Understanding the effects of nurses, patients' hospital rooms, and patients' perception of control on the perceived quality of a hospital

Service marketing researchers suggest that the physical environment, the people, and the process strongly affect consumers' judgements when they evaluate services. Previous research has rarely applied this general framework to help identify specific hospital variables that affect the perceived quality of a hospital. This article presents a proposed model and empirical evidence that is based upon this general framework. That is, this article reports the results of a study which found that the physical environment (i.e., patients' perception of their hospital rooms) and people (i.e., patients' perception of nurses) affected patients' perception of hospital quality. The process (i.e., patients' perception of control over the process) did not directly affect their perception of hospital quality. However, patients' perception of control over the process and their perception of their hospital rooms affected their perception of their nurses. Consequently, this research suggests that the general framework identified by service marketing researchers can be applied to help understand how patients develop their perception of hospital quality.     

Satisfaction with hospitalization: a comparative analysis of three types of services

A study of patient's satisfaction with hospital services was undertaken. The purpose of the study was to explore whether and to what extent patients' satisfaction with three types of hospital services (medical, nursing and supportive) is differentially explained by patient's sociodemographic, psychosocial, situational and attitudinal characteristics. To achieve this, 476 patients were interviewed. The results of the analysis of their general satisfaction with hospitalization and a comparative analysis of satisfaction with the three types of services are presented. The best predictors of satisfaction with all three types of services (in order of their importance) are found to be: perceived improvement in health, size of social networks, satisfaction with organizations in the past, and age. The type of ward (medical vs surgical) is found to be a powerful predictor of satisfaction with physicians and nurses only. Ward effect is also interactive--improvement in one's health predicts significantly more satisfaction with medical services in medical wards than in surgical wards. The findings of this study suggest that when clients perceive that their main goal has been achieved (i.e. improvement in health), they tend to attach little importance to deficiencies in the process of achieving it (i.e. the provision of services).     

Patient judgment of the quality of ambulatory care in a Japanese setting

OBJECTIVE: To assess patient satisfaction with a hospital-based ambulatory service in Japan and define the determinants of satisfaction and the patient's intention to return to the service. DESIGN: A questionnaire was developed to measure overall satisfaction, intention to return to the service, patient judgment about the structure/process of the service, patient perception about the global reputation of the service, and other health-related items. The questionnaire was mailed to patients attending the ambulatory service. SETTING AND PATIENTS: All non-psychiatric patients who used the ambulatory service of a 350-bed general hospital in Tokyo in the sampling days were asked to participate. The response rate was 77.2% (1,307 responses). Of these, 1,074 non-proxy and non pediatric responses were used for the main analysis. RESULTS: Based on content analysis and factor analysis, scores for the service components were constructed and found to have high internal consistency and reliability. The results indicated several important points regarding the use of patients' evaluation of ambulatory services as a quality monitoring tool. It was shown that patients' overall satisfaction and intention to return to the same physician were determined primarily by their evaluation of their doctor's conduct and their perceived health outcome. The perceived reputation of the service also was a significant determinant of patient satisfaction and intention to return. Patient satisfaction and intention to return to the hospital were influenced also by non-physician factors such as nurses, clerks, and environmental comforts. Notably, patient intention to return was linked with patient perceived need of care and regularity of care. In multiple-regression results, patient satisfaction with the doctor and with the hospital had different determinants.     

Stress and smoking in hospital nurses.

The smoking behavior of hospital nurses and the association between work-related stress and smoking were studied by means of a questionnaire mailed to the entire direct patient care nursing staff at the University of Michigan Hospital. Prevalence of smoking was considerably lower than in the US nurse population surveyed in 1975 and in the general female population of the same age range surveyed in 1978. Significantly higher scores were obtained for smokers than for non-smokers on scales concerning the physical and emotional stress of the job and the dissatisfaction with its rewards. The results supported more weakly the association of smoking with the perception of stress induced by role ambiguity, by nurse-doctor conflict, and by conflict between nurses. Some personal and situational variables were found to interact with perception of stress and smoking.     

Patient complaint strategies in a general hospital

This study aimed to understand specific complaint behaviors of inpatients regarding perceived problems in the receipt of hospital services and to study the effect of provider responses to the different complaint strategies on patients' overall satisfaction with hospital services. The analysis was performed on 155 patients who had reported a problem in the receipt of services and had acted to elicit a change. Three complaint strategies were studied--formal, informal, and a combination of both. The use of these strategies was studied in relation to type of hospital service and the type of ward where the problem emerged. Two questions were investigated--what strategy leads to the best outcome for the patients? and how does each outcome affect overall satisfaction with hospital services?     

Patient expectations of dental services. Image affects expectations, and expectations affect perceived service quality

The authors construct a theoretical model of the antecedents of expectations for dental services by analyzing survey responses from 240 dental patients. The patients' image of the dentist, tangible cues, situational factors, and patient satisfaction with prior service encounters have the greatest influence on expectations of service, whereas marketing variables, such as price and advertising, appear to have no effect.     

Nutritional care in pregnancy: the patient's view. III. Perceived need for advice and effectiveness of advice received.

Interviews were conducted with ninety-two pregnant women who attended the out-patient clinic of a major obstetrical teaching hospital. Information was obtained on the patients' perception of their need for dietary advice during pregnancy and selected demographic, nutritional, and medical care characteristics, as well as their response to, and satisfaction with, the dietary advice and treatment they received. The patients' perceived need for dietary advice appears to be an important factor in the apparent effectiveness of prenatal dietary counseling. Patients who expressed a need for dietary advice were more likely to consider diet important during pregnancy, to have positive feelings toward nutrition services, to have visited the dietitian, and to report making changes in their diet because of the advice received. Little association was observed between demographic and medical care characteristics of patients or more objective measures of need for dietary advice and the patients' own perception of need. It is suggested that patients whose expressed need for counseling is at variance with objective measures are a group requiring special attention.     

Patients'' satisfaction with care after stroke: relation with characteristics of patients and care.

OBJECTIVES: To evaluate stroke patients' satisfaction with care received and to identify characteristics of patients and care which are associated with patients' dissatisfaction. DESIGN: Cross sectional study. SETTING: Sample of patients who participated in a multicentre study on quality of care in 23 hospitals in the Netherlands. PATIENTS: 327 non-institutionalised patients who had been in hospital six months before because of stroke. MAIN MEASURES: Data were collected on (a) characteristics of patients: socio-demographic status, cognitive function (mini mental state examination), disability (Barthel index), handicap (Rankin scale), emotional distress (emotional behavior subscale of the sickness impact profile) and health perception; (b) characteristics of care: use of various types of formal care after stroke, unmet care demands perceived by patients, unmet care demands confirmed by their general practitioners, continuity of care, and secondary prevention, and (c) patients' satisfaction with care received. RESULTS: 40% of the study sample were dissatisfied with at least one type of care received. Multivariate analyses showed that unmet care demands perceived by patients (odds ratio (OR) 3.2, 95% confidence interval (95% CI) 1.8-5.7) and emotional distress (OR 1.8, 95% CI 1.1-3.0) were the main variable associated with dissatisfaction. CONCLUSIONS: Patients' satisfaction was primarily associated with emotional distress and unmet care demands perceived by patients. No association was found between patients' satisfaction on the one hand and continuity of care or secondary prevention on the other; two care characteristics that are broadly accepted by professional care givers as important indicators of quality of long term care after stroke. IMPLICATIONS: In view of these findings discussion should take place about the relative weight that should be given to patients' satisfaction as an indicator of quality of care, compared with other quality indicators such as continuity of care and technical competence. More research is needed to find which dimensions of quality care are considered the most important by stroke patients and professional care givers.     

‘Genuine doctor care’: Perspectives on general practice and community‐based care of Australian men experiencing homelessness

People with complex health and social needs, including tri‐morbidity and homelessness, are challenging for modern healthcare systems. These clients have poor health and social outcomes. They tend to use available health resources inefficiently, with fragmented, uncoordinated use of multiple health and social care services. Increasing access for these clients to well‐supported general practice care may be an effective response to these challenges. The aim of this study was to explore client experiences of, and attitudes to, community‐based healthcare, and general practice in particular, to identify opportunities to improve healthcare provision. Five focus groups with a total of 20 men currently experiencing homelessness were facilitated by the corresponding author in an inner‐city homeless hostel. Discussions were transcribed, coded and analysed thematically. The analysis was informed by earlier focus group discussions with community‐based homeless healthcare providers. Participants reported reluctance to engage with healthcare providers outside times of perceived crisis, and experiences of stigma and dismissive care. Some participants were sceptical of the motivations of health and social care providers, including general practitioners. Presentations with physical and psychological pain featured prominently in participant accounts. Three key themes identified important aspects of client experiences of community‐based healthcare which indicate potential areas for improvement. These themes were as follows: the relative invisibility and low salience of general practice compared to hospital‐based emergency and inpatient services; discontinuity within community‐based healthcare and across transitions between community‐based and other healthcare; and inconsistent and unsatisfactory general practitioner responses to physical and psychological pain. These responses included apparent over‐prescribing, under‐prescribing and short‐term ‘band‐aid’ responses. Generalist medical expertise was valued in general practitioners, but not consistently experienced. A number of challenges and opportunities exist, at both individual and system levels, for general practice to realise its potential to deliver effective, compassionate and efficient care to clients experiencing homelessness.     

Carrot and sticks? The Community Care Act (2003) and the effect of financial incentives on delays in discharge from hospitals in England

BACKGROUND: The belief that many delays in discharge from hospital were caused by social service departments (SSDs) led to the Community Care Act 2003 giving NHS hospitals in England the power to charge SSDs. METHODS: We surveyed 150 SSDs in England about the implementation of the Act and used routine data to analyse trends in the number of delayed discharge patients; the number and cause of delayed discharge bed days by sector; and the proportion of inpatient bed days that consisted of delayed discharges. FINDINGS: Most hospitals opted not to charge SSDs for delays. Almost two thirds of SSDs (62%) made no payment of any kind to an acute hospital in 2004/05 and 2005/06, preferring to work collaboratively. The fall in number of 'delayed discharge patients' is a long term trend which precedes the implementation of the 2003 Act. Delayed discharge bed days accounted for 1.58% of all inpatient bed days in 2004/05. Contrary to popular opinion, the NHS accounted for two thirds (67%) of bed day delays, lack of suitable alternative NHS provision and services is a key factor. Patients are being discharged in greater numbers and earlier in their post-acute recovery phase. There are however questions about the quality and safety of early discharge. For example, emergency hospital readmissions rates have risen from 5.4% in 2002/03 to 6.7% in 2005/06, and patient dissatisfaction is significant. CONCLUSION: Although delays in discharge from acute hospital beds have fallen, the quality of discharge and the capacity of Primary Care Trusts (PCTs) and SSDs to ensure appropriate and adequate post-discharge care is not as it should be. Contrary to popular perception, social services delays are of less significance than delays attributable to the NHS. There is no evidence to support government policy of charging SSDs for delay. Other factors, including NHS provision, are important, and a comprehensive overview of health and social care is vital.     

Patient expectations at a multicultural out-patient clinic in Switzerland

BACKGROUND: Recognizing patient expectation is considered as an important objective for primary care physicians. A number of studies suggest that failure to identify patient expectations can lead to patient dissatisfaction with care, lack of compliance and inappropriate use of medical resources. It has been suggested that identifying patient expectations in multicultural contexts can be especially challenging. OBJECTIVES: The aim of the study was to compare health care expectations of Swiss and immigrant patients attending the out-patient clinic of a Swiss university hospital and to assess physicians' ability to identify their patients' expectations. METHODS: Over a 3-month period, all patients attending the out-patient clinic at a Swiss university hospital were requested to complete pre-consultation surveys. Their physicians were requested to complete post-consultation surveys. Outcome measures were patients' self-rated health, resort to prior home treatment, patients' expectations of the consultation, physicians' perception of their patients' expectations and agreement between patients and physicians. RESULTS: We analysed 343 questionnaires completed by patients prior to their consultation (> 50% immigrants) and 333 questionnaires completed by their physicians after the consultation. Most expectations were shared by all patients. Physicians had inaccurate perceptions of their patients' expectations, regardless of patients' origin. CONCLUSIONS: Our study found no evidence that immigrant patients' expectations differed from those of Swiss patients, nor that physicians had more difficulty identifying expectations of immigrant patients. However, physicians in our study were generally poor at identifying patients' expectations, and therefore inter-group differences may be difficult to detect. Our results point to the need to strengthen physicians' general communication skills which should then serve as a foundation for more specific, cross-cultural communication training.     

Health and other service needs in a metropolitan area

This article describes the extent to which respondents in a metropolitan area reported their need for help in eight selected problem areas. Large discrepancies between the perceived need and the actual use of services are identified for these problem areas, and possible explanations for such disparities are given. A more comprehensive approach to the analysis of social service needs is proposed.     

Influence of sociodemographic and neighbourhood factors on self rated health and quality of life in rural communities: findings from the Agriproject in the Republic of Ireland

OBJECTIVE: To examine the influence of sociodemographic and neighbourhood factors on self rated health, quality of life, and perceived opportunities for change (as one measure of empowerment) in rural Irish communities. DESIGN: Pooled data from cross sectional surveys two years apart. SETTING: Respondents in four randomly selected rural district electoral divisions with a population size of between 750 and 2000. PARTICIPANTS: 1738 rural dwellers aged 15-93, 40.5% men, interviewed at two time points. MAIN OUTCOME MEASURES: Determinants of self rated health (SRH), quality of life (QOL), and perceived opportunities for change, rated on a closed option Likert scale and assessed in multivariate logistic regression models. MAIN RESULTS: Overall 23.8% of the sample reported poor SRH, 22.2% poor QOL, and 50.1% low perceived opportunities for change. Low financial security and dissatisfaction with work were each significantly associated with poor SRH (OR = 1.96 (1.50 to 2.56) and 1.54 (1.11 to 2.14)), with poor QOL (OR = 2.04 (1.56 to 2.68) and 1.87 (1.34 to 2.61). Concern about access to public services was significantly predictive of SRH (OR = 1.47 (1.11 to 1.94)) rather than access to health care (that is, hospital and GP services). There were distinct sex specific patterns and a generational effect for educational status in men. Variables associated with social networks and social support were less strongly predictive of SRH and QOL when economic measures were accounted for. CONCLUSION: Inter-relations between indicators of health status, wellbeing, and deprivation are not well studied in rural communities. Material deprivation has a direct influence on both health status and quality of life, although immediate sources of support are relatively well preserved.     

RESPONSE OF DEPUTISING SERVICES IN MELBOURNE TO ACUTE CEREBROVASCULAR EPISODES: AN EVALUATION

Between March 1978 and September 1979, a stroke incidence study was carried out in Melbourne. Of the 300 subjects who sought help from a general practitioner, in 68 the call was answered by a member of a deputising service. Each of the latter subjects was matched for age, severity and time of onset with a patient whose call had been responded to by his own general practitioner. Response times, use of hospital resources, mortality and residual disability in survivors were compared. It was concluded that, in this condition at least, the deputising services provide fast, effective care meeting the needs of both general practitioners and patients in perceived emergency situations.     

‘Just because a doctor says something,doesn't mean that [it] will happen’: self‐perception as having a Fertility Problem among Infertility Patients

Only some individuals who have the medically defined condition ‘infertility’ adopt a self‐definition as having a fertility problem, which has implications for social and behavioural responses, yet there is no clear consensus on why some people and not others adopt a medical label. We use interview data from 28 women and men who sought medical infertility treatment to understand variations in self‐identification. Results highlight the importance of identity disruption for understanding the dialectical relationship between medical contact and self‐identification, as well as how diagnosis acts both as a category and a process. Simultaneously integrating new medical knowledge from testing and treatment with previous fertility self‐perceptions created difficulty for settling on an infertility self‐perception. Four response categories emerged for adopting a self‐perception of having a fertility problem: (i) the non‐adopters – never adopting the self‐perception pre‐ or post‐medical contact; (ii) uncertain – not being fully committed to the self‐perception pre‐ or post‐medical contact; (iii) assuming the label – not having prior fertility concerns but adopting the self‐perception post‐medical contact; and (iv) solidifying a tentative identity – not being fully committed to a self‐perception pre‐medical contact, but fully committed post‐medical contact. (A virtual abstract of this paper can be viewed at: https://www.youtube.com/channel/UC_979cmCmR9rLrKuD7z0ycA ).     

Analysis of the Expenses Linked to Hospital Stays: How to Detect Outliers

When hospital financing depends on a budget which in turn depends on the pathologies being treated, it is necessary to detect hospital stays which show discrepancies between the resources they consume and the medical characteristics they present. Deterministic nonparametric frontier models are used to rank hospital stays according to their expenses taking into account the severity of the patients' conditions. As these models are very sensitive to the extreme stays, a robust frontier model, the order-m frontier is used. The too-efficient stays are highlighted and described. The mean expenses are estimated after excluding too-efficient and inefficient stays. This mean is higher than the mean estimated by using classical trimming rules.     

Hurricane Katrina's impact on pediatric and adult patients with sickle cell disease

OBJECTIVE: Hurricane Katrina, making landfall in the U.S. in late August 2005, disrupted the medical infrastructure of New Orleans. We hypothesized that Hurricane Katrina measurably affected the ability of patients with sickle cell disease (SCD) to receive necessary and adequate health care. Differences in health care delivery among children and adults in New Orleans prior to the hurricane prompted our interest in these two groups. METHODS: In May 2006, an anonymous survey was administered via either telephone or written questionnaire to patients in the greater New Orleans, Louisiana area with SCD and/or their guardians. The survey was intended to gauge patients' access to and satisfaction with specialized health care in the months following Hurricane Katrina. CONCLUSIONS: Adult patients with SCD who relied almost exclusively on New Orleans' main public hospital (Charity Hospital) for specialized sickle cell services reported significant frustration/dissatisfaction with their medical care eight months after the storm. In contrast, pediatric patients with SCD and their guardians, who rarely received care within the public hospital system, reported more satisfaction with their care. There was a statistically significant difference between the two groups in their responses to the perception of quality of their health care.     

Case and disease management and improved integration of healthcare services in Spain. 2008 SESPAS Report

The boundaries between health services levels are artificial as they are answers to health organizations' problems rather than to patients' needs. However, given that these boundaries are in place, coordination between these levels should overcome the difficulties so that patients receive the services they require. Case management (patients in specific situations, such as hospital discharge) and disease management (patients with specific diseases, such as diabetes) aim to solve problems of coordination either by improving the organization of health services or by adding a new structure to the already existing structure. These forms of management are highly attractive answers to coordination problems but have no scientific basis nor is there any empirical evidence of a positive impact on patients' health or the cost of services. Case and disease management programs are vertical structures that weaken the horizontal structure in Spain, i.e. primary care. The need for case and disease management programs is an argument to push for a pro-coordination reform of primary care that gives power, responsibility and autonomy to general practitioners, so that they would be able to coordinate clinical and social services according to patients' needs.     

Factors that influence cancer patients' overall perceptions of the quality of care.

OBJECTIVE: This study outlines predictors of cancer patients' overall perceptions of the quality of care. DESIGN AND SETTING: Our sample included 2790 patients who received cancer care services during 2004 in 15 comprehensive cancer programmes across Ontario, Canada. Patients were classified into three groups: those receiving both chemotherapy and radiotherapy (n = 752), those receiving only chemotherapy (n = 1044), and those receiving only radiotherapy (n = 994). An ordinal logistic regression model for each patient group was performed to determine which variables most affected the probabilities of the patients' overall evaluations of the quality of care. Potential control variables were patients' age, sex, type of cancer, self-assessed health, and who completed the survey. RESULTS: Among seven common predictors of the overall quality perception across the three models, four should be of particular interest because patients perceived them as relatively problematic aspects of care. These are 'was informed about follow-up care after completing treatment', 'knew next step in care', 'knew who to go to with questions', and 'providers were aware of test results'. These predictors explained between 25 and 34% of the variance (depending on the model) of the overall perception of quality. The explanatory power of these predictors did not change across sex and age group. 'Self-assessed health' was the only control variable that remained in all three models. CONCLUSIONS: From a practical perspective, improvement efforts are best focused on factors that are strong predictors as well as on those for which there is a low score. Thus, on the basis of this study, practitioners' improvement efforts might be constructively focused on the four predictors mentioned above.     

A Study of Expectations and the Marital Quality of Participants of a Marital Enrichment Seminar

This longitudinal study investigated the effects of expectations of effort of self and spouse on the marital quality of marital enrichment seminar participants. Self‐report measures of marital quality, expectations regarding effort put into implementing what was learned during the seminar, amount of perceived effort, and satisfaction with effort were administered before and after the seminar, as well as at a 2‐month follow‐up. Participants (147 women, 95 men) attended community‐based marital enrichment seminars in 12 U.S. cities. Multivariate path models indicated that larger discrepancies between expectations of effort postseminar and perceived effort at 2‐month follow‐up were associated with less satisfaction with perceived effort. Furthermore, participants' dissatisfaction in their spouses' effort had a negative effect on marital quality while controlling for initial marital quality, whereas dissatisfaction in their own effort did not. These findings highlight the possible detrimental effect that unmet spousal expectations can have. Implications for marital enrichment programs and couples therapy are discussed.