By Otani, Koichiro; Kurz, Richard S; Harris, Lisa E; Byrne, Frank D
Koichiro Otani, Ph.D., assistant professor, School of Public and Environmental Affairs, Indiana University-Purdue University, Fort Wayne, Indiana; Richard S. Kurz, Ph.D., professor, Saint Louis University School of Public Health, St. Louis, Missouri; and Lisa E. Harris, M.D., associate professor, Indiana University School of Medicine, Indianapolis, Indiana
EXECUTIVE SUMMARY
Our study1 aimed to identify which attributes of a primary healthcare experience have the most impact on patient satisfaction as well as which aspects of each attribute are most significant in patients’ response to the services they receive. The three attributes examined in this study were access, staff care, and physician care. Analyses of the aspects of each attribute controlled for age, gender, and race. Data used in this study were obtained through a survey questionnaire with random sampling, resulting in the sample size of 8,465. The psychometric properties of the questionnaire were also examined and showed appropriate reliability and validity. The multiple regression analysis showed that among the three attributes, physician care was most influential, closely followed by staff care, with access having much less influence.
Further analyses revealed that specific aspects of each attribute were more influential on patient satisfaction. Within the physician care attribute, patients were found to be rational consumers who were looking for surrogate indicators of correct diagnosis and treatment options among the measures available to them. They were much less likely to be influenced by so-called bedside manner. Within the staff care attribute, willingness and compassionate behaviors of staff and prompt service were most important. Within the access attribute, patients sought caring interaction with appointment personnel. After considering the findings, we discuss possible actions for healthcare managers.
For more information on the concepts in this article, please contact Dr. Otani at [email protected]. To purchase an electronic reprint of this article, go to www.ache.org/pubs/jhmsub.cfm, scroll down to the bottom of the page, and click on the purchase link.
Patient satisfaction is a subjective judgment of the quality of care, but it is a driving force when patients have a choice of providers or the opportunity to recommend a provider to others. Satisfied patients return when they need a healthcare service and recommend their provider to friends and relatives when those individuals are searching for an appropriate healthcare provider. Dissatisfied patients seldom return when they have other choices, and they relate their negative experiences to others. Thus, it is very important to improve patient satisfaction levels, especially in today’s competitive healthcare environment in which managed care companies use patient satisfaction as a tool in determining their reimbursement rates.
There have been many patient satisfaction studies, the earliest of which attempted to identify patient characteristics such as age, gender, and race to predict patient satisfaction levels (Andersen, Kravits, and Anderson 1971; Apostle and Oder 1967; Bertakis, Roter, and Putnam 1991; Dolinsky 1997; Dolinsky and Caputo 1990; Fox and Storms 1981; Hulka et al. 1975; Kaim-Caudle and Marsh 1975; Linn 1975; Meng et al. 1997; Sullivan 1984). Another group of research analyzed healthcare attributes-such as nursing care, physician care, admission process, and discharge process-to identify attributes that influence overall patient satisfaction (Dansky and Brannon 1996; Marr and Greengarten 1995; Oswald et al. 1998; Ross, Steward, and Sinacore 1993; Ware, Snyder, and Wright 1976; Ware et al. 1975). A third group analyzed the psychometric properties of patient satisfaction instruments (Marshall et al. 2001; Zaslavsky et al. 2000).
A new group of patient satisfaction studies focuses on the noncompensatory and nonlinear relationship between healthcare attributes and overall patient satisfaction, with the intention of increasing patient satisfaction in an efficient manner. These studies indicate that interventions aimed at reducing negative effects are more efficient for increasing patient satisfaction than those directed at improving positive effects (Otani, Harris, and Tierney 2003; Otani and Harris 2004; Otani and Kurz 2004; and Otani et al. 2003).
Beyond identifying influential patient characteristics, these latter studies found attributes of healthcare experiences that improve patient satisfaction. However, they fell short of specifically identifying what aspects of these attributes are important to improve patient satisfaction. Our study attempts to specifically determine not only the attributes of a healthcare experience (in this case, a primary care visit) that have the most impact on patient satisfaction but also the aspects of each healthcare attribute that are most significant to the patient’s response to the services they receive.
METHODOLOGY
Site
The study site included five university-affiliated practices of Indiana University Medical Group-Primary Care in Indianapolis, Indiana. These practices serve mostly managed care populations and use a centralized electronic medical record (McDonald et al. 1999; Harris et al. 1999). Each primary care practice is, in general, managed autonomously. These sites use patient satisfaction data in continuous quality improvement as well as physician evaluation and compensation.
Data Collection
Data used in this study were obtained through a survey questionnaire (Harris et al. 1999). The patient satisfaction survey was mailed within three days of the patients’ primary care visit, and follow-up telephone calls were placed to patients who did not respond after two mailings. This study used a random sampling method for patient visits between October 1996 and November 2000 such that 25 surveys were obtained per physician every six months. Approximately 15 board-certified general internists provided primary care to adults at the five sites. Patients who were younger than 18 years of age were excluded from the analysis, resulting in the sample size of 8,465. The total response rate was 53.9 percent.
The survey questionnaire included the Medical Outcomes Study Visit-Specific Questionnaire (which contains nine items that assess satisfaction with a specific outpatient visit) (Rubin et al. 1993) and a modified version of the American Board of Internal Medicine’s Patient Satisfaction Questionnaire (which contains 12 items that address physician encounters) (PSQ Project CoInvestigators 1989). In addition, the survey included other items developed by the quality improvement committee of Indiana University Medical Group-Primary Care. Those items measured access to care and satisfaction with office processes and personnel. The survey instrument is available on request from the authors.
Variables
Independent variables. Multiple items were used to measure each of the three primary care attributes (access, staff care, and physician care). A composite index (CI) was created for each attribute as the mean of the items that measure that attribute. If more than 25 percent of the items were missing for a patient, the CI was not computed and the missing value was assigned. When less than or equal to 25 percent of the items were missing, the mean score of the valid items was computed. The instrument used a five-point Likert scale that ranged from poor ( 1 ) to excellent (5); thus, the higher numbers indicated higher attribute reactions (higher satisfaction). Summary statistics for all variables are presented in Table 1.
The validity of questionnaire items in the survey was assessed. A structural equation measurement model was built to confirm the convergent and discriminant validity of the satisfaction instrument. Specifically, confirmatory factor analysis was conducted to analyze the factor structure of the instrument. The goodness-of-fit statistics showed a good model fit (root mean square error of approximation (RMSEA) = 0.12, goodness-of-fit index (GFI) = 0.90). The reliability of each attribute was examined by the Cronbach’s alpha coefficient. The obtained values of the reliability estimates were all greater than 0.89, which indicates a strong internal reliability among items in the same attributes. All lambda weights (factor loadings) were statistically significant at α = 0.05, which indicates that all selected items loaded highly on the corresponding constructs, or attributes. After the analyses, the final model was determined to include three constructs with 27 items (see Table 1).
TABLE 1
Descriptive Statistics and Coefficients of Survey Items
TABLE 1
Descriptive Statistics and Coefficients of Survey Items
Dependent variable. The overall satisfaction variable included one item in the questionnaire that asked the patient’s overall satisfaction with the quality of care and service of the visit. Descriptive statistics are presented in Table 1.
Control variables. Control variables used in the analysis included individual patient characteristics, including age, gender, and race, as predisposingvariables. The mean age of the patients was 49.54 years, and the standard deviation was 16.24 years for this adult sample of 8,465. Female patients accounted for 67.8 percent of the participants. As for race, 46.2 percent were white; 26.6 percent were African American; 1.3 percent were Asian; 0.3 percent were Hispanic; and 25.6 percent were other ethnic origins, including unknown. There were no missing values for the age variable and very few for the gender variable. Descriptive statistics for control variables are presented in Table 2.
Analysis
The analysis of this study consisted of two parts. The first part examined three attributes, using multiple regression analysis, to determine the effect of each attribute on patient satisfaction. The three attribute variables (access, staff care, and physician care) were entered together with control variables. The second part examined the items that comprised each attribute to identify what aspects (items) of the attribute were critical in increasing patient satisfaction. All aspects in each of the influential attributes were simultaneously analyzed using multiple regression analysis, with overall patient satisfaction as a dependent variable. The statistical significance for each coefficient of the aspects was examined, and the sizes of the coefficients that showed statistical significance were compared. The larger the coefficient was, the greater the influence on overall patient satisfaction.
RESULTS
Table 3 shows the result of the multiple regression analysis, with the three attributes (access, staff care, and physician care) and the control variables as independent variables and overall patient satisfaction as a dependent variable. Each attribute showed a positive relationship with overall patient satisfaction and was statistically significant at α = 0.05. For control variables, age was positively related to overall patient satisfaction and was statistically significant. Female gender showed a positive relationship but was not statistically significant. Regarding race, African-American patients showed a positive relationship that was statistically significant; in other race categories, however, the relationships were not statistically significant. Among the three attributes, physician care showed the largest parameter estimate (0.468), followed by staff care (0.443) and access (0.141).
TABLE 2
Descriptive Statistics of Control Variables
TABLE 3
Parameter Estimates of Three Attributes and Control Variables on Overall Satisfaction
Because the physician care attribute showed the largest parameter estimate, the next question became, what aspects of the physician attribute are most influential? The 14 aspects in the physician care attribute were simultaneously analyzed, using multiple regression analysis that included control variables, to determine how much each aspect was related to overall patient satisfaction. Of the 14 aspects in the physician care attribute, two aspects showed far- larger coefficients, followed by another aspect that showed a larger coefficient than the others. Seven aspects were statistically significant and were positively related to overall patient satisfaction. The two most influential aspects in this attribute were “explanation of what was done for you” and “length of time spent with the doctor or physician assistant,” with coefficients of .241 and .212, respectively. Another aspect that showed the third largest coefficient was “the technical skills (thoroughness, carefulness, competence) of the doctor or physician assistant,” with a coefficient of .109. Other coefficients were much smaller than these three.
The staff care attribute that showed the second largest parameter estimate was analyzed to compare eight aspects within that attribute. Of the eight aspects in the staff care attribute, six aspects were statistically significant and positively related to overall patient satisfaction. The most influential aspect was “the personal manner of the nurse or staff member who assisted the doctor or physician assistant with your visit,” with the largest coefficient of .207, followed by “the efficiency of the office staff at check out,” with .199. The third aspect, with a coefficient of .173, was “length of time waiting at the office.” The next three aspects-“the technical skills of the nurse (drawing blood, taking blood pressure, giving shots),””the efficiency of the office staff at check in,” and “the personal manner of the office staff at check out”-showed somewhat smaller coefficients, at .113, .097, and .063, respectively.
The third attribute-access, which had a much smaller parameter estimate than staff care and physician care attributes-was also analyzed. The attribute had five aspects, and all of them were statistically significant and positively related to overall patient satisfaction (see Table 1). The aspect “the personal manner (courtesy, respect, sensitivity, friendliness) of the person with whom you spoke when you made the appointment” had the largest coefficient, at .243. The second aspect, “how long you waited to get an appointment,” and the third, “the helpfulness of the person with whom you spoke when you made the appointment,” showed smaller coefficients (.160 and .132, respectively) than the first one. The last two aspects, “getting through to the office by phone” and “length of time waiting on the phone,” showed much smaller coefficients (.084 and .063, respectively) than the first one.
DISCUSSION
Patients are anxious about their uncertain conditions when they visit doctors. They expect the physician to make the right diagnosis and provide the right treatment. However, patients are not able to directly assess whether the physician’s diagnosis and treatment options are correct. Thus, patients have to rely on other aspects that they can assess, and they believe those aspects are related to the correct diagnosis and treatment option.
Our results clearly support this assumption. Patients in the study were most influenced by the very reason that they visited their physicians-that is, to receive care from the physician and his or her staff. With regard to the physician care attribute, the most influential aspect, “explanation of what was done for you,” indicated that patients need physicians to help solve their health problems. The second influential aspect, “length of time spent with the doctor or physician assistant,” implied that within the visit timeframe the doctor did everything needed for the patient and that the patient had time to ask questions and express concerns; thus, the patient would be led to believe that the diagnosis and treatment must be correct.
These aspects are not direct measures by which patients can assess the appropriateness of their diagnosis and treatment, but they are good proxy measures that are available to patients. The third aspect, “the technical skills (thoroughness, carefulness, competence) of the doctor or physician assistant,” was also likely to be viewed by patients as directly related to correct diagnosis and treatment. Unless providers are perceived as having competent technical skills, the patient will not view the visit as satisfactory.
The less influential aspects of the physician attribute are associated with dimensions that may be described in general as bedside manner. Although these aspects did influence patient satisfaction in our study, their impact was much smaller than for factors related to the reason for the visit-to receive the right diagnosis and treatment.
Interaction with staff members, including nurses at primary care practices, showed the second largest parameter estimate. The difference between this attribute and the leading attribute of physician care was very small, which indicates that this attribute is also veiy influential for increasing patient satisfaction. Our examination of the aspects of this attribute also produced important results: The personal manner of the staff was more important in the examination room than in other activities. This finding may indicate that patients are most anxious in the examination room; thus, compassionate care from the staff does influence patients’ comfort levels. Patients would probably have less anxiety regarding checking in, walking through the practice setting, or checking out. However, our findings suggest that patients were concerned with the efficiency of the staff during the check-out process, which includes receiving additional instructions after the physician visit, clarifying billing or insurance issues, and making another appointment. The reasons for the importance of this aspect of the visit were not entirely clear but may include the patient’s desire to leave and act on the physician’s advice immediately. The third influential aspect was the length of waiting time at the office. This result is not surprising as it is a frequent concern of patients (Kurz and Scharff 2003) and has been addressed by process improvement experts (Nolan et al. 1996; Murray and Berwick 2003).
The access attribute was the third most influential in overall patient satisfaction, but its impact was much smaller than the other two attributes. To visit physicians, patients typically made a phone call for an appointment. Our results suggest that patients pay attention to the way that the person in charge of scheduling appointments responds to them. The first aspect, “the personal manner (courtesy, respect, sensitivity, friendliness) of the person with whom you spoke when you made the appointment,” and the third aspect, “the helpfulness of the person with whom you spoke when you made the appointment,” both indicate the importance of the appointment personnel’s interaction with patients. The second aspect, “how long you waited to get an appointment,” can be very critical, as patients may get upset if they have to wait before they see a doctor. The length of time that patients need to wait for an appointme\nt is affected by characteristics of the medical practice and the patient’s medical condition or personal and family demands. However, patients with overt symptoms from an acute or a chronic illness may perceive an immediate need for medical attention, heightening this aspect’s influence on patient satisfaction.
CONCLUSION
This study shows that in primary care settings, physician characteristics affect patient satisfaction more than other attributes of care do. Previous studies conducted on hospital discharged patients demonstrate that nursing care has the most influence on patient satisfaction (Otani and Kurz 2004; Otani et al. 2003). In a hospital setting, patients interact with nurses much more than with other hospital personnel, including physicians. In outpatient settings, as in this study, the physician is the focus of the patient’s experience. Thus, the physician becomes key to patients, and those aspects of physician care that most directly affect the patient’s medical concern are most influential on patient satisfaction.
This study also specifically examined the aspects of the physician care attribute that had the most positive impact on overall patient satisfaction. Two items, “explanation of what was done for you” and “length of time spent with the doctor or physician assistant,” were found to be the most important and influential aspects in the physician care attribute. Other aspects-bedside manner and a physician’s caring demeanor-did influence overall patient satisfaction, but their impact was much smaller. Thus, to increase overall patient satisfaction, it is important to improve the aspects of the physician attribute that are related to the nature of the patient-physician interaction-that is, the physician making sure that the patient understands the services provided and the physician spending appropriate length of time with the patient.
The staff care attribute, including nursing care, showed the second largest impact on overall patient satisfaction. Even though this attribute only placed second, its difference from the leading attribute of physician care was not large; thus, it is worth investigating and improving. The most influential aspect was “the personal manner of the nurse or staff member who assisted the doctor or physician assistant with your visit,” which indicates that patients seek caring and compassionate behaviors from the staff, including nurses. Considering the patients’ feelings of anxiety and dependency while in the doctor’s office, it is logical that the staffs behavior in alleviating patient’s anxiety and comforting them would be viewed as the most important aspect of the staff care attribute. The second and third aspects, “the efficiency of the office staff at check out” and “length of time waiting at the office,” are also under the control of management. Process improvement in these aspects of the visit have been addressed, as noted earlier; thus, models for immediate interventions by the managers of primary care practices are available and can be implemented without extensive research. Developing and using a protocol and providing guidelines regarding these aspects would help staff members work more efficiently. Changing the workflow or reducing the waiting time is difficult, but informing patients of the reasons for the wait can improve patients’ perception.
The third most influential attribute was access. Although this attribute played a less significant role in patient satisfaction, it nonetheless requires attention. The most influential aspect of this attribute, “the personal manner (courtesy, respect, sensitivity, friendliness) of the person with whom you spoke when you made the appointment,” focused on the positive interaction between patients and scheduling staff. The third aspect, “the helpfulness of the person with whom you spoke when you made the appointment,” also revolved around such interaction. Thus, it seems that patients look at how appointment personnel respond to their requests. With this in mind, the appropriate training of appointment personnel may be warranted.
The second aspect of the access attribute, “how long you waited to get an appointment,” is a complex issue and may require more study to address. However, patients with immediate symptoms undoubtedly perceive a need for medical attention. Hence, a referral system or assessment of the patient condition at the appointment time may be instituted to address this situation.
Our detailed analyses revealed that patients are rational consumers. They look for surrogate indicators of correct diagnosis and treatment options, which were the only measures of satisfaction they could use. The results from this study indicate that patients may find these surrogate indicators in their perceptions of the feedback they receive from their physicians and the amount of time their physicians spend with them. Because managed care and other factors influence the time spent with patients, this aspect of care should receive careful attention in patient satisfaction improvement efforts. The study found that patients also consider how staff members and other personnel interact with them. These aspects consistently showed that patients were influenced by the willingness and compassionate behaviors of staff members. Improvement of staff behavior may come from providing adequate training and may result in employee satisfaction with their work.
This study also revealed that certain aspects of the three attributes were more important for intervention than were others. An analysis that identifies influential attributes is important but is only the first step to improving patient satisfaction. Through the detailed analysis of each attribute, it is possible to find important aspects that would provide primary care managers with more information to increase patient satisfaction more efficiently. With increasing competition and uncertainty in healthcare, it may be necessary for providers to make an extra effort to put themselves in the patients’ shoes, analyzing patients’ as well as staffs behavior.
Healthcare providers routinely collect patient satisfaction data. However, many of them spend little time in analyzing these data, which would provide managers with valuable information to improve the quality of care they provide. The data are often underutilized. Also important are the psychometric properties (validity and reliability) of the patient satisfaction questionnaire, which should measure healthcare-specific issues and should provide consistent (reliable) outcomes. The psychometric properties of the patient satisfaction questionnaire used in this study were confirmed.
Focusing the intervention strategy on certain aspects of the attributes examined is much more cost efficient than attempting to improve all aspects of the three attributes. Such a strategy will encourage patients to choose those facilities with which they are most satisfied.
LIMITATIONS AND SUGGESTIONS
First, this study used a comprehensive patient satisfaction questionnaire that was carefully developed to ensure reliability and validity of the measurement. Patients are increasingly becoming better educated about their Healthcare, so their expectations and opinions about healthcare are changing as well. Thus, some aspects of the three attributes measured here may not be adequately included in future measurements because patients’ views are changing.
Second, this is a cross-sectional study. The cross-sectional study design can claim an association but does not establish a causal relationship. However, previous research into this topic indicates that patients combine their reactions to attributes to form their overall satisfaction. Thus, it is recommended that should a researcher implement an intervention program that improves some aspects of three attributes, the researcher should observe the change in overall satisfaction levels to establish the causal relationship.
Third, the data were collected from five primary care practices in Indianapolis, Indiana. Even though Indianapolis is a major city with a diverse population and even though the sample size for this study is large, the study’s generalizability to other geographic areas is limited.
Note
1. This study has been approved by Institutional Review Board at Indiana University-Purdue University, Fort Wayne (Rf. #00-358E) and by Institutional Review Board at Indiana University-Purdue University, Indianapolis (IRB #9906-42, EX0008-11B).
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PRACTITIONER APPLICATION
Frank D. Byrne, M.D., FACHE, president, St. Marys Hospital Medical Center, Madison, Wisconsin
Achieving exceptional patient satisfaction is a process, not the result of random acts of kindness and good intentions. Much has been written about attributes that correlate with overall patient satisfaction in the inpatient setting. Common, proprietary survey tools used to assess satisfaction with the inpatient experience typically include a correlation index that ranks attributes based on their impact on satisfaction. Otani, Kurz, and Harris have studied attributes of the primary healthcare experience and have correlated the impact of specific aspects of each attribute to overall patient satisfaction.
Knowledge of attributes and aspects of attributes is essential to the development of specific processes to achieve patient satisfaction. Increasingly, patients have service expectations because of the general trend toward consumerism, their financial stake in their healthcare expenses, and other factors. Many healthcare organizations have elegant service recovery programs to address patient complaints, but such programs are not adequate to ensure high levels of satisfaction. Consumer studies in non- healthcare settings estimate that only 1 in 20 dissatisfied customers makes a formal complaint; most dissatisfied customers just do not return.
Increased public reporting of patient satisfaction data underscores the importance of making and maintaining patients happy. One large employer found that sharing health plan satisfaction data with its employees led to a 27 percent swing in health plan enrollment, from the lowest ranked to the highest ranked plan, in just one open-enrollment period. As it is with inpatient care, effective communication is a major component of patient satisfaction efforts in the outpatient setting. This is evidenced by the high correlation of communication factors, such as “explanation of what was done for you” in the study.
A few words of caution in interpreting the results of this study are in order. First, the finding that access attributes did not correlate more strongly with patient satisfaction was surprising. Recent satisfaction data from other settings suggest a high correlation between ease of access and overall satisfaction, and outpatient settings that ease access by using techniques such as same-day scheduling of appointments report significant improvement in satisfaction. Perhaps access has increased in importance since the authors collected their data. This attribute warrants further study. second, the authors correctly state that patients frequently use the quality of their service experience and the courtesy with which they are treated as surrogates for clinical competence and quality. This trend should dissipate as patients increasingly obtain access to clinical quality data. Patients will have clear quality expectations from both the service and clinical dimensions of their healthcare experience.
The authors should be commended for their diligence in achieving a 53.9 percent response rate. Their confirmation that specific aspects of attributes of the primary care patient experience correlate with overall satisfaction will help organizations develop plans with defined outcome measures to help achieve patient satisfaction. Follow-up research into this topic could involve (1) repeating this study to see if aspect and attribute rankings have changed and (2) conducting a before-and-after study that assesses the impact of a process improvement that is designed to positively influence key attributes.
Copyright Health Administration Press Sep/Oct 2005
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