Research on Patient Satisfaction Potential Directions

Ruth Belk Smith, University of Maryland
Paul N. Bloom, University of North Carolina
Kelley Sonon Davis, University of Maryland
ABSTRACT - This research is concerned with several issues. There is the need for general understanding in the area to help the focus of the public health care system and to help provide guidance to health care marketers in understanding their consumers. Finally, the domain of satisfaction both as patient and generic satisfaction is discussed and the implications for marketing to consumers in general and in the health area are discussed.
[ to cite ]:
Ruth Belk Smith, Paul N. Bloom, and Kelley Sonon Davis (1986) ,"Research on Patient Satisfaction Potential Directions", in NA - Advances in Consumer Research Volume 13, eds. Richard J. Lutz, Provo, UT : Association for Consumer Research, Pages: 321-326.

Advances in Consumer Research Volume 13, 1986      Pages 321-326

RESEARCH ON PATIENT SATISFACTION POTENTIAL DIRECTIONS

Ruth Belk Smith, University of Maryland

Paul N. Bloom, University of North Carolina

Kelley Sonon Davis, University of Maryland

ABSTRACT -

This research is concerned with several issues. There is the need for general understanding in the area to help the focus of the public health care system and to help provide guidance to health care marketers in understanding their consumers. Finally, the domain of satisfaction both as patient and generic satisfaction is discussed and the implications for marketing to consumers in general and in the health area are discussed.

INTRODUCTION

Most of the studies in what has come to be called consumer satisfaction/dissatisfaction (CS/D) have approached its conceptualization and measurement in terms of consumer products or shopping outlets. Only a few have dealt with services (Day and Bodur 1977, Darden and Rao 1977, Braden 1979). Since a high proportion of consumers report dissatisfaction with some services (Day and Bodur 1977), it would seem appropriate to investigate this area for additional insight into the nature of CS/D. One research area in particular which appears to have been ignored is patient satisfaction with medical services. It is quite likely that research on consumer product/service satisfaction can be enriched by research that adds to the limited existing literature on patient satisfaction (Swan and Carroll 1979).

Besides contributing to a more general understanding of consumer satisfaction/dissatisfaction, additional research on patient satisfaction could prove valuable for resolving certain public policy questions about the U.S. health care system. Public attitudes toward this system, and toward the professions in general, have become more negative, manifesting themselves in the form of a variety of policy proposals that suggest removing some control over health care delivery from the health-care professions themselves. Evidence concerning patient satisfaction may offer some leverage for the health care sector against social aggregation. (e.g., community medicine or the formation of adverse public policy). On the other hand, evidence concerning patient dissatisfaction could suggest a need for greater social control.

Additional research on patient satisfaction could also be useful in guiding the marketing activities of health-care practitioners in the turbulent environment they are facing. There is no longer any question that health care must be marketed; the question now is how to market it. Research on patient satisfaction could contribute co the development of improved marketing approaches.

Thus, research on patient satisfaction can contribute to our understanding of consumer satisfaction/dissatisfaction in general, while at the same time providing practical help for formulating public policy and designing health care marketing programs. The purpose of this paper is to suggest several directions for future research on patient satisfaction. The discussion begins by reviewing previous research that is relevant to the study of patient satisfaction. Next, the results of a study on patient satisfaction that was recently conducted by the American College of Obstetricians and Gynecologists are reported. Though this study was not actually conducted by the authors, it is discussed here because it is illustrative of the kind of research that has been done in the past on patient satisfaction. The study's research design and findings provide a good basis from which to suggest new research directions. The last section of the paper reviews several research directions where methodological and substantive contributions can be made to our understanding of patient satisfaction.

Conceptualization of Patient Satisfaction

Research into consumer satisfaction has generally approached its conceptualization and measurement from two distinct theoretical perspectives: (1) in terms of the extent to which the individual feels his/her prior expectations of product performance have been confirmed or disconfirmed in the consumption process (Anderson 1973, Day 1977, Churchill and Suprenant 1982), and (2) in terms of the psychological distance between the product/service and the individual's ideal product/service in a multidimensional space representing salient product attributes (Day 1977). Most studies using the confirmation or disconfirmation of prior expectations approach have used one of three psychological theories as frameworks for studying the psychological processes associated with the assessment of the consequences of decisions: cognitive dissonance or assimilation theory, contrast theory, and assimilation-contrast theory. These theories provide alternative predictions of how the consumer behaves when expectations are not met by product/service performance (Anderson 1973).

The attributional approach visualizes the consumer as making rational decisions in order to maximize utility and satisfaction, and as implicitly or explicitly evaluating the cause of the performance (Valle and Wallendorf 1977). Although utility theory is highly abstract, it does provide an elegant model thereby the consumer experiences satisfaction or dissatisfaction and is also the method used in most previous research on patient satisfaction. Therefore, this approach will be emphasized in the remainder of this paper.

Conceptually, consumer satisfaction has been defined as the overall post-usage response to many different facets of a product/service (Aeillo, Czepiel and Rosenberg 1977), as the person's immediate reaction to a complex situation (Randy 1977), and as dependent on not only the product/ service but on the experience surrounding the acquisition (Cardozo 1965). Evaluation may encompass a number of attributes of the product/service, and in the patient satisfaction literature a number of attributes have been reported. According to Churchill and Suprenant (1982), satisfaction can be operationally assessed as the sum of the satisfactions with the various attributes of the product or service.

Several studies have found provision of information to be an important aspect of physician conduct in determining satisfaction (Ware and Snyder 1975, Doyle and Ware 1977, Comstock and Slome 1973, Jenry 1976, Berhanovic and Marcus 1976, King and Goldman 1975), a result paralleled in consumer product research (Hunt 1977, Wall, Dickey and Talarzyk 1977). The lack of information provisions has been found to lead to poor compliance with treatment (Korsch and Negrete 1972) and can be therefore considered an important professional quality, or instrumental attribute, of patient satisfaction. Hulka and others (1970) found three domains: cost/convenience of the service, personal qualities of the physician, and professional qualities of the physician. Similarly, three other independent studies identified much the same domains: professional and personal qualities of the physician, and access mechanisms (cost, payment structure, location, waiting time, etc.) (Ware and Snyder 1975, Doyle and Ware 1977, Manglesdorf 1979). This suggests a limited set of basic attributes which determine satisfaction with a medical service and which describe domains not unlike the instrumental expression dimensions of consumer satisfaction postulated by Swan and Combs (1976).

The conceptualization for consumer satisfaction/dissatisfaction proposed here is very similar to the above mentioned domains, but it has been generalized for potential application to general CS/D. The three domains of this model include the (1) instrumental domain, which corresponds to professional qualities of the physician, (2) expressive domain, meaning personal qualities of the physician, and (3) access mechanisms, which include cost/convenience.

FIGURE 1

DIAGRAM OF CONCEPTUAL MODEL

Though the study discussed in this paper is about patient satisfaction, it is proposed that this model also applies to general CS/D. Suppose, for example, that a person is going to have dinner in a restaurant. He decides whether to have fast food or eat in a sit down place, what price he wants to ply, and what location he wants to go to. These are access mechanisms. If it is a very expensive restaurant, he wants the hostess and/or waitress to be pleasant and helpful and a nice atmosphere, falling into the expressive domain. Finally, he wants the food to be good and prepared correctly, this would fall into the instrumental domain.

It is expected that levels of satisfaction are expressed by patients according to the extent to which doctor and patient have the case summary evaluation (salience) of attributes or domains. This similarity or overlapping of perceptions has been called agreement or understanding in descriptions of interpersonal systems (e.g. Chaffee and McLeod 1968).

The Study

Typical of the previous research on patient satisfaction is a study recently conducted for the American College of Obstetricians and Gynecologists by a commercial marketing research firm. The study began by interviewing twelve OB/GYNS from across the country and asking them to choose the most important determinants of patient satisfaction. Participating physicians were predominantly male, in group practice, and from urban areas. In-depth interviews were conducted either in person or on the telephone with each of twelve physicians. They were asked (1) to comment on the importance of those issues emerging from the literature to their practice and (2) to discuss those aspects of the physician-patient relationship they wanted most to be addressed in a planned patient survey.

The issues included on the subsequent questionnaire were (1) medical costs, (2) billing and insurance procedures, (3) waiting time and appointment procedure, (4) information about procedures and treatment provided by the physician, (5) prenatal, postnatal, and primary care, (6) perceptions of breast and pelvic examination, (7) desire to learn breast self-examination, and (8) desire to discuss sexual topics with the physician. The three domains discussed most frequently in the literature, access mechanisms (1-3), instrumental qualities of the physician (4-7) and personal qualities of the physician (8) were all judged important issues by the physicians. Personal qualities of the physician appear to be perceived as the least important of the domains to physicians since only one issue (8) addresses this domain.

The questionnaire was pretested among 20 women between the ages of 21 and 35. After minor revisions, 200 questionnaires, consisting of 45 closed-ended questions and three open-ended questions, were mailed to each of the twelve OB/GYN practices. Closed-ended questions were scaled from 3 to 6 points, depending on the nature of the question (i.e., for attitudes toward suspects of the exam categories were "very comfortable, somewhat comfortable, as comfortable as can be expected, somewhat/very uncomfortable). Questionnaires were personally distributed by a staff member to the first 200 patients who arrived for appointments. Of 2,400 distributed questionnaires, 1,349 were received which were usable--a response rate of 56.2 percent. Table 1 shows the composition of the sample.

TABLE 1

COMPOSITION OF THE SAMPLE

Although the response rate was fairly high, certain biases were present, and the results must be interpreted with due caution. Response rates varied considerably among separate practices, from a high of 99 percent to a low of 19.5 percent. Non-respondents could be the most dissatisfied patients, particularly those in practices with the lower response rates. The distribution of questionnaires to the first 200 patients arriving for appointments may have biased the sample toward those patients with particular reasons for more frequent visits (e.g., obstetrical patients nearer term, gynecological patients with specific problems needing regular treatment). This method also excluded patients in the hospital and, most important, those who no longer used the particular practice. The latter group may well be the most dissatisfied since purchase and consumption are linked to repeat purchase and brand loyalty by satisfaction (Churchill and Suprenant 1982). In addition, the data were collected from private practices and excluded indigents who must rely on public medical care; however, since patients of private practice are freer to exercise choice, satisfaction is a more necessary outcome of continued consumption of the services of a particular practitioner.

Finally, the response categories for most of the questions were upwardly biased. Possible responses to "satisfaction with scheduling appointments" were "very satisfied," "satisfied," and "dissatisfied;" response categories for adequacy of information provided were similar: "very adequate," "adequate," and "inadequate." Such biased items lead the respondent to provide "right" (more positive) answers (Babbie 1973).

Results

For comparison, Tables 2 and 3 contain the responses to the close ended and open ended questions. While positive results were high for close ended questions, nearly 75: of the open ended questions had negative responses.

Access Mechanisms.

Patients seemed quite satisfied with scheduling of appointments. About three-fourths of the respondents were very satisfied, about one-fourth were satisfied, and only 1% were dissatisfied. Open-ended responses indicated, however, that a number of patients have to wait too long to get an appointment, and requests were made for more varied hours as well as for receptionist to inform by telephone and in person if the doctor was running far behind schedule.

TABLE 2

SURVEY RESULTS

TABLE 3

SUMMARY OF OPEN ENDED QUESTIONS

Helpfulness of the staff was rated as very good (by about 3/4 of the sample) or good (1/4). Again, only 1% reported the staff as not helpful. Open-ended responses indicated less satisfaction with the staff, requesting more respect, friendliness, and more satisfactory information. Most patients (88%) said they received sufficient information on billing and insurance procedures; most (91%) thought fees charged were reasonable, while 9% thought them unreasonable. Open-ended responses again indicated more dissatisfaction; fees were considered too high in relation to the short amount of time spent with the physician.

Instrumental Qualities of the Physician.

Just over half the respondents found examinations very comfortable, 20% found them somewhat comfortable, 25% found them "as comfortable as can be expected," and about 45 found them uncomfortable. Patients rated information received about problems, exams, and treatment as very adequate (73%) or adequate (25%); while opportunity to ask questions and physician willingness to respond were rated even higher (83% very adequate, 15% adequate, 2% inadequate). Again, open-ended responses indicated a desire for the physician to spend more time with them, a feeling of being rushed, and a desire for physicians to initiate more discussion. Many (41%) indicated a desire for more instruction on breast self-examinations; about half were very satisfied with prenatal/postnatal primary care (45% satisfied and 5% dissatisfied).

Personal Qualities of Physician

Most patients (84%) felt the physician was the appropriate person with whom to discuss sexual topics and 71% said they felt comfortable doing so. However, about two-thirds either did not want the physician to initiate the discussion (42%) or were not sure (26%). Verbatim responses ranged from indicating gratitude for special concern to disappointment at seeming lack of concern.

Implications

The implications from the study are that patients are generally satisfied with access mechanisms and the instrumental qualities of the physician. Verbatim responses indicated less satisfaction with these areas, perhaps due to the nature of the closed-ended questions and the halo effect in testing. Typically, high levels of satisfaction with different aspects of medical care have been reported (Freer, Burdette, and Crocker 1971, Day and Bodur 1977, Justice and McBee 1978), but Noyes (1974) argued that these high scores could be due to a tendency for patients to respond with stereotyped, socially acceptable answers.

The results of the study indicate three important findings. First, the conceptual domains of patient satisfaction appear to be adequately identified. Second, although agreement exists between doctors and patients on the importance of two domains, access mechanisms and instrumental qualities of the physician, a lack of agreement appears concerning the third domain of personal physician qualities. The personal qualities of the physician, deemed less important by the physicians themselves, appeared to be more important to patients and the area of least satisfaction. This indicates that physicians are not fulfilling an important need which exists in order to ensure complete patient satisfaction. Third, analysis of open-ended questions (the verbatim responses) indicates some divergence from closed-ended responses. The major shortcoming of closed-ended questions lies in the structuring of responses; that is, the response categories should be exhaustive, mutually exclusive and unbiased (Babbie 1973). This may explain the divergence of responses and may indicate to patient satisfaction researchers and practitioners that "true" responses may not emerge with only closed-ended questions. It seems, therefore, importance to continue to encourage open-ended responses in order to get a more accurate impression of satisfaction and also to bring to attention unquestioned issues which are important to the patient Consumers of health care, although traditionally "satisfied" according to research instruments, may indeed not be quite as apt to indicate satisfaction when allowed to express themselves freely. Research (e.g., Blair et al 1977) indicates that particular methods should be used when eliciting responses on sensitive subjects such as drinking and sex.

Research Directions

This assessment of the ACOG survey reveals some issues which may be useful in directing future research. These directions can be addressed in terms of methodological and substantive issues.

Methodological Issues.

The shortcomings of the sampling approach may be overcome by more careful attempts to include non-respondents. Instead of distribution to the first appointment arrivals, efforts could be made to elicit responses from patients whose visits are less frequent, those who may deliberately schedule appointments on certain days (e.g., Friday or Saturday) or dates (e.g., end of month), those who frequently cancel appointments, those in the hospital after delivery or surgery, and those who have left the practice.

The instrument could also be improved. The three conceptual domains of patient satisfaction which emerged from the literature appeared to have been identified and agreed upon as important by both physicians and patients. However, personal qualities of the physician were deemed more important by patients than physicians, thus there should be a more even balance of attributes represented.

Other consumer satisfaction/dissatisfaction measurement approaches might be used. To avoid the tendency for patients to respond with-stereotyped, socially acceptable answers, before and after treatment measures for fulfillment of expectations could be employed (Noyes 1974). Recent research on satisfaction has focused on the relationship among perceived expectations, disconfirmation, and satisfaction (e.g., Oliver 1979, 1980). Churchill and Suprenant (1982) found that the effects of perceived expectations, performance evaluations, disconfirmation and satisfaction differ for durable and non-durable products; disconfirmation positively affected satisfaction with a non-durable good while satisfaction with a durable good was determined solely by product performance. This type of research has not been applied to services and could provide further insights into the determinants of satisfaction in general and patient satisfaction in particular.

Another approach which has not been explored in patient satisfaction research is the analysis of the physician patient dyad itself, although this is still the primary mode of health care consumption (Parsons 1960). The seller-buyer dyad has often been analyzed in terms of the personal selling role (e.g., Larsen and Rootman 1976), and studies have found a positive relationship between satisfaction with medical care and the degree to which the physician conformed to the role that the patient expected (e.g., Swan and Carroll 1979). One method of such analysis which might be useful would involve assessing perceived expectations and subsequent evaluations of the dyad performance of both patient and physician in order to K e accurately determine the amount of agreement which exists between patient and physician. Lack of agreement on expectations and evaluations of certain attributes may result in dissatisfaction.

This method is based on the co-orientation and A-B-t model (Newcomb 1953), where the patient (A) is oriented to both the physician (B) and the object of health care (X) (Figure 2). The differences in orientation and perceptions of the other persons orientation may lead to satisfaction or dissatisfaction.

FIGURE 2

A-B-X MODEL

Finally, different questioning techniques could be used. The closed-ended response categories should be more care fully balanced in order to reduce yea-saying by respondents. More open-ended/unaided recall items might elicit better accuracy of responses, especially if placed before the closed-ended questions. The use of counter-biasing statements and projective techniques (Kinnear and Taylor 1983) might yield more honest readings of patient satisfaction (Blair et al 1977).

Substantive Issues.

From the open-ended responses, it appears that some is sues which were not included in the questioning are important to patients. Systemization of appointment scheduling may increase satisfaction based on suggestions that patients be informed both in person (those already waiting) and by telephone (those with appointments later in the day), if the physician is far behind schedule. Other comments indicated lack of support staff courtesy and inadequacy of printed information.

A final issue concerns the restriction of ideas in the study of those specific to obstetricians/gynecologists. Insights might be gained not only from consumer satisfaction/dissatisfaction concepts in general but from even broader perspectives in marketing literature.

There are several areas for research that are suggested based on the results of this study. First, the same basic study could be repeated using unbiased response generators. This would validate the results of the first study. Then, to test the usefulness of the conceptualization to general patient satisfaction/dissatisfaction, a similar study could be performed for a tangible product type (such as an automobiles), and a product that has both tangible and intangible aspects (such as a restaurant). Finally, there is the potential to study the applications of this model for general consumer satisfaction/dissatisfaction. For example, in this study the patients found the expressive domain the most important for tangible products or other services? A contingency model might be developed for the three domains and the kind of product or service being offered.

Another issue that can be raised is the affiliation of the party conducting the research. Having an organization conduct it's own research or interpret the results may not lead to the most objective of conclusions. For example, in the ACOG study, there was a lot of yea-saying among the close-ended questions, and even some of the open ended responses were "qualified." An example of this might be "Dr. X seems very rushed and doesn't answer my questions, but otherwise I'm perfectly satisfied and feel he's an excellent doctor." The doctors may interpret that response to mean that the complaint is minor when in fact, it may be a very important concern. This isn't to say this is done on purpose, but one might expect the doctor to subconsciously interpret a response to favor his best interest.

CONCLUSIONS

Negative public attitudes toward the U.S. health care system and toward the profession in general indicate a necessity for further research on satisfaction with these services. This study indicates future research directions which may contribute to a more general understanding of consumer satisfaction/dissatisfaction in general and patient satisfaction in particular, and which could contribute to public policy and marketing decisions in the health care industry. If methods of increasing patient satisfaction can be found which do not compromise the patient's trust or the physician's standards of quality then there is less need for public policy which removes control of health care delivery from the health care professionals.

Research on patient CS/D can have impact upon medical practice marketing in several ways. By finding out what patients are unhappy about, the physician has a basis from which to initiate change to bring about an increase in patient satisfaction. While satisfaction is based on how close the patient and the doctor salient attributes are, change can only be made on one site of the dyad - by the doctor. This fact underscores the need for physicians to learn what their patients expectations are. For example, if many patients feel that the staff is unfriendly and not helpful, the doctor (as a manager) a should make sure that the staff does behave in a friendly and helpful manner. Also, research can uncover more broad goals toward which the physician can work. In this study, for instance, it can be inferred that many patients want a doctor who is kind and caring, but not overly friendly, and who is efficient without being mechanical. The study also pointed out the different expectations patients have. For example, some patients want the doctor to initiate conversations on sexual topics, while others feel they should be the ones to initiate the discussion. This gives responsibility to the physician to "feel out" the wishes of his patients, 80 he can act accordingly. Finally, research on patient satisfaction can bring out important issues that aren't directly related to immediate patient satisfaction. In this study, most of the women considered the OB/GYN to be her primary care physician. With this knowledge, physicians should not overlook problems that are not related to his or her specialty, thinking that it is being taken care of by another doctor. Research on patient CS/D is important because without the knowledge it gives the physician, s/he can't make the informed marketing decisions that are becoming more and more necessary in today's health care market.

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