download.
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IJHCQA 27,1
Developing a Persian inpatient satisfaction questionnaire Mohammad Arab
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4 Received 18 October 2011 Revised 17 January 2012 28 May 2012 27 August 2012 16 December 2012 Accepted 16 December 2012
Department of Health Management & Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
Arash Rashidian Department of Health Management & Economics, Knowledge Utilization Research Center, Tehran University of Medical Sciences, Tehran, Iran
Abolghasem Pourreza, Maryam Tajvar, Roghayeh Khabiri Nemati and Ali Akbari Sari Department of Health Management & Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran, and
Abbas Rahimi Forooshani Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran Abstract Purpose – Valid and reliable measures are required for assessing patient satisfaction meaningfully. The purpose of this paper was to develop and validate a Persian-language in-patient satisfaction questionnaire for patients discharged from Iranian medical and surgical services. Design/methodology/approach – The cross-sectional survey included 400 patients randomly selected from six Tehran hospitals. A total of 405 patients responded to the questionnaire (76.3 percent response). To assess inter-item reliability and construct validity, factor analysis was carried out. Items belonging to each factor and their Cronbach’s alpha coefficient were calculated. Findings – A total of seven dimensions were identified: doctor-patient communication; nursing care; convenience; visitors; cleanliness; costs; and general satisfaction. Together, these dimensions explained 60 percent of the variance. All items, except three, revealed loadings above 0.4, while Cronbach’s alpha exceeded 0.8 for all dimensions, except visitors (0.66). Patient satisfaction levels were relatively high. Practical implications – Results must be interpreted cautiously owing to high satisfaction, which should not be considered as comprehensive evidence of high performance without important additional service-performance information. Qualitative studies are recommended to complement the authors’ quantitative satisfaction study. Originality/value – The patient satisfaction questionnaire strives to be a valid and reliable instrument for assessing in-patient satisfaction with hospital services in Iran.
International Journal of Health Care Quality Assurance Vol. 27 No. 1, 2014 pp. 4-14 q Emerald Group Publishing Limited 0952-6862 DOI 10.1108/IJHCQA-10-2011-0059
Keywords Reliability, Validity, Inpatient satisfaction, Questionnaire Paper type Research paper
This study was funded and supported by research council of Tehran University of Medical Sciences (TUMS); Grant no: 87.04.27.6813. The authors are thankful to Zahra Negahban and Elham Movahed for their valuable assistance in data collection.
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Introduction Patient satisfaction is among the most widely used outcome measures in health services research, demonstrated by the growing tools created to assess patient satisfaction in recent years. Some authors consider patient satisfaction to be the primary healthcare outcome (Donabedian, 1966; Gonzalez et al., 2005). Hospitals managers are increasingly implementing programs to improve patient satisfaction. Three fundamental realities appear to be driving this momentum. First, patient satisfaction can significantly affect staff reputation. Second, patient satisfaction has been accepted as an important service-quality measure (Kenagy et al., 1999). Third, physicians are paying greater attention to patient satisfaction because it is associated with patient compliance (Aragon et al., 2003), clinical outcomes (Pichert et al., 1998) and more recently the patient’s tendency to take legal action against clinicians (Aragon et al., 2003; Hickson et al., 2002). Existing research shows that satisfied patients are more likely to follow treatment instructions and medical advice, probably because they are more likely to believe that treatment will be effective (Hardy et al., 1996; Grogan et al., 2000). Several challenges are relevant to measuring patient satisfaction, including what to measure, how to measure and how valid the measurement is (Kenagy et al., 1999; Pichert et al., 1998). Nevertheless, several researchers have attempted to develop well-grounded instruments for measuring patient satisfaction (Hendriks et al., 2001; Salomon et al., 1999; Labarere et al., 2001; Gonzalez et al., 2005). However, those questionnaires are largely developed in countries that are culturally and socially different from Iran. Because of such explicit differences, any questionnaire’s applicability to Iran’s context may be challenged. Apart from patient satisfaction instruments developed outside Iran, there are a few locally-developed instruments. However, these tools have not been validated systematically. Therefore, we attempted to develop a new questionnaire by: reviewing existing national and international in-patient satisfaction questionnaires; using existing tools to develop a revised questionnaire; and assessing the questionnaire’s validity. The theoretical foundation of developing the patient satisfaction instrument in this research is the Williams (1994, p. 510) definition: “evaluation based on the fulfilment of expectations”. If this broad definition is accepted then it is possible to examine instrument validity: is it properly measuring what it intends to measure, i.e. service-evaluation by the patient? This would be the first reliable and valid inpatient satisfaction measure in Iran, which could also be adapted culturally to other Persian-speaking countries and used by staff in several general hospitals. Research question and method Developing the questionnaire We looked at several sources and the methods that researchers employed to determine the questions included in the questionnaire. Initially, an electronic search using Ovid Medline identified the instruments developed up to April 2009 to evaluate in-patient satisfaction at national and international levels. Keywords included “inpatient satisfaction questionnaire”, “hospital care”, “validity” and “reliability”. Two independent, experienced reviewers screened the article titles and abstracts to determine their eligibility. We then extracted relevant information from eligible articles sequentially. Discrepancies were resolved by consensus between the two reviewers after discussion. The first, draft questionnaire was drawn from reviewing existing in-patient satisfaction questionnaires and selecting relevant questions. This draft
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contained 46 questions. Then, interviews were carried out with hospitalized patients to elicit their comments about the positive and negative care-aspects they received during hospitalization. Further interviews were conducted with healthcare professionals to explore their opinions about the questionnaire. The interviews resulted in changes to question wording and seven more questions were added (including satisfaction with service costs and payment processes). This questionnaire was subsequently evaluated in a pilot study. We assessed questionnaire face validity by presenting it to 15 patients with different educational levels and evaluated item clarity and instrument features. Content validity was evaluated using six experts’ (university lecturers and healthcare professionals) opinions. They checked whether satisfaction was comprehensively covered in the questionnaire. Content validity was further enriched using relevant textbooks and academic sources. A pilot study led to further changes in the questionnaire, including rewording or removing some items. These changes were applied to questions that received low response rate, or where more than one option was selected by some patients. The final questionnaire contained two parts: socio-demographic variables including age, gender, educational level, marital status, employment status and medical insurance; and 52 questions representing all steps that a patient follows in a chronological order from hospital admission to discharge. These questions aimed to evaluate patient satisfaction within seven dimensions including: (1) doctor communication (13 items); (2) nursing care (six items); (3) convenience (17 items); (4) visitors (two items); (5) cleanliness (five items); (6) hospital expenditure (three items); and (7) general satisfaction (six items). The items were scored using a five-point Likert-type scale, ranging from strongly agree (1) to strongly disagree (5). Implementation We used the questionnaire in a survey to measure inpatient satisfaction. Six general teaching hospitals affiliated to the Tehran University of Medical Sciences (TUMS) were selected after the hospital chief and administrator agreed to this research. A total of 400 patients were selected using a proportional stratified random sampling approach. Our sampling frame was patients discharged from each hospital between November and December 2009. We used random number tables to select patients. Deciding sample sizes for each hospital was proportionate to their bed number to ensure adequate representation in the overall sample. Patients were included in the study if they had been in the hospitals for longer than 48 hours and were aged 15 years, and above. Surgical and medical ward patients were included, although patients with serious health conditions, such as terminal diseases or psychoses, identified as unable to complete the questionnaire, were excluded. The questionnaires were completed via face-to-face interviews at discharge from hospital by three fieldworkers who were selected based on their previous experience,
training and performance during training. Additionally, we attempted to ensure that interviewer characteristics, e.g. age and education, were as homogenous as possible to minimize interviewer bias. One check for interviewer bias during the fieldwork was that some interviews were repeated by a different fieldworker to check for consistency between the answers. However, interviewer bias can never be completely ruled-out owing to possible inconsistencies in the way questions are asked.
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7 Statistical analyses We used principal component, exploratory factor analysis (EFA) rather than confirmatory factor analysis (CFA) with Varimax rotation to assess construct validity and to determine the dimensions and items included within each dimension. We applied EFA rather than CFA because we had no a priori hypothesis to test whether construct measures are consistent with our understanding of the construct’s nature. If the EFA loadings were greater than 0.4 (Hair, 2009) then the factor loadings, communalities at the item level, Eigenvalues and explained variance at the scale level were calculated. Once each dimension was recognized, scores were calculated by adding the values attributed to the answers to all items in each dimension. The scoring scale for each dimension was set between 0 and 100, in which 100 indicated highest satisfaction. Domain reliability was evaluated using internal consistency. The t-test and one way ANOVA were used to assess relationships between patient demographics and their satisfaction with hospital services. Ethics Ethical approval came from the Tehran University of Medical Sciences (TUMS) Ethics Committee. The patients were informed about the study’s purpose and what was expected from them. The patients were assured about their rights to withdraw at any stage. Anonymity and confidentially were guaranteed. Findings Sample response Out of 400 patients, 305 responded (response rate ¼ 76.3 percent). No socio-demographic difference was observed between those who answered the questionnaire and those who did not. However, there was a difference in the hospital services; with a higher percentage admitted for surgery. Findings revealed that 64.3 percent of non-respondents were female (average age 42 þ 11). Most non-respondents were married (66 percent). Sample characteristics Most participants (68.5 percent) were female, married (69 percent) and held a degree ranging from high school education to diploma (34.4 percent). Housewives constituted the highest frequency (48.5 percent). Most participants had medical insurance (76 percent) and were referred by a physician (38.4 percent). Internal consistency Factor analysis loadings and internal consistencies in each domain are exhibited in Table I. Component coefficients matrix was used to evaluate each item’s importance and weight in assessing satisfaction. The findings proved that all 52 items studied can
Table I. Factor loadings and internal consistency results 0.75 0.70 0.69 0.68 0.67 0.67 0.66 0.61 0.52 0.46 0.45 0.38 0.64 0.62 0.60 0.58 0.57 0.52
Factor 2 Nursing care
0.64 0.63 0.62 0.60 0.59 0.58 0.58 0.56 0.53 0.52 0.52 0.48 0.48 0.47
Factor 3 Convenience
Factor 4 Visitors
Factor 5 Cleanliness
Factor 6 Costs
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Doctors do their best Access to doctors Doctors’ explanation of the disease and treatment Doctors’ deal with patient Doctors’ use of simple and understandable words Doctors’ interest in patients’ questions Doctors’ experience and skills Education at discharge Doctors’ explanation of regime Killing time Patients’ opinion of visits by different doctors Patients’ opinion of visits by medical students Nurses’ education at discharge Nurses’ explanations are understandable Nurses’ interest in patients’ questions Nurses’ experience and skills Nurses’ care of patients Nurses’ empathy Patients’ clothes Space for religious acts Condition of the room Privacy during examination or tests Global assessment of the physical conditions Admission staff’s deal with patient Space for property of patient Para clinic staff’s deal with patient Sleep disturbance due to environmental conditions Diagnostic tests Visitors disturbed by staff Transfer to wards Quality of the food Global assessment of the physical
Factor 1 Doctor’s communication
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(continued)
Factor 7 General satisfaction
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Note: n ¼ 305
Delay in admission Complaint’s system Difficulty in hospitalization Visitors disturbed by staff Visiting hours, time the visitors spent in the room, and quantity of visitors Number of toilets and baths Bath cleanliness Toilet cleanliness Room cleanliness Patient clothes cleanliness Logical cost of services Cost-effective services Unaffordable services General satisfaction of the hospital General satisfaction of the wards Recommending the hospital to the others Interest in readmitting to the hospital Thinking about switching hospitals Satisfaction of treatment’s result
Factor 1 Doctor’s communication Factor 2 Nursing care 0.45 0.41 0.36
Factor 3 Convenience
0.36
0.37
Factor 4 Visitors
0.63 0.63 0.62 0.60 0.57
Factor 5 Cleanliness
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0.61 0.60 0.36
Factor 6 Costs
0.79 0.78 0.73 0.70 0.64 0.63
Factor 7 General satisfaction
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Table I.
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measure patient satisfaction in TUMS hospitals based on the 0.4 cut-off value. Only three items had slightly lower loadings. However, as we found them conceptually important, they were kept in the questionnaire. In Table I, the highest weight belongs to items 51 and 52 and the least importance and weight in items 37 and 13. Regarding internal consistency, Cronbach’s alpha coefficients were 0.8 for all domains except “visitors” (0.66), indicating good reliability (Table II), (Hair, 2009).
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10 Patients’ demographic characteristics and their overall satisfaction Table III demonstrates the relationship between patient demographics and their overall satisfaction with hospital services. A significant relationship was established between gender, educational level, age, employment status and hospital (general or specialty) from where patients were discharged and with their satisfaction level ( p , 0.01). There was no significant relationship between marital status, insurance and referral type, and satisfaction ( p . 0.05). Discussion Various methods were employed to develop the questions, including electronic medical searches, reviewing related literature, interviews with hospitalized patients and healthcare professionals; all somehow suggest the questionnaire is valid. Additionally, the instrument’s particular scope was in line with others (Rubin, 1990; Hendriks et al., Doctor-patient Nursing General communication care Convenience Visiting Cleanliness Costs satisfaction
Table II. Internal consistency coefficients and intra- and inter-scale correlations
Doctor’s communication Nursing care Convenience Visiting Cleanliness Costs General satisfaction
0.91 0.30 0.38 0.49 0.45
0.87 0.26 0.32 0.28
0.66 0.38 0.30
0.92 0.51
0.81
0.42
0.49
0.32
0.42
0.53
0.52
0.91
Note: Italicized numbers represent the Cronbach’s alpha coefficient
Variable
Table III. Relationship between demographic variables and overall satisfaction
0.88 0.35 0.29 0.30 0.35 0.33
Gender Various hospitals Marriage status Education Insurance type Referral type Age Employment status
Tests
p-value
t ¼ 0.165 F ¼ 13.93 t ¼ 1.05 F ¼ 7.73 F ¼ 1.35 F ¼ 2.42 F ¼ 5.96 F ¼ 4.14
0.02 , 0.001 0.056 , 0.001 0.23 0.06 0.001 0.003
Note: Analysis of variance (ANOVA) and Tukey’s test for multiple comparisons were used
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2001) indicating our questionnaire’s construct validity. The Crohnbach alphas were acceptable and the results were supported by what was obtained in other patient satisfaction questionnaires (Labarere et al., 2001; Carey and Seibert, 1993; Gonzalez et al., 2005). We explored patient satisfaction in TUMS hospitals. Cronbach alpha coefficients in all areas were high, except for visitors (0.66), despite only two items, which suggested a high consistency between items (Table II). These results are largely consistent with other studies (e.g. Gonzalez et al., 2005) confirming the study’s internal reliability. Nevertheless, the results show that some questions and domains still merit improvement and thus some other psychometric properties have to be checked. Two domains (i.e. visitors and cleanliness) had high ceiling effects and low Cronbach’s alpha, so both need further study to improve their psychometric properties. Perhaps one reason for a relatively lower coefficient for the visitor domain was that, according to the authors’ experiences, public hospital staff do not deal well with visitors. Since doctor-patient communication and nursing care play central roles in improving and restoring patients’ health, these domains attract patients’ attention. Findings showed that satisfaction with these domains was considerable. Dissatisfaction with ward facilities and cleanliness was extensive. Since satisfaction with nutrition and laundry services can affect hospital accreditation, hospital managers should take effective steps to improve these services, which may lead to more satisfied customers and improve hospital staff reputation. Several studies have been carried out dealing with inpatient satisfaction measurement. But the first question is whether patient satisfaction is a valid concept? In other words, whether high patient satisfaction signifies high-quality services (Williams, 1994). When a patient is referred to a health service, he/she has expectations. While at the center, patients are likely to evaluate all workers and their behavior and might ultimately announce their satisfaction or dissatisfaction with them. But the Zastowny et al. (1998) study showed that patients’ expectations only justified around 10 percent of the variance in their satisfaction, so the satisfaction seemed not to be affected by expectations; there are many other factors, not all known, which might influence patient satisfaction. These observations, therefore, point to the difficulty interpreting questionnaire-based satisfaction studies. Studies indicate that quantitative questionnaire results show greater satisfaction compared to qualitative ones. Hopkins et al. cited in Williams, 1994) argue that people mostly tend to show their dissatisfaction in a qualitative form and are reluctant to describe that in a scale format such as quite satisfied, some satisfied, I have no idea, quite unsatisfied, etc. Despite these limitations, Ware (1995) reviewed 45 articles and concluded that patient satisfaction was a suitable indicator for estimating service quality. Satisfaction studies usually focus on a specific healthcare setting such as a hospital and consider both medical and non-medical aspects. As such, these studies may reflect complex, perceived needs, expectations and experience (Kavosi et al., 2011). When patients express their satisfaction, it might indicate three different statuses (Williams, 1994): (1) I evaluated this service aspect and it fully conformed to my demands. (2) I do not think that I have the ability to evaluate the services. But I have full confidence in medical staff.
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(3) Healthcare delivery did not meet my expectations, but I do not want to criticize them because I think they are doing their best. As such, satisfaction studies should be interpreted with care. In Table III, there were significant relationships between gender, hospital, educational level, age and employment status with patient satisfaction ( p , 0.01). These findings are seemingly consistent with similar studies conducted in this area (e.g. Quintana et al., 2006; McKinley, 2001). In fact, more experienced, better informed and educated patients often expressed less satisfaction. This is not always significant and involves some interfering variables such as expectations and entitlement, and might also interact with ethnicity as a demographic variable (Lewis, 1994). Similarly, a study conducted by Garroute et al. (2004) that evaluated hospital satisfaction among American Indian patients found a significant relationship between satisfaction and the patient’s character. The current study suggests that dissatisfaction is low, e.g. dissatisfaction with doctors and nurses were about 14.9 percent and 10.3 percent, respectively. The results somehow imply that patients are satisfied with hospital services. This finding should be interpreted with care. Given the patients’ social and cultural background, their satisfaction might be at least in part due to information asymmetry and poor knowledge about the patients’ rights charter. These may lead to lower expectations among patients. Therefore, it could be argued that some educational intervention to notify patients of their rights and raising their expectations might lead to different results in user dissatisfaction with hospital services studies. As an example, Griffin Hospital staff in the USA performed an educational intervention to raise patients’ expectations and make them familiar with the Charter of Rights (GHO, 2004). They observed that dissatisfaction increased after the educational intervention. Two further reasons might explain patient satisfaction. First, it may be due to social desirability bias, which is explained by individuals responding in a way which they think is socially acceptable. This bias may cause individuals to over-report their satisfaction levels (Sjostrom and Holst, 2002). Second, courtesy, which is related to social desirability, implies that patients and other social groups have a tendency to give answers that they believe the interviewer wants to hear, rather than what they really feel (Glick, 2009). After all, high-quality service should be present in hospitals, which could improve clinical outcomes and patient satisfaction while reducing cost, and ultimately create competitive advantage for staff (Kenagy et al., 1999). The current study has some limitations. One was related to the data-collection time period. Seasonal factors or vacation periods could determine the pathologies presented in the hospitals and consequently the workload for hospital workers. This might affect patients’ assessments. It might be advisable, therefore, to carry out satisfaction surveys at different times of a year. Future studies should aim to identify other variables that might improve the questionnaire in capturing patient satisfaction. We recommend that this scale should be further evaluated in studies involving larger sample sizes comprising people from other Iranian regions. Implications for research and practice Our questionnaire, designed to measure patient satisfaction, has shown statistically acceptable reliability and validity, making it a strong tool to be used in similar studies
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in similar contexts. Evaluating inpatient satisfaction in healthcare organizations, using this multi-dimensional questionnaire appears to improve healthcare. However, the results must be interpreted with caution owing to our high satisfaction scores and should not be considered as a comprehensive evidence of high service performance. It is advisable to use a qualitative study to complement such studies. Given that the current questionnaire was developed using Iranian patient and experts’ opinions, questionnaire items are culturally important. This is because the items that are culturally important and appropriate were emphasized by patients and experts in the interviews. However, different regions may have different cultural and social norms and patients discharged from Tehran hospitals may not fully represent those discharged from hospitals in other cities. This questionnaire should be further scrutinized by researchers to improve its applicability as a standard tool for measuring patient satisfaction in Iran hospitals. References Aragon, S.J. and Gesell, S.B. (2003), “Patient satisfaction theory and robustness across gender in emergency departments”, American Journal of Medical Quality, Vol. 18 No. 6, pp. 229-241. Carey, R.G. and Seibert, J.H. (1993), “A patient survey system to measure quality improvement: questionnaire reliability and validity”, Medical Care, Vol. 31 No. 9, pp. 834-845. Donabedian, A. (1966), “Evaluating the quality of medical care”, Milbank Memorial Fund Quarterly Journal, Vol. 44 No. 3, pp. 166-203. Garroute, E. and Robert, M. (2004), “Patient satisfaction and ethane identity about American Indian older adults”, American Journal of Psychiatry, Vol. 59 No. 3, pp. 1-3. GHO (2004), available at: www.griffinhealth.org/PatientVisitor/Default.aspx (accessed October 2010). Glick, P. (2009), “How reliable are surveys of client satisfaction with healthcare services? Evidence from matched facility and household data in Madagascar”, Social Science and Medicine, Vol. 68 No. 2, pp. 368-379. Gonzalez, N., Quintavna, J.M., Bilbao, A., Escobar, A. and Aizpuru, F. (2005), “Development and validation of an in-patient satisfaction questionnaire”, Quality in Health Care, Vol. 17 No. 6, pp. 465-472. Grogan, S., Conner, M., Norman, P., Willits, D. and Porter, I. (2000), “Validation of a questionnaire measuring patient satisfaction with general practitioner services”, Quality in Health Care, Vol. 9 No. 4, pp. 210-215. Hair, G.F., Black, B., Babin, B., Anderson, R.E. and Tatham, R.L. (2009), Multivariate Data Analysis, 6th ed., Pearson, Upper Saddle River, NJ. Hardy, G.E., West, M.A. and Hill, F. (1996), “Components and predictors of patient satisfaction”, British Journal of Health Psychology, Vol. 1, pp. 65-85. Hendriks, A.A., Vrielink, M.R., Smets, E.M., van Es, S.Q. and De Haes, J.C. (2001), “Improving the assessment of (in) patients’ satisfaction with hospital care”, Medical Care, Vol. 39 No. 3, pp. 270-283. Hickson, G.B., Federspiel, C.F. and Pichert, J.W. (2002), “Patient complaints and malpractice risk”, Journal of the American Medical Association, Vol. 287 No. 22, pp. 2951-2957. Kavosi, Z., Rashidian, A., Majdzadeh, R., Pourmalek, F., Pourreza, A., Arab, M. and Mohammad, K. (2011), “Assessing health system responsiveness: a household survey in 17th district of Tehran”, Iranian Red Crescent Medical Journal, Vol. 13 No. 5, pp. 302-308.
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