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Determinants of Patient Satisfaction: A Study among 39 Hospitals in an In-

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Article in International Journal for Quality in Health Care · June 2011

DOI: 10.1093/intqhc/mzr038 · Source: PubMed

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International Journal for Quality in Health Care 2011; Volume 23, Number 5: pp. 503 –509 10.1093/intqhc/mzr038
Advance Access Publication: 29 June 2011

Determinants of patient satisfaction: a

study among 39 hospitals in an in-patient
setting in Germany
TONIO SCHOENFELDER1, JOERG KLEWER2 AND JOACHIM KUGLER1
1
Department of Public Health, Dresden Medical School, University of Dresden, Loescherstrasse 18, 01309 Dresden, Germany, and
2
Department of Public Health and Health Care Management, University of Applied Sciences Zwickau, Dr.-Friedrichs-Rings 2A,
08056 Zwickau, Germany
Address reprint requests to: Tonio Schoenfelder, Department of Public Health, Dresden Medical School, University of Dresden,
Loescherstrasse 18, 01309 Dresden, Germany. Tel: þ49-37421-20396; Fax: þ49-3761-186720; E-mail: [email protected]

Accepted for publication 30 May 2011

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Abstract
Objective. To identify key determinants of patient satisfaction.
Design. Data used were obtained through a self-administered, post-visit questionnaire by random sampling during the period
of January 2009 to September 2009.
Setting. Thirty-nine hospitals in Germany.
Participants. A total of 8428 patients.
Main Outcome Measure. Global patient satisfaction was measured by a single item question. Attributes of medical aspects
of care were measured using 12 items, performance of service using 3 items and different dimensions of patient expectations
using 12 items. Medical aspects of care and performance of service items were entered into logistic regression analysis to
identify determinants of patient satisfaction.
Results. The results of the analysis showed that there are 10 determinants of global patient satisfaction. The outcome of treat-
ment was overall, the most salient predictor followed by nursing kindness as the second most important component. Items
reflecting information receiving about the undergoing treatment do not have a major influence on patient satisfaction.
Conclusion. The analysis identified key determinants that should be altered first in order to improve global patient satisfac-
tion. The results also indicate that some aspects of the hospital stay are not seen as relevant by patients and therefore are
unrelated to satisfaction ratings. The findings suggest that variables measuring patients’ perceptions of care are more impor-
tant determinants of global patient satisfaction in comparison to demographics and visit characteristics. Results of the present
study have implications for health providers aiming at improving the service quality and quality of care.
Keywords: health services research, patient satisfaction, quality management, hospital medicine, survey research

Introduction patterns of communication. Even though patients may not

be able to judge specific technical aspects, they provide the
Satisfaction can be described as a patient’s reaction to several best source of accurate information regarding clarity of expla-
aspects of their service experience [1]. Patients thereby evalu- nations, helpfulness of information patients are receiving,
ate the health-care services as well as the providers from barriers to obtaining care or the physician’s interpersonal
behavior [5, 6].
their own subjective point of view [2, 3]. There are several
Though numerous works have addressed this topic, patient
motivations for surveying patient satisfaction. It may influ- satisfaction remains difficult to determine [7]. It is a multidi-
ence health-care utilization, can be a predictor of subsequent mensional concept consisting of various aspects which all of
health-related behavior [1, 4] and whether patients are willing which do not necessarily have to do with the actual quality of
or not to recommend their health-care provider to others care and service experienced by the patient. One criticism of
[1, 3]. Patient satisfaction is a useful measure in assessing patient satisfaction ratings has been the inability to account for

International Journal for Quality in Health Care vol. 23 no. 5

# The Author 2011. Published by Oxford University Press in association with the International Society for Quality in Health Care;
all rights reserved 503
Schoenfelder et al.

expectations about medical care, which may be influenced by In total, 31600 post-paid surveys were distributed; 10 045
prior experiences with the health-care system [8]. In addition, were finally completed, resulting in a response rate of 32%.
patient characteristics also have an impact: older patients and Out of the total number of completed surveys, 1617 ques-
those with lower levels of education appear to be more satis- tionnaires were considered problematic due to excessive
fied [9]. Furthermore, psychosocial determinants play a role in missing and ambiguous data. Thus, these questionnaires
the sense that patients report greater satisfaction than they were excluded and only 8428 surveys were finally analyzed.
actually feel because they fear negative consequences in case
they give negative feedback [10].
Questionnaire design
In Germany, measuring satisfaction has been mandatory
since 2005 as an element of quality management reports The questionnaire represents a modified version of a survey
regarding service quality and quality of care which have to be instrument used by one of the statutory health insurances,
published by all providers aiming at supporting patients with which in turn was developed on the basis of a review of
information in order to allow benchmarking of hospitals patient satisfaction literature, published instruments and ver-
[11]. As a consequence, several questionnaires have been batim patient responses to questions about hospital quality.
used to evaluate in-patient care. Dimensions of what is being Translating foreign survey instruments seemed inappropriate
measured differ between these instruments. Therefore, as because of substantial structural differences between health-
long as hospitals do not use the same instrument, each pub- care systems. The original instrument has been used in two
lished patient satisfaction data reflects only the service quality previous regional surveys by the statutory health insurance;
and quality of care of its respective hospital. however, results were not published. For the present study,

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As a solution, a patient satisfaction survey among all 39 the order of questions was modified to make the question-
hospitals of the administrative district of Dresden was con- naire fit on two pages and one question was added which
ducted to measure the outcome of in-patient health services clarified in which department the patient was treated.
of the entire area and to identify key determinants that The modified questionnaire was submitted to 38 discharged
predict higher patient satisfaction. inpatients to ensure that wording, format length and sequen-
cing of the questions were appropriate.
The 37-item questionnaire was drafted in German and
enquired about patient demographics and visit characteristics
of the hospital stay (Table 1). The instrument also collected
Method data regarding medical and service attributes of the under-
gone treatment, patients’ expectations of forthcoming health-
Research setting and data collection
care events, importance of hospital setting and the kind of
The data set used in this study was obtained through a self- recommendation on a hospital patients would prefer. A
administered, post-visit questionnaire during the period of description of the items is shown in Table 2. One item col-
January 2009 to September 2009. The survey was conducted lected information concerning global satisfaction with the
in the district of Dresden (Germany) and included all 39 hospital stay in general. Patients responded on a six-point
hospitals of the area. Participants were recruited from six scale ranging from ‘excellent/absolutely necessary’ to ‘very
departments: surgery, internal medicine, urology, neurology, poor/completely unnecessary’. For data analyses, the lowest
ophthalmology and pediatrics. In 2008, about 245 000 rating was coded with ‘1’, the highest with ‘6’.
patients were hospitalized in these six departments and 39 The questionnaire did not contain a billing dimension, as
hospitals. Survey participants were policy-holders of four it would not apply to the German system, in which patients
statutory health insurances, which together have a market are not required to pay for hospitalizations.
share of 85% of the region’s total population. In order to
include all area hospitals in the survey and to ensure all
Analysis
patients receive the same questionnaire, the statutory health
insurances were chosen as source of contact because there To identify dimensions of the questionnaire, factor analysis
was the potential risk some hospitals would deny partici- with Varimax rotation was performed. The Kaiser-Meyer-
pation due to the additional expenditure in organization Olkin measure of sampling adequacy was high (0.90), indicat-
and time. ing the matrix was well suited for factor analysis [12]; 27 items
Study participants were randomly selected based on were submitted. Factor loadings of 0.4 or greater were con-
gender, age and the market share of their health insurance. sidered significant for defining the factors. Each item was
Data source was the health insurances’ internal data pool. attributed to the factor on which it had the highest loading.
Sample selection criteria included only individuals who spent Six components (eigenvalues .1), which accounted for
at least one night or more in the hospital throughout 2008. 63% of the total variance, were identified (Table 2).
Participation was completely anonymous and voluntary. The Cronbach alpha was used in order to estimate the internal
questionnaire was accompanied by a cover letter informing consistency of the subscales resulting in scores of 0.60 – 0.92.
the participants about the purpose of the study, and about The distribution of the satisfaction scores was skewed
their consent to participate when sending back the toward higher satisfaction. Therefore, the non-parametric
questionnaire. Kruskal – Wallis test was used to assess the effects of age and

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 Determinants of patient satisfaction † Patient experience

Table 1 Characteristics of the patient sample gender on global satisfaction ratings. General associations
between satisfaction ratings and visit characteristics were
Variable Number of patients (%) investigated with x 2-tests and Fisher’s exact test when cell
.................................................................................... counts were small. All associations were considered signifi-
Gender 5774 (100) cant at P , 0.05 level.
Male 2995 (51.9) In order to assess determinants of patient satisfaction,
Female 2779 (48.1) logistic regression analysis with stepwise backwards likelihood
Missing 2654 ratio testing for model selection was performed. The depen-
Age 8373 (100) dent variable was the patient’s global satisfaction rating for
,15 634 (7.6) the complete hospital stay; it was dichotomized into
15 – 20 144 (1.7) ‘excellent/good’ (reference) versus ‘fair/acceptable/poor/
21 – 30 363 (4.3) very poor’. Independent variables were entered, which mir-
31 – 40 384 (4.6) rored the patients’ experiences with the hospitals’ services;
41 – 50 706 (8.4) these were items of the factors ‘medical aspects of care’ and
51 – 60 1168 (13.9) ‘performance of service’. Therefore, variables addressing
61 – 70 1859 (22.1) patient expectations were not entered. Additionally, all vari-
71 – 80 2270 (26.9) ables significant by bivariate analysis were included. The per-
80þ 845 (10) formance of the estimated model was tested on a validation
Missing 55 sample. Therefore, the data set was divided into two groups:

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Quantity of hospitalizations 8205 (100) 70% of the cases were used for model development and
within previous 5 years the remaining data were used as validation sample for model
1–2 5091 (62) testing. Because some of the analyzed questionnaires con-
3–5 2372 (29) tained missing values, and therefore were excluded in the
.5 742 (9) logistic regression, 4381 cases were used for model develop-
Missing 223 ment and 1271 for validation. Data were analyzed using
Department 7968 (100) SPSS 15.0 for Windows (SPSS Inc., Chicago, IL).
Surgery 2699 (33.9)
Internal medicine 2301 (28.9)
Urology 1091 (13.7) Results
Neurology 781 (9.8)
Pediatrics 589 (7.4) The majority of the study sample was male, aged 71 – 80 and
Ophthalmology 507 (6.4) reported 1– 2 hospitalizations within previous 5 years.
Missing 460 Approximately 3368 (40%) participants were sent to hospital
Source of admission 8381 (100) by a specialist and 2560 (31%) by their GP. A minority of
Specialist 3368 (40.2) respondents (919, 11%) reported post-discharge compli-
General practitioner 2560 (30.5) cations and 5704 (69%) assessed length of stay to be appro-
Emergency 1881 (22.4) priate. Approximately 6819 (82%) patients would use the
Self-admission 472 (5.6) facility again in the case of another hospitalization (Table 1).
Transfer from another clinic 100 (1.2)
Missing 47
Length of stay 8243 (100) Satisfaction ratings
Too short 782 (9.5) In total, 6595 (80%) patients rated the global satisfaction
Appropriate 5704 (69.2) with hospital stay related to all performed services either
Too long 509 (6.2) ‘excellent’ or ‘good’. The grouped median score was 5.04.
Do not know 1248 (15.1) Kindness of the hospitals’ physicians (5.36) and nurses (5.34)
Missing 185 reached the highest scores, while clear information about
Complications 8245 (100) anesthesia (4.64) and medication (4.50) received the lowest
Yes 919 (11) ratings (Table 3).
No 7326 (89)
Missing 183
Use facility again? 8296 (100) Associations between satisfaction and patient
Yes 6819 (82.2) demographics and visit characteristics
No 440 (5.3)
Do not know 1037 (12.5) Gender, department, source of admission, and number of
Missing 132 previous hospitalizations were not associated with global
satisfaction. Patients’ age, however, was related to level of

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Schoenfelder et al.

Table 2 Results of the factor analysis and reliability testing

Factors and abbreviated items (number of items) Factor loadings Variance explained (in %) Cronbach alpha
.............................................................................................................................................................................

Factor I: Medical aspects of care (12) 29.16 0.92

Individualized medical care 0.84
Clear reply of inquiries by physicians 0.82
Clear information about undergoing operations 0.82
Clear information about medication 0.77
Discharge procedures and instructions 0.76
Clear information about anesthesia 0.70
Physician’s knowledge of patient anamnesis 0.69
Kindness of the hospital’s physicians 0.67
Organization of procedures and operations 0.66
Outcome of treatment 0.65
Efficiency of admitting procedure 0.56
Kindness of the hospital’s nurses 0.51
Factor II: Service expectations (4) 13.54 0.82
Expectations of nurses’ kindness 0.83

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Expectations of physicians’ kindness 0.82
Expectations of quality of food 0.74
Expectations of accommodation 0.73
Factor III: Performance of service (3) 6.71 0.71
Accommodation 0.76
Cleanliness 0.74
Quality of food 0.65
Factor IV: Setting (3) 4.81 0.77
Distance between clinic and place of residence 0.91
Location and accessibility 0.89
Clinic size 0.51
Factor V: Recommendation (3) 4.75 0.60
General practitioner 0.80
Specialist 0.79
Relatives and friends 0.48
Factor VI: Expectations of care (2) 3.92 0.68
High quality care 0.83
Clear information about undergoing treatment 0.78

satisfaction (P , 0.001). A comparison of the grouped Results of the multivariate logistic regression
median values of the global satisfaction score showed that analysis
younger patients of age groups ,15, 15 – 20 and 21 –30
The analysis revealed 10 determinants of global patient satis-
rated this aspect with 4.43, 4.72, 4.66, respectively.
faction (Table 4). The most influential determinants were
Among the other patients, the global satisfaction score in
outcome of treatment (OR 3.70) and kindness of the hospi-
the age group of 31 – 40 consistently decreased from 4.93
tal’s nurses (OR 2.78) and physicians (OR 1.96). Four vari-
to 5.10 in the age group of .80 years. Study participants
rating global satisfaction from ‘fair’ to ‘very poor’ reported ables of the medical aspect of care factor were not included
significant lower willingness to be hospitalized in the in the regression model: clear reply of inquiries by physicians,
same clinic again (P , 0.001). Patients reporting post- clear information about medication, anesthesia and under-
discharge complications were less satisfied with their going operations. Regarding the performance of service
complete hospital stay in comparison to patients without component, lower ratings of accommodation and quality of
complications (P , 0.001, 4.49 with complications versus food resulted in decreasing global patient satisfaction.
5.16 without), were also less willing to be hospitalized Cleanliness was the only service aspect not included in the
again in the same clinic (P , 0.001) and reported length model. The results of the model development sample were
of stay to be too short (P , 0.001). similar to those of the validation sample: 92.7% versus

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 Determinants of patient satisfaction † Patient experience

Table 3 Levels of global patient satisfaction, satisfaction with Table 4 Results of the multivariate logistic regression
medical aspects of care and satisfaction with performance of analysis: determinants of global patient satisfaction
service; 6.0 ¼ best, 1.0 ¼ worst
Variable OR (95% CI) P-value
....................................................................................
Abbreviated item Grouped
content median Outcome of treatment 3.70 (3.10 – 4.48) ,0.001
.................................................................................... Kindness of the hospital’s 2.78 (2.19 – 3.54) ,0.001
Global satisfaction with hospital stay 5.04 nurses
Medical aspects of care Kindness of the hospital’s 1.96 (1.51 – 2.56) ,0.001
Kindness of the hospital’s physicians 5.36 physicians
Kindness of the hospital’s nurses 5.38 Organization of procedures 1.68 (1.39 – 2.00) ,0.001
Efficiency of admitting procedure 5.23 and operations
Outcome of treatment 5.17 Quality of food 1.60 (1.40 – 1.92) ,0.001
Clear reply of inquiries by physicians 5.14 Accommodation 1.50 (1.25 – 1.79) ,0.001
Individualized medical care 5.10 Individualized medical care 1.46 (1.22 – 1.75) ,0.001
Organization of procedures and operations 5.04 Discharge procedures and 1.43 (1.23 – 1.66) ,0.001
Physician’s knowledge of patient anamnesis 4.85 instructions
Clear information about undergoing operations 4.74 Physician’s knowledge 1.38 (1.15 – 1.65) ,0.001
Discharge procedures and instructions 4.66 of patient anamnesis

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Clear information about anesthesia 4.64 Efficiency of admitting 1.25 (1.10 – 1.50) 0.018
Clear information about medication 4.50 procedure
Performance of service Clear information about /
Cleanliness 5.34 undergoing operations
Accommodation 5.14 Clear information about /
Quality of food 4.98 anesthesia
Clear information about /
medication
Clear reply of inquiries by /
92.2% of all cases were assigned correctly. The physicians
Nagelkerke-R2 resulted in 0.72. Cleanliness /

n ¼ 4381, Nagelkerke R2 ¼ 0.72. ‘/’, non-significant variable.

Post-visit expectations, recommendation of clinic

and setting
Main findings
After their hospital stay, patients attached the highest priority
to high quality care (5.77), followed by clear information The results of the regression analysis showed that there are
about their undergoing treatment (5.62) as well as nursesa- 10 determinants of global patient satisfaction. Thereby, both
pos; (5.43) and physicians’ kindness (5.41). Patients attached medical and service elements of the hospital stay were
least importance to quality of food (4.80) and accommo- important dimensions. The outcome of treatment was overall
dation (4.74). Recommendation by relatives or friends on a the most salient predictor of global patient satisfaction fol-
certain hospital (3.39) was less important than recommen- lowed by nursing and physicians’ kindness. These results are
dations by specialists (5.23) and GPs (4.88). Regarding consonant with prior research which highlighted the impor-
setting, patients attached least importance to clinic size tance of communication between patients and hospital staff
(3.26), followed by distance between clinic and place of resi- [10, 13]. The major impact of nursing kindness and its
dence (4.55), and location (4.73). greater meaning in comparison to physicians’ kindness corre-
sponds with other study results [14, 15], which found com-
munication with nurses and nursing care to be more
important to patients. Possibly, patients experience more
Discussion contact with nurses than doctors as nurses are the first
responders to patients if they feel discomfort or have general
The study identified key determinants of patient satisfaction questions [15].
in the investigated in-patient setting. Most prior research ana- Both organization of admission and discharge were associ-
lyzed data gained from patients of a very limited number of ated with global patient satisfaction. Patients attached most
hospitals. Analyzed data in this study were obtained from importance to discharge procedures and instructions, which
randomly selected patients of all 39 Dresden area hospitals is partly inconsistent with study research of Elliott et al. [15],
using the same method; therefore, results are an outcome who found discharge information to be of least importance
measure for the health services of the entire district. to patients. However, the strength of this association was

507
Schoenfelder et al.

rather small compared with most of the other variables in Regarding the high levels of satisfaction, there is a risk of
the regression model. an acquiescence and a social desirability bias that may have
Items reflecting information receiving such as information resulted in an over-reporting of satisfied patients [10, 22].
about anesthesia, medication or undergoing operations did Another explanation could be the use of the single-item
not have a major influence on patient satisfaction, although questions. Most patients tend to give positive answers if they
patients indicated these aspects would be highly relevant for are asked how satisfied they were [23, 24] even though if
future hospital stays. These results may suggest that patients’ they have complaints about specific aspects of the received
lack of medical knowledge could have been influential, result- care [6].
ing in patients are not being able to judge if the received It is unknown if proxy responses were involved in answer-
information is correct. ing the questionnaire. This may represent another source of
This possibly also explains the heavy influence of the two bias because patients receiving assistance when completing a
service components, quality of food and accommodation on questionnaire were found to be less satisfied than individuals
global satisfaction. Possibly, patients look for surrogate indi- who did so on their own [25].
cators of correct diagnosis and treatment to measure their In this study, a brief and feasible instrument was used.
own satisfaction [3]. However, cleanliness was not a predictor However, when revising the questionnaire, additional vari-
of global patient satisfaction. ables addressing patient demographics and visit character-
Regarding gender and age, the study results are consistent istics should be included. For example, while the personal
with most prior research that found similar satisfaction scores evaluation length of stay was recorded, the actual length of
among men and women [9, 16, 17] and older patients being stay should also be included. Possibly, patients with a pro-

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more satisfied with received services than younger individuals longed stay due to more serious conditions would have made
[9, 18]. One possible reason regarding the higher satisfaction different experiences on which to base their judgment com-
rating of older study participants could be that older patients pared with patients with a one-night stay.
may be treated differently, e.g. more gently than younger ones With exception of the factor ‘recommendation’, the
[19]. However, the relation between global satisfaction and age internal consistency was satisfactory. To perform the
faded when examining with multivariate techniques. regression analysis, the data set was divided into a develop-
Prior research indicated that a low health status leads to lower ment and a validation sample to avoid an overestimation of
satisfaction scores [8, 20], which concurs with the results of the the parameters. Gained results were similar, indicating the
present study. Complications had a significant influence on variables serve as reliable determinants of global patient satis-
different aspects of satisfaction in the bivariate analysis. Patients faction. The logistic regression model explains 72% of the
reporting about post-discharge complications were less likely to observed variation, indicating a very good data fit [26].
rate satisfaction regarding service and medical aspects of care as In summary, the present study identifies determinants of
‘excellent’ or ‘very good’. Patients with experienced post- patient satisfaction and delivers information about aspects of
discharge complications significantly reported length of stay as the hospital stay that are not seen as relevant by patients.
too short. These patients’ judgments may have been affected by Findings are based on data gained from a large number of
previous intensive political discussions, assuming that with the hospitals from one geographical area. Specifically, the degree
introduction of the diagnosis- related groups in Germany length to which patients were satisfied with the kindness of nurses
of stay would decrease to a dimension that would deteriorate the and physicians showed strong predictive utility for overall
quality of care. patient satisfaction, while information regarding technical
quality of care was not related to satisfaction ratings.
Additionally, amenities which are not directly linked to the
Methodology
received care (such as accommodation) were of much impor-
Patients of all 39 hospitals of one geographical area from six tance to patients. Therefore, future research should put
different departments were included in the data set and were emphasis on collecting information about additional hotel
randomly selected. Sample selection was based on the aspects, regardless if these are important to patients or rep-
internal data pool of the participating statutory health insur- resent proxies for other aspects of the hospital stay. The
ances, covering 85% of the total population of the area in results also suggest that variables measuring patients’ percep-
which the study was conducted in. Findings are representa- tions of care are more important determinants of global
tive for in-patients of the six departments in the investigated patient satisfaction in comparison to demographics and visit
area. characteristics. Found variables are alterable and, therefore,
The 32% response in the present study may introduce a provide implications for health providers aiming at improving
potential selection bias that could affect generalizability and the service quality and quality of care.
validity of the results. However, Lasek et al. [21] found that
the impact of non-response bias on satisfaction surveys of
hospitalized patients might be relatively small. Acknowledgements
As the effect of non-response was not assessed in the
present study, it is not possible to draw conclusions whether The authors thank the patients for their participation and
there were any differences in demographic or clinical also gratefully acknowledge Gregor Schoenfelder for his help
characteristics. with manuscript preparation.

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