From 1986 to 1992, the Health Care Financing Administration publicly reported hospital mortality rates as an effort to aid consumers in selecting hospitals (10). Hospitals with over twice the expected mortality rate saw very little change in volume during that time. Patients do not seem to be affected by morbidity and mortality statistics but more by personal stories of care. Patient perception of quality is assessed through dimensions of what is personally valued, and often they do not distinguish between the provider of the service and the service received.
Being treated with respect and dignity and involvement in treatment decisions are intangible issues of patient satisfaction that are paramount issues for patients (11).
As many as one quarter of 13,000 patients discharged from 51 Massachusetts hospitals reported problems with patient satisfaction issues such as the involvement of families in their care, communication and coordination of care, and the transition from hospital to home (12). Patients who had been admitted to academic health centers and teaching hospitals generally reported more problems than those cared for in community hospitals. As it turns out, service outcomes such as patient satisfaction drive market share and profitability for hospitals (13). With the average medical/surgery hospital charge amounting to $12,083, hospitals cannot afford to lose patients and, therefore, revenue due to issues of patient dissatisfaction (14). Recruiting new patients as customers is 5 times more costly than retaining an existing customer base (15).
There is compelling evidence from well-developed lines of research demonstrating that increasing patient satisfaction improves clinical outcomes, such as functional status and physiologic measures of health (16,17). Finally, it is important for clinicians to know that it has been clearly demonstrated that satisfied patients improve physician satisfaction (18,19).
Psychology of Satisfaction
To create a culture of customer service excellence in hospitals and achieve outstanding patient satisfaction, it is necessary to understand the intangible aspects of perception and expectation that contribute to patient satisfaction. The “First Law of Service” provides a useful, simple mathematical model of satisfaction (20). The formula for this model is Satisfaction = Perception – Expectation. If a patient’s perception of their hospital experience meets or exceeds the expectation, there will be a corresponding degree of satisfaction. However, if the perception does not meet the expectation, there will be resulting dissatisfaction. Thus, patient satisfaction results from meeting or exceeding patients’ expectations. Patient perceptions of care can be measured directly from patient satisfaction surveys, focus groups, and telephone surveys. A hospital’s reputation and market share are indirect measurements of patient perceptions. There are 2 main directions in which patient satisfaction can be influenced: by working on what the patient perceives and on what the patient expects.
Expectations are integral to the experience of being a customer. There has been confusion and controversy in health care as to whether patients are in fact customers. This confusion may be at the root of the overall service failing of hospitals (21). “The more horizontal they are, the more they are a patient. The more vertical they are, the more they are a customer” (22). Using a technical definition, a customer is anyone who has expectations about process operations or outputs (23). Therefore, all patients are customers, but not all customers are patients (21). Hospitals have a whole list of primary and secondary customers, each of whom has his or her own set of expectations. Patients and their families can be seen as primary customers, and referring physicians, third-party payers, external overseers, communities, shareholders, and employees are all secondary customers of hospitals.
Expectations are psychological phenomena that can be defined as beliefs created and sustained by cognitive processes (24). Expectations of patients as hospital customers rise from past experiences of their own or of others, as well as from current needs and unique internal preferences that form the basis of a value system. Expectations cannot be mandated, because they are based in self-gratification. However, expectations may change over time, and, very importantly, they can be measured and perhaps modified through education. For most people, illness and hospitalization is a rare event. Patients will know something is wrong and that treatment is needed, but most won’t know the nature of their disease, the diagnostic and therapeutic options, and the likely outcomes. Therefore, patients seek out health care professionals who have the opportunity to inform them on what to expect as a way to begin the process of managing expectations.