Question

Hospital questionnaires: spend some time reviewing the mission and goals of the organization you select so that you understand what they are trying to accomplish and why the question year was used for evaluation

describe how you would redesign the survey and explain how your revision would improve it.

Answer 1

Over the past 20 years, patient satisfaction surveys have gained increasing attention as meaningful and essential sources of information for identifying gaps and developing an effective action plan for quality improvement in healthcare organizations.

The design of a questionnaire will depend on whether the researcher wishes to collect exploratory information (i.e. qualitative information for the purposes of better understanding or the generation of hypotheses on a subject) or quantitative information (to test specific hypotheses that have previously been generated).

Exploratory questionnaires: If the data to be collected is qualitative or is not to be statistically evaluated, it may be that no formal questionnaire is needed. For example, in interviewing the female head of the household to find out how decisions are made within the family when purchasing breakfast foodstuffs, a formal questionnaire may restrict the discussion and prevent a full exploration of the woman's views and processes. Instead one might prepare a brief guide, listing perhaps ten major open-ended questions, with appropriate probes/prompts listed under each.

Formal standardised questionnaires: If the researcher is looking to test and quantify hypotheses and the data is to be analysed statistically, a formal standardised questionnaire is designed. Such questionnaires are generally characterised by:

· prescribed wording and order of questions, to ensure that each respondent receives the same stimuli

· prescribed definitions or explanations for each question, to ensure interviewers handle questions consistently and can answer respondents' requests for clarification if they occur

· prescribed response format, to enable rapid completion of the questionnaire during the interviewing process.

Given the same task and the same hypotheses, six different people will probably come up with six different questionnaires that differ widely in their choice of questions, line of questioning, use of open-ended questions and length. There are no hard-and-fast rules about how to design a questionnaire, but there are a number of points that can be borne in mind:

1. A well-designed questionnaire should meet the research objectives. This may seem obvious, but many research surveys omit important aspects due to inadequate preparatory work, and do not adequately probe particular issues due to poor understanding. To a certain degree some of this is inevitable. Every survey is bound to leave some questions unanswered and provide a need for further research but the objective of good questionnaire design is to 'minimise' these problems.

2. It should obtain the most complete and accurate information possible. The questionnaire designer needs to ensure that respondents fully understand the questions and are not likely to refuse to answer, lie to the interviewer or try to conceal their attitudes. A good questionnaire is organised and worded to encourage respondents to provide accurate, unbiased and complete information.

3. A well-designed questionnaire should make it easy for respondents to give the necessary information and for the interviewer to record the answer, and it should be arranged so that sound analysis and interpretation are possible.

4. It would keep the interview brief and to the point and be so arranged that the respondent(s) remain interested throughout the interview.

Each of these points will be further discussed throughout the following sections. Figure 4.1 shows how questionnaire design fits into the overall process of research design that was described in chapter 1 of this textbook. It emphasises that writing of the questionnaire proper should not begin before an exploratory research phase has been completed.

The steps preceding questionnaire design

Even after the exploratory phase, two key steps remain to be completed before the task of designing the questionnaire should commence. The first of these is to articulate the questions that research is intended to address. The second step is to determine the hypotheses around which the questionnaire is to be designed.

It is possible for the piloting exercise to be used to make necessary adjustments to administrative aspects of the study. This would include, for example, an assessment of the length of time an interview actually takes, in comparison to the planned length of the interview; or, in the same way, the time needed to complete questionnaires. Moreover, checks can be made on the appropriateness of the timing of the study in relation to contemporary events such as avoiding farm visits during busy harvesting periods.

There are nine steps involved in the development of a questionnaire:

1. Decide the information required.
2. Define the target respondents.
3. Choose the method(s) of reaching your target respondents.
4. Decide on question content.
5. Develop the question wording.
6. Put questions into a meaningful order and format.
7. Check the length of the questionnaire.
8. Pre-test the questionnaire.
9. Develop the final survey form.

Deciding on the information required

It should be noted that one does not start by writing questions. The first step is to decide 'what are the things one needs to know from the respondent in order to meet the survey's objectives?' These, as has been indicated in the opening chapter of this textbook, should appear in the research brief and the research proposal.

One may already have an idea about the kind of information to be collected, but additional help can be obtained from secondary data, previous rapid rural appraisals and exploratory research. In respect of secondary data, the researcher should be aware of what work has been done on the same or similar problems in the past, what factors have not yet been examined, and how the present survey questionnaire can build on what has already been discovered. Further, a small number of preliminary informal interviews with target respondents will give a glimpse of reality that may help clarify ideas about what information is required.

Define the target respondents

At the outset, the researcher must define the population about which he/she wishes to generalise from the sample data to be collected. For example, in marketing research, researchers often have to decide whether they should cover only existing users of the generic product type or whether to also include non-users. Secondly, researchers have to draw up a sampling frame. Thirdly, in designing the questionnaire we must take into account factors such as the age, education, etc. of the target respondents.

Choose the method(s) of reaching target respondents

It may seem strange to be suggesting that the method of reaching the intended respondents should constitute part of the questionnaire design process. However, a moment's reflection is sufficient to conclude that the method of contact will influence not only the questions the researcher is able to ask but the phrasing of those questions. The main methods available in survey research are:

· personal interviews
· group or focus interviews
· mailed questionnaires
· telephone interviews.

Within this region the first two mentioned are used much more extensively than the second pair. However, each has its advantages and disadvantages. A general rule is that the more sensitive or personal the information, the more personal the form of data collection should be.

Decide on question content

Researchers must always be prepared to ask, "Is this question really needed?" The temptation to include questions without critically evaluating their contribution towards the achievement of the research objectives, as they are specified in the research proposal, is surprisingly strong. No question should be included unless the data it gives rise to is directly of use in testing one or more of the hypotheses established during the research design.

There are only two occasions when seemingly "redundant" questions might be included:

· Opening questions that are easy to answer and which are not perceived as being "threatening", and/or are perceived as being interesting, can greatly assist in gaining the respondent's involvement in the survey and help to establish a rapport.

This, however, should not be an approach that should be overly used. It is almost always the case that questions which are of use in testing hypotheses can also serve the same functions.

· "Dummy" questions can disguise the purpose of the survey and/or the sponsorship of a study. For example, if a manufacturer wanted to find out whether its distributors were giving the consumers or end-users of its products a reasonable level of service, the researcher would want to disguise the fact that the distributors' service level was being investigated. If he/she did not, then rumours would abound that there was something wrong with the distributor.

Develop the question wording

Survey questions can be classified into three forms, i.e. closed, open-ended and open response-option questions. So far only the first of these, i.e. closed questions has been discussed. This type of questioning has a number of important advantages;

· It provides the respondent with an easy method of indicating his answer - he does not have to think about how to articulate his answer.

· It 'prompts' the respondent so that the respondent has to rely less on memory in answering a question.

· Responses can be easily classified, making analysis very straightforward.

· It permits the respondent to specify the answer categories most suitable for their purposes.

Disadvantages are also present when using such questions

· They do not allow the respondent the opportunity to give a different response to those suggested.

· They 'suggest' answers that respondents may not have considered before.

With open-ended questions the respondent is asked to give a reply to a question in his/her own words. No answers are suggested.

Example: "What do you like most about this implement?"

Open-ended questions have a number of advantages when utilised in a questionnaire:

· They allow the respondent to answer in his own words, with no influence by any specific alternatives suggested by the interviewer.

· They often reveal the issues which are most important to the respondent, and this may reveal findings which were not originally anticipated when the survey was initiated.

· Respondents can 'qualify' their answers or emphasise the strength of their opinions.

However, open-ended questions also have inherent problems which means they must be treated with considerable caution. For example:

· Respondents may find it difficult to 'articulate' their responses i.e. to properly and fully explain their attitudes or motivations.

· Respondents may not give a full answer simply because they may forget to mention important points. Some respondents need prompting or reminding of the types of answer they could give.

· Data collected is in the form of verbatim comments - it has to be coded and reduced to manageable categories. This can be time consuming for analysis and there are numerous opportunities for error in recording and interpreting the answers given on the part of interviewers.

· Respondents will tend to answer open questions in different 'dimensions'. For example, the question: "When did you purchase your tractor?", could elicit one of several responses, viz:

"A short while ago".
"Last year".
"When I sold my last tractor".
"When I bought the farm".

Such responses need to be probed further unless the researcher is to be confronted with responses that cannot be aggregated or compared.

It has been suggested that the open response-option questions largely eliminate the disadvantages of both the afore-mentioned types of question. An open response-option is a form of question which is both open-ended and includes specific response-options as well. For example,

What features of this implement do you like?

· Performance
· Quality
· Price
· Weight
· Others mentioned:

The advantages of this type of question are twofold:

· The researcher can avoid the potential problems of poor memory or poor articulation by then subsequently being able to prompt the respondent into considering particular response options.

· Recording during interview is relatively straightforward.

The one disadvantage of this form of question is that it requires the researcher to have a good prior knowledge of the subject in order to generate realistic/likely response options before printing the questionnaire. However, if this understanding is achieved the data collection and analysis process can be significantly eased.

Clearly there are going to be situations in which a questionnaire will need to incorporate all three forms of question, because some forms are more appropriate for seeking particular forms of response. In instances where it is felt the respondent needs assistance to articulate answers or provide answers on a preferred dimension determined by the researcher, then closed questions should be used. Open-ended questions should be used where there are likely to be a very large number of possible different responses (e.g. farm size), where one is seeking a response described in the respondent's own words, and when one is unsure about the possible answer options. The mixed type of question would be advantageous in most instances where most potential response-options are known; where unprompted and prompted responses are valuable, and where the survey needs to allow for unanticipated responses.

There are a series of questions that should be posed as the researchers develop the survey questions themselves:

"Is this question sufficient to generate the required information?"

For example, asking the question "Which product do you prefer?" in a taste panel exercise will reveal nothing about the attribute(s) the product was judged upon. Nor will this question reveal the degree of preference. In such cases a series of questions would be more appropriate.

"Can the respondent answer the question correctly?"

· An inability to answer a question arises from three sources:

· Having never been exposed to the answer, e.g. "How much does your husband earn?"

· Forgetting, e.g. What price did you pay when you last bought maize meal?"

· An inability to articulate the answer: e.g. "What improvements would you want to see in food preparation equipment?"

"Are there any external events that might bias response to the question?"

For example, judging the popularity of beef products shortly after a foot and mouth epidemic is likely to have an effect on the responses.

"Do the words have the same meaning to all respondents?"

For example, "How many members are there in your family?"

There is room for ambiguity in such a question since it is open to interpretation as to whether one is speaking of the immediate or extended family.

"Are any of the words or phrases loaded or leading in any way?"

For example," What did you dislike about the product you have just tried?"

The respondent is not given the opportunity to indicate that there was nothing he/she disliked about the product. A less biased approach would have been to ask a preliminary question along the lines of, "Did you dislike any aspect of the product you have just tried?", and allow him/her to answer yes or no.

"Are there any implied alternatives within the question?"

The presence or absence of an explicitly stated alternative can have dramatic effects on responses. For example, consider the following two forms of a question asked of a 'Pasta-in-a-Jar' concept test:

1. " Would you buy pasta-in-a-jar if it were locally available?"
2. "If pasta-in-a-jar and the cellophane pack you currently use were both available locally, would you:

· Buy only the cellophane packed pasta?
· Buy only the pasta-in-a-jar product?
· Buy both products?"

The explicit alternatives provide a context for interpreting the true reactions to the new product idea. If the first version of the question is used, the researcher is almost certain to obtain a larger number of positive responses than if the second form is applied.

"Will the question be understood by the type of individual to be interviewed?"

It is good practice to keep questions as simple as possible. Researchers must be sensitive to the fact that some of the people he/she will be interviewing do not have a high level of education. Sometimes he/she will have no idea how well or badly educated the respondents are until he/she gets into the field. In the same way, researchers should strive to avoid long questions. The fewer words in a question the better. Respondents' memories are limited and absorbing the meaning of long sentences can be difficult: in listening to something they may not have much interest in, the respondents' minds are likely to wander, they may hear certain words but not others, or they may remember some parts of what is said but not all.

"Is there any ambiguity in my questions?"

The careless design of questions can result in the inclusion of two items in one question. For example: "Do you like the speed and reliability of your tractor?"

The respondent is given the opportunity to answer only 'yes' or 'no', whereas he might like the speed, but not the reliability, or vice versa. Thus it is difficult for the respondent to answer and equally difficult for the researcher to interpret the response.

The use of ambiguous words should also be avoided. For example: "Do you regularly service your tractor?"

The respondents' understanding and interpretation of the term 'regularly' will differ. Some may consider that regularly means once a week, others may think once a year is regular. The inclusion of such words again present interpretation difficulties for the researcher.

"Are any words or phrases vague?"

Questions such as 'What is your income?' are vague and one is likely to get many different responses with different dimensions. Respondents may interpret the question in different terms, for example:

· hourly pay?
· weekly pay?
· yearly pay?
· income before tax?
· income after tax?
· income in kind as well as cash?
· income for self or family?
· all income or just farm income?

The researcher needs to specify the 'term' within which the respondent is to answer.

"Are any questions too personal or of a potentially embarrassing nature?"

The researcher must be clearly aware of the various customs, morals and traditions in the community being studied. In many communities there can be a great reluctance to discuss certain questions with interviewers/strangers. Although the degree to which certain topics are taboo varies from area to area, such subjects as level of education, income and religious issues may be embarrassing and respondents may refuse to answer.

"Do questions rely on feats of memory?"

The respondent should be asked only for such data as he is likely to be able to clearly remember. One has to bear in mind that not everyone has a good memory, so questions such as 'Four years ago was there a shortage of labour?' should be avoided.

Putting questions into a meaningful order and format

Opening questions: Opening questions should be easy to answer and not in any way threatening to THE respondents. The first question is crucial because it is the respondent's first exposure to the interview and sets the tone for the nature of the task to be performed. If they find the first question difficult to understand, or beyond their knowledge and experience, or embarrassing in some way, they are likely to break off immediately. If, on the other hand, they find the opening question easy and pleasant to answer, they are encouraged to continue.

Question flow: Questions should flow in some kind of psychological order, so that one leads easily and naturally to the next. Questions on one subject, or one particular aspect of a subject, should be grouped together. Respondents may feel it disconcerting to keep shifting from one topic to another, or to be asked to return to some subject they thought they gave their opinions about earlier.

Question variety:. Respondents become bored quickly and restless when asked similar questions for half an hour or so. It usually improves response, therefore, to vary the respondent's task from time to time. An open-ended question here and there (even if it is not analysed) may provide much-needed relief from a long series of questions in which respondents have been forced to limit their replies to pre-coded categories. Questions involving showing cards/pictures to respondents can help vary the pace and increase interest.

Closing questions

It is natural for a respondent to become increasingly indifferent to the questionnaire as it nears the end. Because of impatience or fatigue, he may give careless answers to the later questions. Those questions, therefore, that are of special importance should, if possible, be included in the earlier part of the questionnaire. Potentially sensitive questions should be left to the end, to avoid respondents cutting off the interview before important information is collected.

In developing the questionnaire the researcher should pay particular attention to the presentation and layout of the interview form itself. The interviewer's task needs to be made as straight-forward as possible.

· Questions should be clearly worded and response options clearly identified.

· Prescribed definitions and explanations should be provided. This ensures that the questions are handled consistently by all interviewers and that during the interview process the interviewer can answer/clarify respondents' queries.

Ample writing space should be allowed to record open-ended answers, and to cater for differences in handwriting between interviewers.

Physical appearance of the questionnaire

The physical appearance of a questionnaire can have a significant effect upon both the quantity and quality of marketing data obtained. The quantity of data is a function of the response rate. Ill-designed questionnaires can give an impression of complexity, medium and too big a time commitment. Data quality can also be affected by the physical appearance of the questionnaire with unnecessarily confusing layouts making it more difficult for interviewers, or respondents in the case of self-completion questionnaires, to complete this task accurately. Attention to just a few basic details can have a disproportionately advantageous impact on the data obtained through a questionnaire.

Use of booklets	The use of booklets, in the place of loose or stapled sheets of paper, make it easier for interviewer or respondent to progress through the document. Moreover, fewer pages tend to get lost.
Simple, clear formats	The clarity of questionnaire presentation can also help to improve the ease with which interviewers or respondents are able to complete a questionnaire.
Creative use of space and typeface	In their anxiety to reduce the number of pages of a questionnaire these is a tendency to put too much information on a page. This is counter-productive since it gives the questionnaire the appearance of being complicated. Questionnaires that make use of blank space appear easier to use, enjoy higher response rates and contain fewer errors when completed.
Use of colour coding	Colour coding can help in the administration of questionnaires. It is often the case that several types of respondents are included within a single survey (e.g. wholesalers and retailers). Printing the questionnaires on two different colours of paper can make the handling easier.
Interviewer instructions	Interviewer instructions should be placed alongside the questions to which they pertain. Instructions on where the interviewers should probe for more information or how replies should be recorded are placed after the question.

In general it is best for a questionnaire to be as short as possible. A long questionnaire leads to a long interview and this is open to the dangers of boredom on the part of the respondent (and poorly considered, hurried answers), interruptions by third parties and greater costs in terms of interviewing time and resources. In a rural situation an interview should not last longer then 30-45 minutes.

Piloting the questionnaires

Even after the researcher has proceeded along the lines suggested, the draft questionnaire is a product evolved by one or two minds only. Until it has actually been used in interviews and with respondents, it is impossible to say whether it is going to achieve the desired results. For this reason it is necessary to pre-test the questionnaire before it is used in a full-scale survey, to identify any mistakes that need correcting.

The purpose of pretesting the questionnaire is to determine:

· whether the questions as they are worded will achieve the desired results

· whether the questions have been placed in the best order

· whether the questions are understood by all classes of respondent

· whether additional or specifying questions are needed or whether some questions should be eliminated

· whether the instructions to interviewers are adequate.

Usually a small number of respondents are selected for the pre-test.

The respondents selected for the pilot survey should be broadly representative of the type of respondent to be interviewed in the main survey.

If the questionnaire has been subjected to a thorough pilot test, the final form of the questions and questionnaire will have evolved into its final form. All that remains to be done is the mechanical process of laying out and setting up the questionnaire in its final form. This will involve grouping and sequencing questions into an appropriate order, numbering questions, and inserting interviewer instructions.

A well designed questionnaire is essential to a successful survey. However, the researcher must develop his/her own intuition with respect to what constitutes 'good design' since there is no theory of questionnaires to guide him/her.

A good questionnaire is one which help directly achieve the research objectives, provides complete and accurate information; is easy for both interviewers and respondents to complete, is so designed as to make sound analysis and interpretation possible and is brief.

There are at least nine distinct steps: decide on the information required; define the target respondents, select the method(s) of reaching the respondents; determine question content; word the questions; sequence the questions; check questionnaire length; pre-test the questionnaire and develop the final questionnaire.

Over the past 20 years, patient satisfaction surveys have gained increasing attention as meaningful and essential sources of information for identifying gaps and developing an effective action plan for quality improvement in healthcare organizations. However, there are very few published studies reporting of the improvements resulting from feedback information of patient satisfaction surveys, and in most cases, these studies are contradictory in their findings. This article investigates in-depth a number of research studies that critically discuss the relationship of dependent and independent influential attributes towards overall patient satisfaction in addition to its impact on the quality improvement process of healthcare organizations.

Healthcare industries have seen recent movements towards continuous quality improvement and this has gained momentum since 1990 and according to Donabedian's declaration for incorporating patient perception into quality assessment, healthcare managers thus incorporate patient centered care as a major component in the healthcare mission.The healthcare managers that endeavor to achieve excellence take patient perception into account when designing the strategies for quality improvement of care. Recently, the healthcare regulators shifted towards a market -driven approach of turning patient satisfaction surveys into a quality improvement tool for overall organizational performance. In 1996, evaluation of patient satisfaction was mandatory for all French hospitals. Laurent et al. 2006 conducted a study in a tertiary teaching hospital in France aiming to assess the opinions of clinical staff towards the effect of in-patient satisfaction surveys on the quality improvement process. A favorable result of 94% revealed that the patient was able to judge hospital service quality, especially in its relational, organizational and environmental dimensions.

In Germany, measuring satisfaction has been required since 2005 as an element of quality management reports. Since 2002, the Department of Health (DOH) has launched a national survey program in which all NHS trusts in England have to survey patient satisfaction on an annual basis and report the results to their regulators. Therefore, measurement of patient satisfaction is a legitimate indicator for improving the services and strategic goals for all healthcare organizations.

In this review, the primary aim is to carry out an in-depth investigation into a number of research studies that critically discuss the relationship of dependent and independent influential attributes to overall patient satisfaction in addition to its impact on the quality improvement process within healthcare organizations. The literature also focuses on measurement tools of patient satisfaction.

Methodology and Search strategy

Two methods were used as search strategies. The first was keywords and the second is called the snowball search method. Recent studies published in the last 15 years, from 1997 until 2012 and those written only in English were selected.

The research studies included satisfaction surveys of patients who have been hospitalized or patients visiting the out-patient departments within tertiary hospitals in different foreign countries. The research empirically excluded all patient satisfaction surveys related to ambulatory care centers, specific departments or specialties.

The databases utilized were Google Scholar, Medline, Emerald, Pub-Med and Science Direct, while the main keywords used were: patient satisfaction surveys, quality improvement, patient feedback, hospitals and patient satisfaction measurement. The outcome of the research study was 29 articles that appeared to be highly relevant to the subject under investigation.

The concept of patient satisfaction

There is no consensus between the literatures on how to define the concept of patient satisfaction in healthcare. In Donabedian's quality measurement model, patient satisfaction is defined as patient-reported outcome measure while the structures and processes of care can be measured by patient-reported experiences. Many authors tend to have different perceptions of definitions of patient satisfaction. Jenkinson C et al. (2002) and Ahmed et al. (2011) pointed out that patient satisfaction mostly appears to represent attitudes towards care or aspects of care. While Mohan et al. (2011) referred to patient satisfaction as patients’ emotions, feelings and their perception of delivered healthcare services. On the other hand, other authors defined patient satisfaction as a degree of congruency between patient expectations of ideal care and their perceptions of real care received.

Measurement of patient satisfaction

The reviewed literature agreed on the fact that there is an impact of measuring patient satisfaction on quality improvement of care. Patients’ evaluation of care is a realistic tool to provide opportunity for improvement, enhance strategic decision making, reduce cost, meet patients' expectations, frame strategies for effective management, monitor healthcare performance of health plans and provide benchmarking across the healthcare institutions.

In addition, due to the tendency of healthcare industries to concentrate on patient-centered care; patient satisfaction reflects patients' involvement in decision making and their role as partners in improving the quality of healthcare services. Mohan et al. also deemed the significant correlation between measuring patient satisfaction and continuity of care where the satisfied patients tend to comply with the treatment and adhere to the same healthcare providers. Patient satisfaction represents a key marker of communication and health-related behavior. In contrast, some of the literature dismiss patients' views as a wholly subjective evaluation and an unreliable judgment of the quality of care.

Basically, there are two approaches for evaluating patient satisfaction-qualitative and quantitative. The quantitative approach provides accurate methods to measure patient satisfaction. Standardized questionnaires (either self-reported or interviewer-administrated or by telephone) have been the most common assessment tool for conducting patient satisfaction studies.

There is a great variation in questionnaires as instruments of measuring patient satisfaction. The spectrum includes: instruments provided by private vendors, which are usually not published and their reliability and validity are not clear. Secondly, there are quite a number of publically and standardized instruments such as patient satisfaction questionnaires; PSQ-18 and consumer assessment health plans (CAHPS). Such instruments have the advantage of good reliability and validity; however, offer limited scope of survey questions.Thirdly, internally developed instruments which are mainly generated entirely de novo or import questions from other existing standardized instruments. A survey conducted in 16 academic medical centers across the USA in 2002 to determine the type of patient satisfaction instrument that was used at each center established that the majority of institutions use an internally developed instrument for outpatient satisfaction, while they used private vendor's instruments for inpatient satisfaction. Patient satisfaction measurement tools should be reliable and valid in order to precisely function and to realise the main goal of collecting patient’s feedback.14

Another large survey conducted in major acute care hospitals in five countries (United Kingdom, USA, Sweden, Switzerland and Germany) to determine the applicability and relevance of short form questionnaire (PPEQ- 15) from Picker Patient Experience Questionnaire for inpatient experience concluded that PPEQ -15 demonstrates a high correlation of selected items, high consistence validity across countries and a high association of the gold standard.

On the other hand, Yellen et al. (2002) and Kilbourne et al. (2004) declared that based on many standardized, validated patient satisfaction instruments which have been developed primarily to assess patient satisfaction with specific aspects of care, these have little potential of validity and reliability in other settings of care.6,16 Therefore, selecting an appropriate patient satisfaction instrument is a critical challenge for healthcare organizations.

One critical literature review on survey instruments and other existing studies ascertained that the plethora of survey instruments measuring patient satisfaction in healthcare industries is heartening; however, core instruments need to be standardized and there needs to be centralized uniform information collection.

Determinants of patient satisfaction

In the increasingly competitive market of healthcare industries, healthcare managers should focus on achieving high or excellent ratings of patient satisfaction to improve the quality of service delivery; therefore, healthcare managers need to characterize the factors influencing patient satisfaction which are used as a means to assess the quality of healthcare delivery. In order to understand various factors affecting patient satisfaction, researchers have explored various dimensions of the perceived service quality, as meaningful and essential measures of patient perception of healthcare quality. Kaneet et al. (1997) and Marley et al. stated that measuring satisfaction should "incorporate dimensions of technical, interpersonal, social, and moral aspects of care".2 Research of patient satisfaction in advanced as well as developing countries has many common and some unique variables and attributes that influence overall patient satisfaction.

Most of the studies in the literature review examined the correlation between demographic factors such as age, gender, health status and level of education with patient satisfaction; however, the findings from these studies are conflicting. Two studies, one conducted in Scotland whereby 650 patients discharged from four acute care general hospitals during February and March 2002, and the second study was conducted in 32 different large tertiary hospitals in the USA; both showed that male patients, patients older than 50 years of age, patients who had a shorter length of stay or better health status and those with primary level education had higher scores related to variable health service-related domains.

On the other hand, a national survey performed in different accredited hospitals of Taiwan found that patient characteristics such as age, gender and education level only slightly influenced patient satisfaction but that the health status of patients is an important predictor of a patient’s overall satisfaction.12 In addition, Nguyen et al. (2002) and Jenkinson et al. (2002) declared from their studies that the two strongest and most consistent determinants of higher satisfaction are old age and better health status.8,18 While two studies reported contrary results regarding the influential effect of the two controlled variables (age and gender) on overall patient satisfaction in different aspects of healthcare services. In contrast, a 2006 national survey of 63 hospitals in the five health regions in Norway showed that age, gender, perceived health and education level were not significant predictors of overall patient satisfaction.

These factors are not modifiable and are impractical for healthcare managers that are eager to improve patient satisfaction.Though these patient characteristics should be considered for fair adjustment of patient satisfaction studies in order to be utilized in benchmarking with other healthcare institutions. On the other hand, the researchers extensively discussed the multidimensional attributes of healthcare settings that were shown to be the most potent determinants for improving the overall patient satisfaction. Healthcare managers need to direct more efforts towards those highly ranked attributes and initiate some improvement strategies in other areas of health services that are unsatisfactory from the patient's perspective.

A remarkable outcome of four studies conducted in tertiary hospitals in different countries revealed that the nurses' courtesy, respect, careful listening and easy access of care was particularly the strongest driver of overall patient satisfaction. These aspects of nursing care are highly ranked by patients compared to other independent factors such as physician care, admission process, physical environment and cleanliness. In addition, a study carried out in 430 hospitals in the USA found the nurse work environment and patient-nurse staffing ratio had statistically significant effects on patient satisfaction and recommendations.

In 2011, Otani et al. surveyed 32 different large tertiary hospitals in the USA to identify the relationship of nursing care, physician care and physical environment to the overall patient satisfaction and the results showed that all attributes were statistically significant and positively related to overall satisfaction; however, nursing care was the most critical to increase overall patient satisfaction. The researchers also found that the courtesy and respect of healthcare providers impact more on patient satisfaction while communication and explanation are the second most important aspect In contrast, a survey conducted at 13 acute care hospitals in Ireland revealed that effective communication and clear explanation had the strongest impact in improving the overall patient satisfaction among other attributes of care.These findings provide evidence of the importance of the nursing role as the most significant determinant of overall patient satisfaction.

While three other studies found that interpersonal communication skills of physicians in terms of their attitude, explanation of conditions, level of care, emotional support, respect for patient preferences and involving patients in decision making were more influential factors than clinical competence and hospital tangibles on patient satisfaction. However, a survey conducted in a tertiary care academic hospital in the USA showed that only 33% of physicians were rated as excellent for their communication behavior which suggests that there is room for improvement in physician communication behavior in the hospital to improve quality of care. In addition, the main outcome of a study using the data of 202 participants from general acute care hospitals in the USA, concluded that most determinants of patient satisfaction was related to communication, empathy and caring from hospital personnel.

There are some contrary comments which were disclosed regarding the aspects of hospital environment and amenities which scored lowest for a patient satisfaction index in a study carried out in out-patients departments in South Korea.22 Correspondingly, a study conducted in a public hospital in France found the most common problems experienced by patients were related to hospital living arrangements and amenities.18 A similar result was reported in a study conducted at five hospitals served under the BJC Healthcare System.19 Furthermore, in 2012 Arshad et al. reported that the major dissatisfaction in an out-patients department was the long waiting time and overcrowded registration.26 In contrast, a study carried out in five different hospitals in Scotland found that physical comfort had the highest satisfaction rate compared to other core dimensions: information, coordination of care and emotional support.

Impact of satisfaction surveys results on hospital quality improvement

Over the past 20 years, patient satisfaction surveys have gained increasing attention; however, there is little published research on improvements resulting from feedback information of patient satisfaction surveys,27 and most often these studies are contradictory in their findings.3 Four studies in the literature review investigated to what extent healthcare managers and policy makers obtain patient views to target new quality improvement projects. More recently, a survey conducted in a teaching hospital in France confirmed that reported data from satisfaction surveys led to the implementation of some improvement initiatives mainly in a hospital environment but no significant change in care providers’ behavior such as interpersonal skills.

On the contrary, the main finding of a wide state survey conducted in Victoria, Australia, over a 5 year period showed that very limited improvement initiatives have been commenced.27 On the other hand, in 2002 Barr et al. examined the quality improvement activities in 13 tertiary care hospitals in response to public reports of patient satisfaction. The results showed that each of these hospitals introduced a variety in the range of quality improvement initiatives that address different aspects of care.28 Correspondingly, a survey assessed patients’ perception feedback in 50 hospitals in Massachusetts, which resulted in a wide range of successful improvement projects.

Conclusion

Patient satisfaction is not a clearly defined concept, although it is identified as an important quality outcome indicator to measure success of the services delivery system. Patient evaluation of care is important to provide opportunity for improvement such as strategic framing of health plans, which sometimes exceed patient expectations and benchmarking. The advantages of patient satisfaction surveys rely heavily on using standardized, psychometrically tested data collection approaches. Therefore, a standardized tool needs to be further developed and refined in order to reflect positively on the main goals of patient satisfaction survey. This literature review provides a comprehensive understanding of determinants of patient satisfaction either dependent or in-dependent variables, and compares the magnitude of the effects of various independent healthcare dimensions on overall patient satisfaction. There was a common salient determining factor between the studies which was interpersonal skills in terms of courtesy, respect by healthcare providers in addition to communication skills, explanation and clear information, which are more essential and influential than other technical skills such as clinical competency and hospital equipment.

Although feedback from patient satisfaction surveys is an established yardstick for healthcare quality improvement plans, they are still not being systematically and extensively utilized for developing improvement initiatives. Furthermore, it is agreed that a patient satisfaction questionnaire is considered to be a significant quality improvement tool; therefore, detailed description of the different questionnaires that have been used to assess patient satisfaction surveys will be discussed extensively in a separate study. Finally, this review of various elements of patient satisfaction ranging from its measurement, predictors for improving overall patient satisfaction and impact of collecting patient information to build up strategic quality improvement plans and initiatives has shed light on the magnitude of the subject. It thus provides the opportunity for organization managers and policy makers to yield a better understanding of patient views and perceptions, and the extent of their involvement in improving the quality of care and services. Furthermore, mangers implement effective change by unfreezing old behaviors, introducing new ones, and re-freezing them for better healthcare.