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Journal of Retailing and Consumer Services xxx (xxxx) xxxxxx

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Journal of Retailing and Consumer Services

journal homepage: www.elsevier.com/locate/jretconser

Understanding quality and satisfaction in public hospital services: A

nationwide inpatient survey in Greece

Panagiotis Mitropoulos, Konstantinos Vasileiou, Ioannis Mitropoulos
Department of Business Administration, Technological Education Institute of Western Greece, GR-26500 Patras, Greece


Keywords: Health services compared to the most of other sectors' customer services present some special traits, such as
Patients' satisfaction extreme complexity, co-production, and intangibility, while nancial and human consequences of low quality
HCAHPS are high. This study reports on the ndings of a nationwide HCAHPS questionnaire survey conducted in Greece
Nationwide survey after the implementation of the health system reform due to the nancial crisis regarding the factors determining
inpatient satisfaction in public hospitals. HCAHPS data were initially analysed by factor analysis followed by an
Public hospital
ordinal regression analysis, which aimed to identify the determinants with signicant impact on inpatient
satisfaction. The study results are consistent with prior research which indicated that the communication with
nurses is the most salient predictor of overall patients satisfaction followed by communication with doctors.
Moreover, certain patient (age and health status) and hospital institutional (type and location) characteristics
also contribute signicantly to patients perceived overall satisfaction. Hence, health quality improvement
activities should consider the critical dierences among patient subgroups and hospital types in order to full
consumer needs and preferences more eectively.

1. Introduction Even though patients perceived medical care quality is biased, in

terms of the marketing principles, they are actually the consumers-
Patient satisfaction has been a key issue in assessing the perfor- customers of the healthcare system (Huang et al., 2004), as well as the
mance of health care providers over the last decades (Vogus and exclusive payers, either directly to the private or mostly indirectly
McClelland, 2016; Kleefstra et al., 2015; Schoenfelder et al., 2011; through taxes to the public health providers, of the services delivered to
Xesngi and Karamanis, 2015; Pini et al., 2014). Toundas et al. (2003) them. Consequently, their perceived satisfaction is by far the most
mentioned that over a thousand of studies regarding patient percep- important criterion to evaluate the performance of the medical care
tions about their medical care are published each year. system. Moreover, in several occasions patients satisfaction may play
Patients perceptions with respect to the quality of services provided an important role to their willingness to get involved in their care and
by the health care system suer from subjectivity given that, inter alia, conform to the treatment plans (Sofaer and Firminger, 2005; Vogus and
patients scientic and technical knowledge of medical care issues is McClelland, 2016; Al-Refaie, 2011). Additionally, Huang et al. (2004)
rather limited, and the perceived healthcare quality is subject to the supported that increased levels of patient satisfaction redound to the
patients' physical and psychological situation and their sociodemo- outcomes of the health care system in terms of reduced utilisation of
graphic characteristics (Schoenfelder et al., 2011; Merkouris et al., medical services, advanced prognosis, less malpractice litigation, and a
2013; Vogus and McClelland, 2016; Dempsey et al., 2014). Moreover, higher level of compliance. Therefore, as Pascoe (1983) mentioned
the incredibly complex nature of human disease renders the health care patients satisfaction is hypothesised to be both a dependent variable
procedures extremely complicated, only to mention that even when and a predictor of future health-related behaviour.
there is a consensus about a patient's health state diagnosis, it is very The great importance of patients' satisfaction has led to a great
probable that doctors disagree about the best course of treatment number of dierent instruments for its measurement worldwide, that
(Nembhard et al., 2009). Additionally, the interests and targets of focus on the various aspects of medical care experience, such as
health providers and patients do not, compulsory, coincide, but the communication with healthcare providers, access to hospital, the
decision making depends, more, on health professionals opinion quality of basic amenities, waiting time to make an appointment and
(Nembhard et al., 2009). to be examined at the clinic (Bleich et al., 2009; Aletras et al., 2009).

Corresponding author.
E-mail addresses: pmitro@upatras.gr (P. Mitropoulos), vasileiou@teiwest.gr (K. Vasileiou), mitro@teiwest.gr (I. Mitropoulos).

Received 27 January 2016; Accepted 8 July 2016
0969-6989/ 2017 Elsevier Ltd. All rights reserved.

Please cite this article as: Mitropoulos, P., Journal of Retailing and Consumer Services (2017),
P. Mitropoulos et al. Journal of Retailing and Consumer Services xxx (xxxx) xxxxxx

Most of these instruments are specic to a country's health system or tion of the health system reform due to the nancial crisis, utilising the
type of the hospital rendering comparisons between countries and over data of the nationwide HCAHPS questionnaire survey conducted by the
time practically rather dicult, if not unattainable. Greek Ministry of Health during the period of May 2011 to November
The Hospital Consumer Assessment of Healthcare Providers and 2011. Moreover, the impact of the demographic characteristics of the
Systems (HCAHPS) survey, developed for use in the USA by the Centres patients and the institutional characteristics of hospitals on patients
for Medicare and Medicaid Services (CMS) with the collaboration of the satisfaction was also investigated.
Agency for Healthcare Quality Research (AHRQ) (Elliott et al., 2009a, In this light, the next section presents the methodology and the
2009b; Giordano et al., 2010), has been the most known standardized, sample of the study, followed by our research results. The paper
and unbiased set of measures of patient experience so far (Vogus and concludes with a discussion of our ndings, limitations of our work
McClelland, 2016). The HCAHPS survey has been endorsed by the and recommendations.
National Quality Forum (NQF) in the USA and it was also selected for
the purposes of the European Commission RN4CAST project, which 2. Study sample
involved 12 countries (Belgium, England, Finland, Germany, Greece,
Ireland, The Netherlands, Norway, Poland, Spain, Sweden and Switzer- The survey was administered by the Greek Ministry of Health
land) because of its potentiality to yield comparable results that would (MOH) with the aim to include all the 131 public hospitals operating
allow to obtain objective and meaningful comparisons across health in the national health system. However, 89 hospitals denied participa-
systems on domains that are important to consumers among the tion, claiming that there was a lack of the necessary budget and time.
participating European countries and the USA (Squires et al., 2012). Thus, data was selected by 42 hospitals, which are a fairly representa-
The content validity of the Greek translation of the HCAHPS survey has tive sample of hospitals to mirror the general structure of the national
already been examined by Squires et al. (2012) and achieved an health system.
'excellent' rating. The data were collected by the hospitals' Quality Oce that has the
The HCAHPS survey measures discharged inpatients experiences of responsibility to run the patient satisfaction survey on a yearly basis.
the hospital care, employing 25 patient rating items with respect to Using the simple random sampling technique, the patients received the
communication with nurses and doctors, the responsiveness of hospital corresponding questionnaire the previous day before being discharged
sta, the cleanliness and quietness of the hospital environment, pain and returned it to a secured drop box at the reception before leaving the
management, communication about medicines, discharge information, hospital. Then, at a centralised level, the sample was collected and
overall rating of hospital, and would they recommend the hospital, as validated by the Quality and Eciency Department of the MOH to
well as questions regarding patients demographics (CMS, 2014). ensure that it was representative of each hospital. The sample that was
The interest in evaluating the patients expectations and demands nally selected in the survey contains 5467 inpatients stratied
from the public health system is considerably rising during crisis according to the population of patients that each hospital served.
periods, where all involved stakeholders strive to optimise the e-
ciency and, especially, the eectiveness of the scarce public resources 3. Factor structure of service quality
dedicated to health care (Pantouvakis and Bouranta, 2014; Karanikolos
et al., 2013). Greece has indeed experienced a thrilling transition in the Exploratory factor analysis was conducted to explore latent factors
legislative, political and economic environment since early 2010 with within the questionnaire items and to verify the reliability and validity
enormous consequences on the health care system, given that the cuts of the service dimensions. Factor analysis can identify a more reduced
to hospital budgets exceed 40% and the shortages of personnel and set of variables without interrelationships in order to explain, in the
medical supplies dramatically raised. Kentikelenis et al. (2011) and highest possible degree, the variability found in the answers to the
Zavras et al. (2012) reported that Greeks health status self-evaluation questionnaire. The Principal Component Analysis method and ortho-
has worsened since the outbreak of the nancial crisis while the gonal (varimax) rotation were employed to extract the factors that
proportion of citizens that appreciate that they have limited access to would improve the interpretation of the participants answers with
medical care is steadily increasing. respect to the core part of the questionnaire which contains 11 services
Although, the investigation of patients' satisfaction with the medical attributes. In particular, we used 9 questions rated on a 4-point Likert
care provided by the Greek public hospitals is crucial for developing scale (Never, Sometimes, Usually, Always) covering 3 specic hospital
and implementing quality improvement strategies and activities, most practices: Communication with doctors (3 items), Communication with
of the published studies report on the patients' perceptions before the nurses (4 items) and the physical environment (2 items). The remaining
emergence of the nancial crisis (Niakas et al., 2004; Gnardellis and two items, rated on a dichotomous scale (No/Yes), cover the informa-
Niakas, 2005; Priporas et al., 2008; Matis et al., 2009; Aletras et al., tion about discharge.
2006, 2007, 2009; Panteli and Patistea, 2007; Labiris and Niakas, 2005; The analysis identied four factors with eigenvalues greater than 1.
Papanikolaou and Ntani, 2008; Polyzos et al., 2005; Toundas et al., The Kaiser-Meyer-Olkin statistic is 0.87, indicating strong correlations
2003; Pantouvakis and Bouranta, 2014; Pini et al., 2014; Chandrinou among items and conrms that factor analysis is an appropriate analysis
et al., 2013). Thus, the results from the aforementioned studies cannot of the sample as it exceeds the 0.5 acceptable limit (Kaiser, 1974). In
provide a solid basis for decision making in the contemporary Greek addition, the Bartlett's Test of Sphericity shows that the suitability of
Hospitals conditions, taking also into consideration that their sample the intercorrelation matrix of the 11 variables for factor analysis is
emanated from either a single or a limited number of hospitals and that signicant at the 0.001 level.
they did not follow international procedures and protocols for survey- Factors and items of the questionnaire are described in Table 1. This
ing data from General Hospitals (e.g. HCAHPS). There is only one table also presents the mean and standard deviation of the items, their
reported study on patients satisfaction assessment regarding their factor loadings and the Cronbach's alpha reliability index for each
experience of a Greek general hospital since the outbreak of the principal component. The results indicate strong relationships of the
nancial crisis (Xesngi and Karamanis, 2015). However, their study items within each factor that are independent of those of other factors.
sample concerns only a single general hospital in the capital Athens, The four factors identied, conrmed the four dimensions under
therefore, it is not possible to draw rm conclusions about the whole consideration of the HCAHPS questionnaire. Since all items load as
population of Greek patients. expected, it is evidence that the questionnaire exhibits strong con-
This paper aims to ll the gap in the literature by providing vergent validity.
evidence about the patients satisfaction regarding the medical care Then, we dened the four distinct factors which explain 69.08% of
they experienced from the Greek public hospitals after the implementa- total variance as follows: doctor communication (F-doctor) that

P. Mitropoulos et al. Journal of Retailing and Consumer Services xxx (xxxx) xxxxxx

Table 1
Results of the principle component analysis identication of core service dimensions.

Identied factor Item description Factor loading Mean (SD)

Doctor communication Frequency that doctors treated patient with courtesy and respect 0.793 3.79 (0.51)
(Cronbach alpha=0.79) Frequency that doctors explained things in a way the patient could understand 0.800 3.67 (0.65)
Frequency that doctors listened carefully to the patient 0.848 3.75 (0.57)

Nurse communication Frequency that nurses treated the patient with courtesy and respect 0.789 3.78 (0.53)
(Cronbach alpha=0.83) Frequency that nurses listened carefully to the patient 0.798 3.73 (0.56)
Frequency that nurses explained things in a way the patient could understand 0.690 3.63 (0.68)
Frequency that patient got help immediately after pressing the call button 0.568 3.73 (0.63)

Physical environment Frequency that the patient's room and bathroom were kept clean 0.773 3.67 (0.65)
(Cronbach alpha=0.72) Frequency that the area around patient's room was quiet at night? 0.736 3.41 (0.79)
Discharge Information Hospital sta talked with patient about the availability of necessary help when leaving the hospital 0.813 0.28 (0.44)
(Cronbach alpha=0.60) The patient got information in writing about what symptoms or health problems to look out for after leaving the 0.830 0.24 (0.42)

accounts for 11.59% of the variance, nurse communication (F-nurse) Table 2

that accounts for 40.56% of the variance, physical environment (F- Descriptive data for inpatients.
environment) that accounts for 7.62% of the variance, and information
Variable Percentage Mean (SD)
about discharge (F-information) that accounts for 9.30% of the
variance. Overall satisfaction (scale 110) 8.07 (2.30)
The internal consistency of the questionnaire was measured using Health status (scale 15) 2.96 (1.02)
Age, % (> 45) 66
Cronbach-alpha coecient. The value of Cronbach-alpha for the total
Gender, % female 53
sample was 0.77, verifying the instrument's scaling is reliable since it Nationality, % native 95
exceeds the minimum accepted value of 0.7 (De Vaus, 2002), even
though the low level of alpha is often associated with multidimensional
data and in specic situations such as social sciences some researchers secondary care hospitals are oering all ranges of secondary health
use smaller levels. The factor-wise internal consistency was 0.79 for care. The tertiary care hospitals are equipped with advanced technol-
doctor communication, 0.83 for nurse communication, 0.72 for physi- ogy to oer highly specialised services. Finally, the specialised hospitals
cal environment and 0.60 for discharge information. are dealing with specic medical needs such as psychiatric problems
and certain disease categories. The academic status was a dummy
variable to indicate the hospital's involvement in medical education
4. Regression analysis
with university hospitals being the reference category. Finally, hospitals
were classied by location, in order to attribute the dierences on
An ordinal regression analysis was employed to identify the
policies implemented at the regional level. More specically, the Greek
determinants that have the most signicant impact on inpatient
national health system has a regional structure, allowing local admin-
satisfaction. The survey asked from impatiens to rate their general
istrations to play an important role in determining the responsibilities
degrees of satisfaction or otherwise from their hospital services on a 10-
and formulating proposals to better address local needs. The location
point scale from very low to very high. Accordingly, the single item of
variable encapsulates the 6 health administrative regions of Greece,
the questionnaire that measures the overall patient satisfaction is used
namely 1) Attica, 2) Aegean 3) Epirus & West Macedonia, 4) East
as a dependent variable in the regression procedure. The independent
Macedonia & Thrace, 5) Thessaly, 6) Peloponnese & West Greece.
variables of the study are classied into the following three main
Table 3 presents the descriptive statistics of the institutional character-
istics of the 42 hospitals included in the survey.
The rst group of variables consists of the four factors identied in
As a nal point in the description of the prediction variables, it
the previous section, namely the doctor communication, the nurse
should be mentioned that for all the categorical predictor variables, the
communication, the physical environment and the information about
largest group in our sample was selected as the reference group.
discharge, which capture the quality of services provided within the
The Clog-log link function was employed in the ordinal regression
model. First of all, the appropriate choice of the link function had to be
The second group of variables refers to the demographic character-
istics of the inpatients: gender, age, nationality and the self-reported
health status. More specically, gender was a dummy variable indicat-
Table 3
ing whether inpatients were female or male. Age was transformed into Descriptive data for hospitals.
the two categories, indicating whether the respondent belonged to a
younger (45 years) or to an older inpatient group (> 45 years). Variable Category Frequencies (%)
Nationality was also a dummy variable indicating native (Greek) or
Hospital type Primary 4 (10)
non-native inpatients. Health status was measured by the relevant Secondary 29 (69)
single item of the HCAHPS questionnaire, which asks patients to rate Tertiary 6 (14)
their health status on a ve-point scale from poor (1) to excellent (5). Specialized 3 (7)
Table 2, presents the descriptive statistics for the demographic char- Academic status Non university 35 (83)
acteristics of inpatients that participate in the survey. University 7 (17)
The third group of variables pertains to the institutional character- Health region Attica 7 (17)
istics of hospitals comprising their type, location and academic status. Aegean 10 (23)
Particularly, the type of hospital is specied as primary, secondary, Epirus & West Macedonia 5 (12)
East Macedonia & Thrace 8 (19)
tertiary and specialised. The primary care hospitals are known as
Thessaly 5 (12)
hospital-health centres oering mainly primary health care and dealing Peloponnese & West Greece 7 (17)
with rather trivial treatments of the secondary health care. The

P. Mitropoulos et al. Journal of Retailing and Consumer Services xxx (xxxx) xxxxxx

Table 4 addition, hospitals located in the health regions of Epirus & West
Results of the ordinal regression model: determinants of overall inpatient satisfaction. Macedonia (OR 1.71), East Macedonia & Thrace (OR 1.21), and
Thessaly (OR 1.27), had signicantly higher satisfaction scores than
Predictors (reference group) Odds Ratio (95% Condence p-value
interval) did hospitals in the Attica region.

Service quality 5. Discussion

F- nurse 1.46 (1.411.52) < 0.001
F- doctor 1.43 (1.381.49) < 0.001
F- information 1.26 (1.211.31) < 0.001 The communication with nurses was found to be the most salient
F- environment 1.40 (1.351.46) < 0.001 predictor of overall satisfaction, followed by communication with
Patient characteristics
doctors. These results are consistent with prior research which high-
lighted the importance of communication between patients and hospi-
Gender (female)
tal sta. The major impact of nursing care on patient satisfaction and its
male 0.99 ( 0.818
greater meaning in comparison to physicians care is in agreement with
Age (> 45 years)
the results of Elliott et al. (2009a), who also found that communication
45 years 0.77 (0.700.85) < 0.001
with nurses and nursing care to be more important to patients. One
Nationality (natives)
possible explanation is that inpatients during their stay, interact most
Non natives 1.03 (0.861.23) 0.722
Self-reported health status 1.09 (1.051.13) < 0.001 with nurses than doctors because nurses are the rst responders to
patients when they have concerns or feel discomfort (Schoenfelder,
Institutional characteristics
Type (secondary) The physical environment emerged as the next most important
Primary 1.19 (0.951.48) 0.112
factor with respect to patients satisfaction. Several studies have shown
Tertiary 0.89 (0.661.18) 0.436
Specialized 1.40 (1.111.75) 0.004 that physical environment displays a strong positive correlation with
patient satisfaction (Coulter and Cleary, 2001). Cleanliness is consid-
Academic status (non university)
University 1.23 (0.931.63) 0.140 ered as an important issue, not only as a primary measure to control the
infection risk, but as well as an indicator of the commitment of the
Location (Attica)
Aegean 1.13 (0.971.31) 0.123
hospital sta and the hospital's attention as a whole (Sofaer et al.,
Epirus & West Macedonia 1.71 (1.442.01) < 0.001 2005). Quietness is also important because it is directly related to the
East Macedonia & Thrace 1.21 (1.051.38) 0.006 inpatient's needs to rest or sleep. The factor that the inpatients
Thessaly 1.27 (1.091.47) 0.001 considered as less important was the information about discharge. This
Peloponnese & West Greece 1.15 (0.991.33) 0.056
result is consistent with Elliott et al. (2009a), who also found discharge
information to be of less importance to patients.
made since the categories were ordered (O'Connell, 2000). Given that The patient characteristics that were signicantly related to overall
patients tend to report high levels of satisfaction with health care, the patient satisfaction were both age and self-reported health status.
Clog-log link function exhibits a better t in the regression model since Consistent with the literature, our study showed that the elderly
it is more suitable for analysing the ordered categorical data when the patients tended to report higher satisfaction scores with the received
higher categories are more probable among the other categories. The services than the younger ones (Nerney et al., 2001; Gnardellis and
validity of the estimated model was then explored with the test of Niakas, 2005). One possible explanation for the lower satisfaction
parallel lines. The signicance of this test p=0.991 > 0.05 indicated rating of younger patients could be that they may be treated dierently
that regression coecients were the same across the response cate- (e.g. less gently than older ones) or, that they have unrealistic
gories, suggesting that the model assumption of parallel lines was not expectations due to their lack of knowledge about hospital care
violated in the model. Finally, the overall model goodness-of-t (Young et al., 2000). As in previous studies (Nguyen Thi et al., 2002;
explaining patient satisfaction was assessed by the pseudomultiple Xiao and Barber, 2008), we showed that people who perceived
correlation squared values for Nagelkerke-R2, which was found to be themselves as being healthy were more likely to be more satised with
0.32. hospital care. A possible explanation is that healthier people may be
more satised with life generally, and this attitude stimulates their
ultimate satisfaction with hospital care (Young et al., 2000). Regarding
4.1. Determinants of inpatient satisfaction gender and nationality, both of them were not signicant predictors of
inpatient satisfaction. The study results are consistent with most prior
Table 4 presents estimates of odds ratios (OR) for inpatients with research that found similar satisfaction scores between male and female
respect to their overall satisfaction with hospital's performance. We inpatients (Niakas et al., 2004; Nguyen Thi et al., 2002). Nationality
observe that ten variables were signicantly related to inpatient was unrelated with overall satisfaction showing that patients are
satisfaction (p < 0.05). It is evident that all of the four service treated in Greek hospitals without ethnic disparities.
dimensions were found signicant for describing and explaining The institutional characteristics that were signicantly related to
satisfaction. The most inuential determinants were the communica- overall patient satisfaction were both the location and type of hospitals.
tion with nurses (OR 1.46) and doctors (OR 1.43) followed by the There were high regional variations in patients satisfaction with
physical environment (OR 1.40) and information at discharge (OR Epirus & West Macedonia, Thessaly, and East Macedonia & Thrace
1.26). performing better than the other health regions. The patients hospita-
Regarding the patient characteristics both older age and better lised in the Attica region were the least satised. Considering that most
health status were signicantly associated with higher satisfaction. Age of the largest hospitals are located in Attica since it is the biggest urban
was a stronger determinant (OR 0.77) than the self-reported health area of Greece, a possible explanation of this lower satisfaction is that
status (OR 1.09). In contrast, gender and nationality were not sig- the patients perceive larger hospitals as impersonal and intimidating
nicantly associated with satisfaction. (Young et al., 2000). Furthermore, we found that the inpatients treated
Among the institutional characteristics, both the hospital type and in specialised hospitals were more satised than the others. This may be
location were signicantly associated with overall satisfaction. In attributed to the fact that the sta and the hospital environment in
particular, the specialised hospitals exhibited signicantly higher specialised hospitals are more focused on patients and their specic
satisfaction score than did the other types of hospitals (OR 1.40). In needs, providing better attentiveness, personal care and information

P. Mitropoulos et al. Journal of Retailing and Consumer Services xxx (xxxx) xxxxxx

almost two-thirds of public hospitals operating in the national health

system failed to provide such data claiming that they have a shortage of
the necessary budget and time. Moreover, there is no information
available about the eligible patients that inclined to participate in the
survey. However, because of the relatively large size of the sample
(around 5500 patients) emanated from all the Health Regions and
hospital types, it may be assumed that the nonresponse bias has a minor
on research results. Moreover, the study sample consists solely of
patients of public hospitals, so the study should be extended to private
health providers. Finally, our data come from a single survey, thus, they
provide a snapshot of patients perceptions. Therefore, it would be
rather important to conduct such surveys on a regular basis to under-
stand the ways in which patients satisfaction changes over time as well
as the importance of its determinants factors, in order to launch and
implement more useful health improvement plans in care delivery and


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