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Monday, June 1, 2020

Patient Satisfaction

The Importance of Patient Satisfaction | Qminder

Globalization, technology innovations and demographic changes have contributed to the economic, political and social transformation. Globalization represents a multi-faced phenomenon in the modern society and it has an impact on the global healthcare system (Burcea, Toma and Papuc, 2014). The disparities among health infrastructure in different countries, the free movement of doctors, increased rate of disease burden and the medical tourism has raised governmental difficulties all over the world (Azevedo and Johnson, 2011)

Patient satisfaction regarding the quality of the medical services received is one of the indicators that reflect the true performance of a hospital (Observatorul Român de Sănătate, 2018).

According to the report developed by the Romanian Health Observatory, the Clinical Hospital of Rehabilitation is on the second place in terms of patient satisfaction (Observatorul Român de Sănătate, 2018).


The healthcare service is confronted with many challenges and competition in the development of the private medical providers. The patients have become more informed of the various options of treatment through online platforms. This results in high expectations of patients towards physicians to being able to provide the necessary information on their condition, politeness, empathy and attention from their doctors, which brings them very close to the traditional meaning of consumer profile (Coțiu and Sabou, 2017).


Gradually, the healthcare system undergoes pressures (financial, demographic and technological) in order to deliver good quality services to the patients. As a consequence, the protection of patients’ rights has evolved within the key aspect in the agenda of the new global health (Ahoobim et al., 2012). The national public health organizations, health promotion agencies, health service providers, scientific research institutions and consumers association have put significant efforts to promote and support the patients’ rights protection around the world. In the last decades, researchers have conducted analysis on the rights of patients, their protection and its direct/indirect link with the healthcare quality and its improvement (Green et al., 2012).


There are studies that indicate the importance of customer expectations from the healthcare system. This is described as a means of desires to seek for the assistance from the doctor, demands or wants and preferences. Patients’ expectations are important because it implies their involvement and creates the possibilities to better access health services. These expectations from the Romanian healthcare providers are based on the model on active passivity, which describes the physician-patient relationship in Romania. Within years of passivity, the Romanian system has moved to a more democratic approach. This is a new approach that focuses on the call for more client-centred orientation in the healthcare services. Therefore, the knowledge and awareness are expected to meet the needs of the patients (Ionilã, Ana-Claudia, A C Bara, WJA van den Heuvel, 200AD).


Secondly, patients measure their expectations based on their level of satisfaction with the healthcare services. This is mostly used as an indicator of the medical care outcome (Ionilã, Ana-Claudia, A C Bara, WJA van den Heuvel, 200AD).


Thirdly, the first step to prevent dissatisfied patients is through the knowledge of the patients’ needs, because this may result to discontinuity of care and cost ineffectiveness of the healthcare (Ionilã, Ana-Claudia, A C Bara, WJA van den Heuvel, 200AD).


Patients’ satisfaction is an important part of quality assessment of the healthcare system (Williams et al., 1995). There are two dimensions used to improve the patient satisfaction:

·         The procedural dimension of the quality of the provided services (such as the time spent at the waiting reception before getting the required medical attention), the condition of the accommodation provided according to the needs of the patient, and the doctor or physicians anticipated with the patient’s needs 

·         The personal dimension of the provided service quality-that is, the physical aspect of cleanness, maintenance of the facility, the attitude of the practitioner towards the patients, the demonstration of the body language between the physician and the patient and the voice tone used to address the patients (Agheorghiesei and Copoeru, 2013).


The most used instrument in measuring patient satisfaction is a questionnaire (Popa et al., 2017). This is most of the time implemented during or after the patients are being discharged from the sanitary units.  Studies have shown that the method of assessing the patient satisfaction uses broad and vague terms that result in short term, superficial, and positive answers without any true meaning (Popa et al., 2017).


There are numerous researchers that have brought to attention the term of “patient satisfaction”. Although this term is commonly used in evaluating and guiding the delivery of healthcare services, it is likely to be related to the quality of services rather than the quality of care provided. According to Pomerantz, several changes have occurred within the recent years in the way healthcare service users perceive the quality of care. He suggested that “an increased focus on the patients’ needs and preferences may help better orient medical care, compared to the focus on the adherence to care standards(Popa et al., 2017).


The most frequent aspect of satisfaction and dissatisfaction in the healthcare services is professionalism among the providers. Professionalism is an area that includes various subcategories such as:

·         advancement in medical knowledge,

·         improved level of development in clinical competence,

·         strong ethical morals and standards,

·         sharing of honesty and respect as values,

·         showing empathy, courtesy and kind attitude towards the patients.

In economically developed countries such as the Western European countries and USA, the medical orientation act changed from a “predominantly doctor-oriented approach to a patient centred culture”. This cannot be expressed in Eastern Europe, which is influenced by corruption, informal payments and in-need of a new reform. Since the 1970s, Eastern European countries are slagging behind Western European countries in terms of healthcare quality because of its communist policy throughout the region. Romanian has the lowest level of patient satisfaction in Europe. Romania is faced with other challenges that is related to the lack of access to health services among the less privileged communities.  The general dissatisfaction and cynicism in Romania is owed by the country’s poor economic performance, which limits the freedom of individual to explain a greater degree in behavioural and environmental factors (Popa et al., 2017).


The Romanian healthcare system is functioning based on the same principles in the last 30 years. It is built around the central administration and subsidiary, the medical staff, while the patients or their representatives do not have any control over the decision-making process in order to influence the system which they finance and access (Comisia Prezidențială pentru analiza și elaborarea politicilor din domeniul sănătății publice din România, 2008).


The only major modification in the system was the introduction of the healthcare insurance system, with the scope of strengthening the responsibility role of the main customer of healthcare services – the National Health Insurance House, through direct election of the leading structures at a local level (Comisia Prezidențială pentru analiza și elaborarea politicilor din domeniul sănătății publice din România, 2008)


This brought a larger level of autonomy for the local structures in terms of collecting and managing the insurance funds, which means that the structure gained more legitimacy and direct responsibility in front of the citizens. Although it could have been a significant change, the initiative was not politically accepted and after being approved in the Parliament. The law was significantly modified, leading to the centralization of the National Insurance House, politically controlled by the Ministry of Health and the Ministry of Finances, with a low degree of autonomy and difficulties of separating roles from other institutions.


Inside the healthcare system, the central authority, the Ministry of Health is keeping an organizational structure, central and local, which does not have a real overview over the healthcare needs of the population. Essential areas for an effective functioning of a modern healthcare system are not developed at all in none of the Ministry of Health structures. Systems of quality assurance, patient safety and the risk management are areas which do not have any type of representativity at the level of decision-making structures, although the quality of the medical services provided and patient safety are the areas that sanitary authorities  should constantly monitor (Comisia Prezidențială pentru analiza și elaborarea politicilor din domeniul sănătății publice din România, 2008).


Another important responsibility area is the resource allocation, which practically functions based on the same methods that are not changed for decades. The decisions in these areas are taken without having accepted criteria, both at a national and international level. The allocation of the public resources in the healthcare system must take into consideration the available evidence on statistical data (qualitative and quantitative), prevalence studies and different pathology trends etc, nationally and internationally (Comisia Prezidențială pentru analiza și elaborarea politicilor din domeniul sănătății publice din România, 2008).


An informational system would be required in order to make appropriate decisions. This would allow the identification of the healthcare priorities and would evaluate the method of way resources are used in different levels of the system, in a way that would allow the effective feedback of the decision-making factors (Comisia Prezidențială pentru analiza și elaborarea politicilor din domeniul sănătății publice din România, 2008).


For that, healthcare information systems are required. These would offer the appropriate information in a decent amount of time about various domains such as:

the utilization of the healthcare resources, work productivity, the social and economical impact of the determinants of health and different types of interventions, the coverage rate and accessibility to different healthcare services, etc.  At the current time, Romania does not have a coherent policy in terms  of healthcare information. Because of that, all of the attempts to build an effective informational system in healthcare, based on informational technologies and and modern communication methods did not succeed, even though high amounts of money were invested (Comisia Prezidențială pentru analiza și elaborarea politicilor din domeniul sănătății publice din România, 2008).


Another area of improvement is the incomplete or even confusing legislative and normative framework, in which the roles and responsibilities are not clearly defined or they present similar attributions with other institutions or organizational structures. This problem exists due to the continuous changes of direction as far as the structure and the role of the healthcare system is concerned, but also due to the lack of qualified resources on different decision-making levels (Comisia Prezidențială pentru analiza și elaborarea politicilor din domeniul sănătății publice din România, 2008).


Moreover, an appropriate inter-sectorial approach would be required in order to ensure and maintain good quality of life for the general population. This is because of the fact that numerous of the major determinants of health can not be influence only by the healthcare sector. From this point of view, the capacity of the Ministry of Health to get involved in influencing other sectors to respect the insurance of a healthy living environment is low. There is no official written document to state this role of the Ministry of Health in this direction, matching the recommendations of the European Union which mentions the fact that policy and program evaluation or any other intervention is mandatory.



One of  the recommendations to the stated problems would be to develop a quality assurance mechanism in the Romanian healthcare system. The system highly requires a program of upgrading the quality of the healthcare services, which would provide information related to the quality of the delivered services and would follow the constant progress of the quality of the services. The system will evaluate and improve the quality of the medical services, it will maintain and raise the level of patient satisfaction and will demonstrate the effectiveness of the financial resources invested in the healthcare system (Comisia Prezidențială pentru analiza și elaborarea politicilor din domeniul sănătății publice din România, 2008).


In terms of patient satisfaction and patient experience, measuring the level of satisfaction is necessary, due to the fact that it presents a realistic overview on the patient’s experience and it represents a starting point in improving the services provided, meeting the patients’ expectations or observe the performance of the medical staff (Sherri L. LaVela, 2014).

Patient satisfaction represents the analysis made by the patient alone, persuaded by external and internal factors, based on their opinion on how the services provided made them feel (Sherri L. LaVela, 2014).

In a pilot study realized in an interdisciplinary feeding team clinic, a survey was developed for the patients and their families in order to explore the areas that require improvement and analyze the level of satisfaction as far as the care coordination is concerned. The hospital from the study (Cincinnati Children’s Hospital Medical Center – CCHMC) has its own system for analyzing the patient satisfaction, developed for the individual services provided. The method used by the hospital consisted in applying telephone interviews on a weekly basis, by two marketing research organizations which are oriented in the healthcare domain. The questions that were asked were:

·         Were you able to get an appointment as soon as you wanted?

·         Did the health care provider give you a chance to explain the reasons for your child’s visit? Did they listen to what you had to say about your child?

·         Were you involved in decisions about your child’s care as much as you wanted?

·         When you asked questions, did you get answers you could understand?

 (Claire K. Miller, 2016).

The survey used in the pilot study added three questions to the existing one, using a five-point Likert scale to measure the level of satisfaction between the patient and the healthcare provider. The questions concerned the scheduling appointment, if the healthcare providers understood the concerns and the usefulness of the advices received from the medical staff, rating them from strongly agree to strongly disagree. Moreover, the pilot study included two more open-ended questions related to what could have been better regarding the services received and to detail the positive aspects of patients’ experience.


The surveys were completed at the end of the staying, introduced in an Excel database and further analyzed using descriptive summary statistical methods (Claire K. Miller, 2016).

Even though the setting is different, in order to collect as much relevant data as possible, the telephone interview can be a relevant method of analyzing patient satisfaction, if the necessary resources would be invested (the contract with a marketing company focused on healthcare that would do the interviews).

In order to be applicable at the Rehabilitation Hospital in Cluj Napoca the data with the information of the patients should be introduced in online registers.


In 2015, The Ministry of health introduced the feedback mechanism for the patient satisfaction in the public sanitary units from the Romanian healthcare system (Ministerul Sănătății, 2015).

 “The feedback mechanism of the patient represents all of the measures and procedures which have as objective raising the trust level of the patients in the medical services offered by the public hospitals, through feedback analysis regarding the quality of the services received, the degree of respecting the rights and obligations both by the patients and the medical staff. The mechanism also includes a component of managing the ethical complaints that happened in the sanitary unit, through the Ethics Committee” (Ministerul Sănătății, 2015).


The mechanism offers the patient the opportunity to fill in a questionnaire at the moment of the discharge by receiving a text message on the mobile phone with a link to fill it online, and all of the public sanitary units must apply the methodology of the feedback mechanism of the patient (Ministerul Sănătății, 2015).


We have observed that there is an internal questionnaire about patient satisfaction on the website of the Rehabilitation Hospital. After reading the law regarding the patient satisfaction mechanism developed by the Ministry of Health, the standard questionnaire of patient satisfaction must be implemented by all public hospitals.


Even though the Rehabilitation Hospital was ranked on the second place at patient satisfaction level, according to the Romanian Health Observatory, the response rate was low (5,9%), meaning that there were 630 responses out of 11983 discharges. The low response rate means that the conditions might not be as satisfying as they were presented.


Improvements for the Rehabilitation Hospital:

·         Promoting and insisting on the feedback mechanism developed by the Ministry of Health, so that the rate of responses will increase. Having two questionnaires might lead to having biased results (due to the fact that some patients might complete it twice, they might even give different answers/opinions, etc);

·         In the case of keeping the current questionnaire, we suggest some modifications on the response options: we noticed the fact that, at some questions there is one negative option and two positive. This might influence the patients in choosing a positive answer, even though it would not necessarily reflect the reality.  One alternative way for having the options can be ”Highly unsatisfied”, ”Unsatisfied”, ”Neither unsatisfied or satisfied”, ”Satisfied”, ”Very satisfied”;

·         As there might be the risk that some of the patients do not complete the online surveys because they are not internet users (for example the elderly or people with a low educational background), a survey in a physical format could be necessary. This would be filled in by the patients at the moment of the discharge, being introduced afterwards in the Ministry’s online database by the person in charge to introduce patient’s data from the hospital;

·         Awareness through word-of-mouth promotion of the survey could also increase the response rates, if it would be done by the hospital staff, or only at the reception of the hospital, both in the moment of admission and the moment of discharge.


Implementing Staff Training:

Most hospital staff such as the physician or the healthcare organizers have expressed their concern to ask patients personal questions that includes their race, ethnicity and language. They believe that it may offend the patient. In addition, most physicians may be time-sensitive towards the modern nature of clinical practice and want to ensure the effectiveness of asking questions. For data to be accurate and consistent, healthcare organizations are required to invest in clinical training among all staff levels (health professionals, administrative staff, hospitals and health plan leadership), which includes integrating the significance of the data for detecting and addressing health care needs. For instance, those assigned to the task of asking questions directly to the patients, enrollers can receive a front-line training on the importance of collecting the information, how to use the information and the means of collecting the data, and how to address the concerns of the patients and other members (Agency for Healthcare Research and Quality, 2014).


The training exercise should be based on the context and the methods of collecting and utilizing the data. For example, health plan staff who do not have face-to-face communication with the enrollers can obtain the demographic information through telephone encounters. Therefore, there should be a training for “telephone means of collecting data” because pre-registration by telephone can occur before hospital admission or ambulatory care appointments.  Before establishing a formal training session with the medical staff, an assessment should be conducted based on the practices and determine what is currently happening and identify the necessary changes. These changes will be clearly communicated among the staff members during the training session (Agency for Healthcare Research and Quality, 2014).


Sharing and Collecting of Data Across the Healthcare System:

The health system is a diverse set of public and private entity that contribute to the collection of data including health surveys, administrative enrolment, billing records and medical records used by different medical department such as the hospitals, CHCs, physicians and health plan management. The data collected on the patient’s race, language and ethnicity are extended to these entities suggesting that each can collaborate to obtain and sustain the patient’s medical record.  No one of the entities can individually gather the necessary information regarding the population of patients, neither can they collect the health data on an individual patient.  Therefore, it is important to increase the integration of data from other sources within and across the healthcare system (Agency for Healthcare Research and Quality, 2014).



All in all, the information stated above presents how the functioning of the healthcare system in Romania affects the sanitary system at a hospital level, directly influencing patient satisfaction. In this sense, measures have been taken, but there is still a lot to pursue in order to have clear and accurate data on the patient satisfaction level and how it can be improved. The suggestions presented are a small step that can be taken to develop the process of collecting data, based on a realistic national approach.



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Sherri L. LaVela, A. S. G., 2014. Evaluation and measurement of patient experience. Patient Experience Journal , 4.Volume 1.

Claire K. Miller, S. P., 2016. Exploring patient satisfaction with interdisciplinary care of complex feeding problems. Patient Experience Journal, Volume 3.

Ministerul Sănătății, 2015. [Online]
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Coțiu, M. A. and Sabou, A. (2017) ‘Patient Satisfaction with Diabetes Care in Romania – An Importance-performance Analysis’, in. Springer, Cham, pp. 297–302. doi: 10.1007/978-3-319-52875-5_62.

Green, S. et al. (2012) ‘Aligning quality improvement to population health’, International Journal for Quality in Health Care, 24(5), pp. 441–442. doi: 10.1093/intqhc/mzs049.

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