Quality Assurance m Health Care, Vol. 3, No. 3, pp. 183-189, 1991 Printed in Great Britain.

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PATIENT SATISFACTION—DOES IT MATTER? Hannu Vuori Chief/Epidemiology, Statistics and Research WHO, Regional Office for Europe 8, Scherfigsvej DK-2100 Copenhagen Denmark {First submitted 1 June 1991; accepted 17 June 1991) The paper aims at answering the question: Has the measurement of patient satisfaction improved the quality of care? After concluding that there is no evidence in the literature, the paper proceeds to look at why the evidence is lacking. Four factors seem to explain it: the objectives, the focus and the originator of the patients satisfaction studies and measurements and difficulties related to the interpretation of the findings. The last part of the paper analyses why patient satisfaction should be taken seriously although we do not know whether its measurement improves the quality of care. They include the fact that the patients are partners in health care; they literally feel in their skin whether care is good or bad. They are also the best judges of certain aspects of care, such as amenities and interpersonal relations. The second reason is the transformation of health care from a sellers' market to a consumers' market where the satisfaction of the patients' needs is part of the definition of quality. Finally, there is the ideological reason that, in a democratic society, the patients should have the right to influence decisions and activities influencing them. Measurement of patient satisfaction realizes the principle of community participation in health care. Key words: Quality of care, quality assurance, patient satisfaction.

DOES THE MEASUREMENT OF PATIENT SATISFACTION IMPROVE CARE?

I have been asked to answer the question "Has the measurement of patient satisfaction improved the quality of care?". The honest answer is: we do not know. A review of the literature yields no evidence. Onefindsboth pious wishes and deep conviction concerning the beneficial impact of the measurement of patient satisfaction. Yet, both research and routine quality assurance have failed to look systematically at the assumed impact. Nelson [1] concurs: "The actual value of patient satisfaction studies as part of total quality measurement process is disputed in both academic literature and the practice of medicine. Where they are used, little is known about their actual effect on the organization and delivery of health services." The opposite question—Does patient satisfaction increase if those aspects of care believed to determine satisfaction improve?—has been studied. When reviewing First presented to the 8th Congress of ISQA, Washington, 29-31 May 1991. 183

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patients' evaluation of quality, Rubin [2] looked at the studies that have assigned patients to standard hospital care vs conditions believed to be of higher quality. The studies found the hypothesized effect on patient satisfaction. WHY IS THERE A LACK OF EVIDENCE? Four factors seem to account for lack of evidence on the impact of the measurement of patient satisfaction on the quality of care. They are the objectives, focus and originator of the studies and difficulties related to the interpretation of the findings. Objectives of the Studies Many studies have measured overall patient satisfaction. Others have looked at the correlation between patient satisfaction and other indicators of quality. But very few studies, if any, have used a before-after design to see what happens to the level of quality after patient satisfaction has been measured. The objectives of US and European studies seem to differ. The European studies are often theoretical. They aim at defining the concept of patient satisfaction or findings its determinants. The American studies are often pragmatic. They often aim at making a hospital more competitive. The Americans use the results to rank hospitals and providers; the Europeans usually keep the results anonymous and often use them to build theory. The lack of before-after studies does not mean that health care providers have not used the results of patient satisfaction studies to improve care. Many hospitals routinely survey the opinions of their clients to eliminate sources of dissatisfaction. What is missing are studies that would have done two things: (a) remeasured patient satisfaction after the improvements and (b) compared the level of satisfaction before and after the changes with other indicators of the quality of care. Focus of the Studies Ware [3] identifies two foci: summary evaluation of care during a specified period and evaluation of satisfaction with an episode of care. Summary evaluation often deals with ratings (value judgements, attitudes, opinions and evaluations); satisfaction with an episode may be more orientated towards reports (descriptions, factual observations and perceptions). In practice, even studies on specific episodes have tended to deal with generalities instead of specifics. According to Geary [4] "in the past, most patient surveys have elicited evaluations as opposed to reports ... they have tended to ask how satisfied a patient is with certain aspects of care rather than whether certain events did or did not occur." The problem with general assessments of satisfaction is that they do not give enough clues for corrections. They may hide that patients can have varying levels of satisfaction with different aspects of care. They also may be misleading because opinions of others, e.g. friends and relatives, or the patient's general attitudes towards health care can colour them. If general findings cannot suggest specific improvements, they can even less guide the evaluation of changes in the quality of care. The results of evaluation would be difficult to interpret. What does a possible change mean: Has the quality of care

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become better or has the patients' reference frame changed? If the quality has improved, what does the betterment result from? Originator of the Studies Particularly in the United States, patient satisfaction studies are often independent of routine quality assurance. In his review of patient satisfaction surveys, Nelson [1] found that 60% were carried out by patient/public relations departments, 30% by administration and only 10% by quality assurance departments. He also foiind that only two institutions used all dimensions of patient satisfaction with other quality indicators. If a quality assurance study serves to maintain public image and competitive edge, it is natural that the measurement tool is simple. It usually does not provide the data needed to evaluate the impact of the study on the quality of care as a whole. Possible poor communication between the public relations and quality assurance departments renders it even more difficult. Interpretation of the Results Before health care institutions or providers invest in changing care as a result of patient satisfaction studies, they want to be sure that the results are unequivocal. However, they are not. They are real and useful but their interpretation often requires analytical skills beyond the resources of a routine quality assurance programme. Patients' satisfaction with care depends on two factors: expectations concerning the care they will get and perceptions about the care they got. Both are subjective and depend on educational, psychological, cultural and experiential factors. Examples illustrate the point. In comparing hospital and primary care patients in Finland, I found a high level of satisfaction but also puzzling differences. The pieces fell together when I took into account the expectations of the patients. The hospital patients took technical competence for granted and detected defects in the behavioral aspects of care and in communication. The patients in general practice took empathy for granted but were slightly suspicious about the technical quality [5]. An exploratory study sponsored by the WHO [6] found big differences in satisfaction with many aspects of care between primary care patients in England, Greece, the Soviet Union and Yugoslavia. The explanation may be confidence in the system. Where the confidence was low, nothing seemed satisfactory. Weiss [7] specifically addressed this issue and found that the more confidence people have in the community medical care system, the more satisfied they are with the care they get. Confidence seemed a more important factor than age, sex, race, education and income. Yet, Nelson [1] found in his review only one study that had attempted to measure patients' perception of the quality of care they received in terms of their initial expectations. WHAT HAS BEEN STUDIED? If the original question remains unanswered, what questions have the studies on, and routine measurement of, patients satisfaction addressed? They range from philosophical and conceptual through methodological to practical:

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• • • • • • •

What is patient satisfaction? Is patient satisfaction important? Can we measure patient satisfaction? How does patient satisfaction relate to other aspects of quality? How satisfied are the patients? With what are the patients satisfied? What influences patient satisfaction? All these questions are important, but why should we bother about measuring patient satisfaction if the studies cannot show that it reaches its purported goal— improvement of the quality of care?

THE NEED TO HEED PATIENT SATISFACTION

There are many reasons—again ranging from philosophical to practical—why we should bother. A Comedy of Three Actors Moliere called medicine a comedy of three actors: the patient, the physician and the disease. Rabelais—always more irreverent—found it a farce. Whatever the nature of the play, the health professionals often forget one actor, the patient. They have several arguments to oppose or belittle the role of patient satisfaction [1,8]: • patients lack the scientific and technical knowledge to assess the quality of care; • patients' physical or mental states may impede objective judgments; • the rapid pace of events—nursing, diagnostics, treatment—prevents patients from having a comprehensive and objective view of care; • physicians and patients may have different goals; the physicians may evenfindthe patients' wishes harmful or not in their best interest; • patient satisfaction cannot be measured in a way that yields useful results because it is difficult to define what "quality" means to patients; • patients are often reluctant to disclose what they really think because of their sense of dependency on, or prior failures, patient-physician communication; • patients cannot accurately recall care process. Besides, patients surveys or interviews cannot measure subjective phenomena. Paradoxically, also the "success" of patient satisfaction studies has contributed to their dismissal as a tool for improving the quality of care. They usually show that the patients are very satisfied with care. The share of satisfied patients is often over 90%. A scholar does not find a phenomenon with so little variation worth studying. An administrator does not believe that such results show a problem worth solving [2]. The doubts of health professionals don't make the patients' views on the quality of care invalid. The patients are, can and should be partners in care. They are the ones who literally feel in their skin—and often also in their pocket book—if something goes qualitatively awry. While they may not be as competent as the providers in assessing the technical quality of care, they are the best judges in many other areas. Donabedian [9] has divided the scope of health care into the science of care, the art of

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care and the amenities (the surroundings in which care is given). The patients are the best judges of the art of care and often the sole judge of the amenities (e.g. food, furnishing, cloths and colors). Whether the providers like it or not, the patients can have different goals for care. Ambroise Pare", the father of surgery denned the tasks of medicine already in 1575 as follows: to cure sometimes, to comfort often, to console always. Traditional quality assurance only looks at cure, the area where the health professionals only sometimes succeed. For many patients with chronic or terminal illnesses, comfort and consolation may be much more important. Measurement of patient satisfaction is the best tool to leam more about these aspects of care. The Customer is the King In the old days, the children would say that they want to become afirefighteror a nurse when asked what they will do when they grow up. Today, they might well say that they want to become a customer. They have noticed that in the marketplace, the consumer is the king. Producers who do not heed the needs and wishes of the consumers do so at their risk. Dissatisfied customers keep the producers on their toes and push for the improvement of quality. Improved education helps the consumers to set criteria for good quality. They are increasingly vocal and well organized to make their voice heard. Market forces are transforming also health care from a seller's market into a buyer's market. They include the need for cost-containment, consumerism, oversupply of physicians and increasing competition both between health care providers themselves and between health care providers and providers of alternative care. This transformation has changed attitudes towards the role of patient satisfaction in quality assurance. George Bernard Shaw claimed that every profession is a conspiracy against laity. In the past, many health professionals seemed to support this claim by preferring definitions of quality that maintain professional control over health care. A good example is the scientific-technological definition of the quality of health services: the degree of application of currently available medical knowledge and technology in the provision of health services [10]. It has no place for the patient. The adherence to this definition reflects what I have called individualism in quality assurance [8]. In the individualistic approach, quality assurance is a somewhat elitist activity stemming from professional ethos and self-interest and aimed at raising the quality of work of the health care providers. The individualistic approach is being replaced by a utilitarian one that aims at doing the greatest good to the greatest number of people. The goal of quality assurance is no longer technical and professional excellence but optimal quality that meets the needs of the patients. In this approach, it is natural to consult the patients. So, consumer orientated definitions of quality are replacing provider orientated definitions. An example is the definition proposed by the European Organization for Quality Control: Quality is the totality of features and characteristics of a product that bear on its ability to satisfy a given need. The consumer is a prime definer of the need. Weiss and Koch [11] aptly summarize the new attitude: "It stands to reason, then, that providers who actively seek and respond to patient opinion will enjoy not only

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healthier and more satisfied patients, but more favorable position in today's competitive health care marketplace. Clearly, good quality is good business." Ware [3] points out the consequences of this attitude for patient satisfaction measurements: "With increasing competition in the medical marketplace, there is-greater demand for tools that are simple and easy to use in monitoring patient satisfaction." Right to Participate

The impact of the ideological factors has been more subtle but pervasive. It stems from two sources: the concept of health and the concept of community participation. In both cases, the World Health Organization has played a role. The impact of the concept of health is clear. The WHO [12] defines health as a state of physical, mental and social well-being. If one accepts this definition, one also has to accept that patient satisfaction has a role in the quality of care. A dissatisfied patient is not in a state of complete mental and social well-being. Although seldom stated, this idea is behind the view that patient satisfaction is much more than an indicator of, or a proxy measure for, the quality of care. A desired outcome of care, patient satisfaction is an essential part of its quality. It does not matter whether the degree of patients' satisfaction reflects the competence of the physician or the quality of care. The important thing is that if patients are dissatisfied, health care hasn't achieved its goal [e.g. 8,9,13]. Community participation is a key tenet of democracy: those influenced by a decision have the right to participate in making that decision. The ultimate expression of this right is election of political decision-makers. In other areas of decision-making and lower levels of government, systematic mechanisms for community participation often lack. The World Health Organization has addressed this issue in health care. The AlmaAta Declaration [14]—WHO'S primary health care bible—states that the people have the right and duty to participate individually and collectively in the planning and implementation of their health care. In health care, as in other areas, community participation can be considered either as an end, something valuable per se, or as a means to get something. The first can be called the democratic, the second one the instrumental approach to community participation [15]. Despite whether community participation has been introduced as a means or an end, it is supposed to benefit health care. It is claimed that if health care is characterized by community participation: (1) more will be accomplished; (2) services can be provided at a lower cost; (3) participation leads to a sense of responsibility; (4) participation guarantees that a felt need is involved; (5) participation ensures that things are done the right way; (6) participation has an intrinsic value for the population; and (7) it provides freedom from dependence on professionals. This list contains the assumed benefits of community participation. The list of the assumed benefits of measuring patient satisfaction looks very similar. The explanation of the similarity is that heeding patients' views is simply a special case of community participation. At a lofty ideological sphere, we can say that letting the patients express their opinions in a patient satisfaction survey or interview corre-

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sponds with casting a vote in the elections. In enables the patients to vent their feelings and gives them the sense that they participate in their care. BEAUTY IS IN THE EYE OF THE BEHOLDER Like beauty, quality is at least partly in the beholder's eye. It has two aspects: quality of action and quality of perception. While not always commensurate with the observations of an outsider, perceptions are powerful. They determine patients' satisfaction and guide their behaviour as much as facts. The degree of satisfaction can determine whether a patient chooses official health care over alternative care, this hospital over its rival, this practice over the one across the street, or sending flowers to the physician over suing him. It simply makes sense to find out how the patients perceive the services they get. REFERENCES 1. Nelson C W and Niderberger J, Patient satisfaction surveys: An opportunity for total quality improvement. Hospital & Health Services Admin 35: 409, 1990. 2. Rubin H A, Can patients evaluate the quality of hospital care. Med Care Rev 47: 267, 1990. 3. Ware J E and Hayes R D, Methods for measuring patient satisfaction with specific medical encounters. Med Care 26: 393, 1988. 4. Cleary P D, Patient assessments of hospital care. QRB 15: 172, 1989. 5. VuoriH, Doctor-patient relationship in the light of patients' experiences. Soc Set Med 2: T23,1972. 6. Caiman M, Katsouyiannopoulos V, Ovcharov V K, Prokhorskas R, Ramie H and Williams S, Consumer evaluation of general practice: an international comparison. In press. 7. Weiss G L, Patient satisfaction with primary medical care. Med Care 26: 383, 1988. 8. Vuori H, Patient satisfaction—an attribute or indicator of the quality of care. QRB 13: 106,1987. 9. Donabedian A, The definition of quality and approaches to its assessment. Explorations in quality assessment and monitoring, Volume I. Health Administration PTess, Ann Arbor, Michigan, 1980. 10. Vuori H, Quality assurance of health services: concepts and methods. WHO, Regional Office for Europe, Copenhagen, 1982. 11. Weissman E and Koch N, Progress notes: special patient satisfaction issue. QRB IS: 166, 1989. 12. World Health Organization, Basic documents. WHO, Geneva 1982 (32nd edition). 13. McMillan J R, Measuring consumer satisfaction to improve quality of care. Health Progress 68: 54, 1987. 14. World Health Organization, Alma-Ata documents. WHO, Geneva, 1978. 15. Vuori H, Overview—community participation in primary health care: a means or an end? Public Health Reviews 12: 331,1984.

Patient satisfaction--does it matter?

The paper aims at answering the question: Has the measurement of patient satisfaction improved the quality of care? After concluding that there is no ...
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