See

discussions, stats, and author profiles for this publication at:

https://www.researchgate.net/publication/235301531

Patient satisfaction with healthcare

delivery systems

Article in International Journal of Pharmaceutical and Healthcare Marketing · April 2008

DOI: 10.1108/17506120810865424

CITATIONS READS

24 655

4 authors, including:

Valentin H Pashtenko Suzanne C. Makarem

CEO Emeritus - Pashtenko Family Tr… Virginia Commonwealth University
6 PUBLICATIONS 25 CITATIONS 9 PUBLICATIONS 84 CITATIONS

SEE PROFILE SEE PROFILE

All content following this page was uploaded by Imad Baalbaki on 14 January 2017.

The user has requested enhancement of the downloaded file. All in-text references underlined in blue are added to the original document
and are linked to publications on ResearchGate, letting you access and read them immediately.
 The current issue and full text archive of this journal is available at
www.emeraldinsight.com/1750-6123.htm

Patient
Patient satisfaction with satisfaction
healthcare delivery systems
Imad Baalbaki
American University of Beirut, Beirut, Lebanon 47
Zafar U. Ahmed
Prince Sultan University, Riyadh, Saudi Arabia and
Texas A&M University at Commerce, Commerce, Texas, USA
Valentin H. Pashtenko
Christopher Newport University, Newport News, Virginia, USA, and
Suzanne Makarem
Temple University, Philadelphia, Pennsylvania, USA

Abstract
Purpose – The purpose of this paper is to provide insight, exploratory research, and support for the
strategic use of hospital secondary support functions as an initial strategy for marketing healthcare,
increasing patient volume, and expanding patient satisfaction.
Design/methodology/approach – This research paper is based upon longitudinal patient satisfaction
and perception studies following both emergency room and elective-stay hospitalization visits in Beirut.
Exploratory statistical methods are used to examine substantial data comprising over 300 patient stays.
Comprehensive information is presented which illustrates patient perceptions, their inflection points, and
the importance of this knowledge in the marketing of hospitals and health care systems.
Findings – This research paper presents that patient perceptions are significantly influenced by
hospital support functions. Further, these perceptions determine hospital reputation, influence future
patient demands, and are integral to the understanding of patients as consumers of health care
systems rather than consumers of medical procedures.
Practical implications – This paper provides support for health care system administrators who
are often at odds with health care core service administrators and personnel with respect to long-term
hospital growth strategies. It illustrates that focusing on increasing core competencies is a
short-sighted approach to developing health care systems. It provides support for growing secondary
support functions as being a more efficient means to increasing long-term core competencies.
Originality/value – The originality of this paper is that it illustrates the conflict between the
immediate medical care that health care systems understand to be their strategy and the strategies
that truly grow hospital health care systems. It illustrates the paradox that requires hospitals to focus
upon secondary support functions rather than core competencies in order to market themselves using
strategies consistent with long-term growth.
Keywords Hospitals, Health services, Customer satisfaction, Patient care, Lebanon
Paper type Research paper

Introduction
International Journal of
Characteristics of health care delivery services Pharmaceutical and Healthcare
Health care systems and hospitals in particular exist as the center for patient/consumer Marketing
Vol. 2 No. 1, 2008
care delivery and are the organizational hub of a much larger health care provider pp. 47-62
network. In this latter capacity the modern hospital must now compete in an q Emerald Group Publishing Limited
1750-6123
ever-expanding role as the provider of outpatient/consumer care, a more competitive DOI 10.1108/17506120810865424
IJPHM health care environment, as well as a the leader of the much larger comprehensive
2,1 managed care system. Consequently, hospitals are providers of services, which are
intangible, inseparable, variable, and perishable. Moreover, existing consumer
marketing research has found that production and consumption of the service occur
simultaneously, so strategies that acknowledge the importance of the consumer must
be integrated into the hospital health care delivery systems process (Craig et al., 2007;
48 Glass et al., 1981; Pugh et al., 2007).
When gathering the information about these systems, patient/consumer/consumers of
health services rely more on personal and intimate sources such as stories and anecdotes
because of the very nature of the service. Then, the providers in the choice set are evaluated
yet again by the patient/consumer before the latter is able to reach a decision. In particular,
consumer marketing studies reveal that the patient/consumer is not alone in the decision
execution; there is a decision-making unit that influences this choice. In fact, in the
healthcare industry, research shows that the decision-making unit likely include an
initiator (family member), an influencer (physician), a decider (physician,
patient/consumer or insurance), a buyer (third party insurance or employer), and the
user (patient/consumer). As a final point, additional research has shown that
patient/consumer involvement in decision making related to his or her health choices is
increasing as patient/consumers are exposed to an increasing number of health care
system providers (Laffel and Blumenthal, 1989; Shortell et al., 2007; Porter and Teisberg,
2007a, b). As a result, health care delivery systems adhere to a long buying process model
and are a high-involvement service. Regardless, lacking strong conceptual support, many
hospital strategies have placed an increased importance on advancing their respective
technical advancements as a measure of achievement. For the reasons mentioned above
however, there exists a need for a greater conceptual understanding over the affects of
correlating health care delivery system strategies with technological achievements.

Research objectives
The increasing gap between healthcare customers’ systematic demands and hospital
core performance leads to an increasing concern for understanding patient/consumers
and patient/consumer families’ needs in a hospital environment. In fact, given the
humanitarian nature of health services, patient/consumer satisfaction in healthcare is
not only important for the sustained profitability or survival of the hospital, but also
for increased effectiveness and efficiency, and for better treatment outcomes.
Healthcare organizations, specifically hospitals, are continuously trying to
improve on their image and their services. However, research has shown that the
core attributes of the service are necessary for patient/consumer satisfaction but are
not a determinant of it. With impatient/consumer sampling shown unreliable and
emergency room sampling impractical because of the nature of medical services at
these stages, hospitals need to focus on assessing patient/consumer satisfaction after
patient/consumer discharge and not, as has been done in the past, while the patient/
consumer is in the hospital. In addition, while subsequent post-discharge patient/
consumer surveys have been conducted, research has shown that these same surveys
repeatedly measure symptoms of broader issues in the care delivery system and not
the problems themselves ( Kendrick et al., 2007; Mintzberg et al., 1998). As a result,
there exists a conceptual as well as a tangible need to differentiate between patient/
consumer core and patient/consumer system assessments.
 The research objectives of this study were fourfold. First, it was to measure levels of Patient
patient/consumer satisfaction with aspects of the health service encounter in the satisfaction
inpatient/consumer and emergency room settings of the health delivery system.
Second, it was to find the elements that are valued by customers and the reasons
behind patient/consumer satisfaction or dissatisfaction. Third, it was to assess the
importance of non-medical customer services in shaping satisfaction. Finally, it was to
reach conclusions about the strategic changes that are necessary in hospital health care 49
delivery systems needed to improve customer satisfaction, whether they pertain to
employees, internal promotion, or customer services.

Literature review
Existing academic research of health care providers reveals different consumer behavior
patterns than within those services that are less personal and less professional. Above
all, due to the nature of medical care, consumers use health care systems such as
hospitals out of need and not choice. Individuals feel unable to make choices about their
treatments, with many feeling comfortable in being passive and leaving all potential
decisions to the nurse or physician in charge (Gandjour, 2007; Puro, 1996; Shortell et al.,
2007). Thus, healthcare service, unlike other non-professional services, is low in search
attributes; that is to say, attributes that can be evaluated by the customer before
selecting a hospital or alternative health care provider or experiencing service. Likewise,
medical care is also low in experience (familiarity) attributes, or attributes that can be
evaluated after experiencing the service but not before (Budd and Raber, 1996; Hunter
and Schmidt, 1990; Lilford et al., 2007; Hunter et al., 1982); instead, the medical service
has more credence (credibility) attributes, which cannot be confidently evaluated
sometimes even after experiencing the service, because of the technical nature of the
service. This has a major influence on the behavior of consumers.
In particular, patient/consumer benefits derived from the features that a hospital
offers depend on patient/consumer needs, wants and perceptions. The patient/consumer
cannot usually understand the medical details of his/her treatment and he/she perceives
that the technical competence of the medical provider is high (Cone, 2007; Deming, 1986;
Jones et al., 2007). Therefore, it is important to understand the importance of the entire
health care delivery system, rather than simply the core medical service that the
patient/consumer has been admitted for, when correlating strategy with advances in
technology. Thus, patient/consumer/consumers want “clues” to convince them of the
competence of the provider like staff sensitivity, explanation of the procedure, and
effectiveness and efficiency (Berry and Bendapudi, 2007; Lillrank, 2003; Pugh et al.,
2007). These shared perceptions subsequently become the basis by which other
patient/consumer/consumers measure the reputation of a specific hospital as well as
assess the institution’s respective “technical” accomplishments.
The perception sharing behavior of healthcare consumers is crucial for medical
institutions to recognize as it allows the achievements of the health care delivery system
to be compared against the advancement of the technological core; the former being
inter-subjective and external measure of success while the latter being the conventional
and objective measure of institutional accomplishment. Of these measures, research has
shown the inter-subjective and external to be the more difficult to understand.
Above all, current consumer marketing research has shown that patient/consumer/
consumers do not express their primary needs beyond the conventional core reason
IJPHM that they are there. Again, this is due to a lack of patient/consumer understanding of
2,1 the technical nature of the service. Hospital achievement appraisals via patient/
consumer assessment during inpatient/consumer stays or emergencies do not measure
perception sharing as this sharing process only commences after the patient/consumer
is released. As a result, health care systems of this type can only gather this
information in situ, and as research has shown, from secondary and tertiary sources.
50 Hospitals are not culpable of failing to integrate patient/consumer assessments at
first sight. For example, research has shown that at the time of admission a
patient/consumer might express only his or her critical need to get rid of the pain.
However, this same research has shown that, when discharged, this same
patient/consumer will evaluate the service (perception sharing) according to various
other hospital factors like food, safety, noise, response time of the nurse, and
competence of physicians (Leonardi et al., 2007; Juran, 1988). As explained, in technical
surroundings patient/consumers will not complain when dissatisfied and will tolerate
the problems that might occur in the complex medical delivery system, if they receive a
courteous treatment from the staff. Consequently, a re-evaluation of patient/consumer
assessments, when they are gathered, as well as what they mean is needed to more
closely correlate hospital strategies with patient/consumers needs during a period of
increased profit incentives.

Strategic drift: overview and importance

Patient/consumer complaints about health care are repeatedly caused by the need of
better individual care rather than the need for lower costs ( Mintzberg et al., 1998;
Wilson et al., 2007; Volpp, 2007). As a result, the appropriate strategic response should
be to focus on the importance of appropriately treating patient/consumers and
their families, in a way that they do not feel alienated, rather than to lower costs
(Glickman et al., 2007; Yang, 2002). Successive studies have then further shown
that patient/consumer complaints are symptoms of broader issues in the care
delivery system and not the problems themselves (Craig et al., 2007; Wijnberg et al.,
2002).
The mismatch between health system demands and core development has resulted
in a “strategic drift,” which has grown over time. This drift has manifested itself as
increasingly higher levels of patient/consumer dissatisfaction (Gilligan and Lowe,
1995). In response to patient/consumer dissatisfaction, hospitals have focused their
efforts upon core delivery issues and have assigned staff accordingly. The result has
been that of lower levels of staff responsiveness to patient/consumers and an
unwillingness to do tasks that are not related to core delivery duties. Predictably,
a weaker health care systems image in the society has resulted, as hospital
management has repeatedly failed to take advantage of these strategic opportunities.
At the same time, hospital measures indicate increased core competencies thereby
creating a strategic contradiction.
This resulting paradox in medical care is that, even excellent medical results
will lead to dissatisfaction if the patient/consumer judges the performance of the
medical provider on non-medical services. As a result, patient/consumers tend to judge
medical service depending on the intangible non-medical delivery systems, rather than
on core results (Figure 1) (Gilligan and Lowe, 1995).
 Patient
Health “System” Demands
Environmental demands and satisfaction
expectations Strategic
Drift
Rate of change

51

Strategic “Core” Development Figure 1.

Patterns of healthcare development
and delivery
Source: Gilligan and Lowe (1995, p. 73)
The mismatch between
environmental demands
and health care
organization delivery

Methodology
Research process
A post-discharge structured survey was designed and administered to patient/consumers
in person. A total of 29 measures was used to assess inpatient/consumer service
perceptions in eight categories: admission, nursing, housekeeping, food service,
physicians’ services, technical services, orderly services, and discharge. A total of
19 measures in five areas (admission, nursing, physicians’ services, technical services, and
discharge) were then used to assess the level of satisfaction with the emergency room
service. There were also two further measures to assess the overall satisfaction with the
service encounter in both cases. Respondents responded to questions related to each
delivery system, or both of them if they fit the adequate requirements. The hypotheses
were then tested using the data collected from respondents.

Hypotheses
The following eight hypotheses are presented. These hypotheses are consistent with
conceptual differences concerning the correlation of hospital strategy to advances in
technology versus the correlation of strategies to hospital health care systems as a
whole. In each, patient/consumer satisfaction is justified from this conceptual basis.
It is the specific objective of these eight hypotheses to illustrate the objectives of this
study as illustrated at the beginning of this paper: that, in hospitals, a strategic model
that is correlated with advances in technology (core) is inadequate for measuring the
effectiveness of the delivery system. Finally, it is submitted that comprehensive
secondary measures of perceptions are needed to assess and to differentiate between
patient/consumer satisfactions with core services versus the hospital delivery system:
H1. There is a direct and positive correlation between specific hospital services
and overall hospital satisfaction perceptions[1].
H2. There is a direct and positive correlation between patient/consumer
satisfactions with specific services and patient/consumer satisfactions of all
services of that type at the hospital[1].
H3. In the emergency room (department), waiting time affects overall perceptions
of the hospital[2].
IJPHM H4. In the emergency room (department), the physicians’ (core) medical treatment
2,1 affects overall perceptions of the hospital[2].
H5. In the inpatient/consumer setting, satisfaction with the nursing act is the most
important determinant of satisfaction with the overall service encounter[2].
H6. Quality of communications with nurses during the service interaction is
52 crucial to patient/consumer satisfaction, in both inpatient/consumer and
emergency room settings[2].
H7. There is a hierarchy among factors that influence patient/consumer
perceptions[3].
H8. Patient/consumers refer to tangible or peripheral elements like waiting time,
quality of food, and staff courtesy rather than clinical “core” competencies as
the determinants of their satisfaction or dissatisfaction[4].

Sampling procedure and data collection questionnaire

Satisfaction or dissatisfaction with the entire medical service experience is a function
of the sum of all experiences in relevant categories. If we examine all the steps of
the patient/consumer’s experience, we can formulate a questionnaire that tests the
successive steps and see how they affect the overall satisfaction. As a result, the
questions were ordered in a way that fit the flow of the customer experience to help
patient/consumers or their relatives remember the encounter as they happened.
The questionnaire had three sections: the first section was aimed at identifying
respondent’s information, necessary to assess whether the respondent fit the
requirements (according to the chosen sample), and to lead him or her to answer
the appropriate section between the second or third sections, or both if possible. The
second section was for emergency room patient/consumers or patient/consumer
relatives. Finally, the third section was related to respondents that have themselves
experienced an inpatient/consumer encounter or that attended to relatives who did.
Note that respondents might be able to fill both second and third sections, if they were
involved in both hospital encounters.
To measure the satisfaction level with each event, act, or overall experience, a
five-point Likert-type scale ranging from “very dissatisfied” to “very satisfied” was
used. In addition, at the end of the second and third sections, two open-ended questions
were inserted to gather information about the elements of the experience that affected
patient/consumers most, be it negatively or positively, to allow for the testing of the
last hypothesis.

Research sample
A cross-sectional sample of 315 respondents was used. The respondents were not
interviewed at the hospital because their medical conditions might not allow them to
fill the survey and because research has shown that their hospital stay might affect
their evaluation.
The sample included former patient/consumers and patient/consumer relatives that
had been directly involved with a healthcare service encounter in either the
inpatient/consumer or the emergency department. The respondents selected had
experienced the hospital encounter within a maximum of three months before the
survey administration, so that they are able to remember the details of the service Patient
encounters. The respondents are also residents of the metropolitan Beirut, Lebanon satisfaction
area. There were no restrictions regarding the hospital visited, however the hospital
name was asked to test for any possible relation between satisfaction attributes and the
hospital. After being pre-tested and adjusted, the questionnaire was administered
face-to-face, and the respondents were first asked if they have been to the hospital in
the last three months before administering the questionnaire. 53
Data analysis and results
Profile, procedure, and tools
The 315 respondents were divided according to age, gender, and hospital experience.
The data were prepared and extracted from the questionnaires by defining 59 variables,
five of which are non-metric variables allowing for the classification of respondents
according to: hospital experience (either patient/consumer or a patient/consumer
relative), hospital name, gender, age group, and the hospital department of the service
encounter. About 50 other variables represented metric measurements of satisfaction
with events, acts, and the overall experience in both hospital departments. Four
variables (two for each department) were non-metric variables indicating whether the
best and worse aspects of the service encounter are related to clinical competence (core)
or to other peripheral factors like cleanliness, friendliness of staff, and waiting time. Data
were entered and analyzed using SPSS, and then the relevant output data were extracted
and used to arrive to the following results and test the research hypotheses. Finally,
Pearson correlations and stepwise regression analyses were run on the data.

Emergency room correlation analysis

The correlation results presented in Table I show that in the emergency setting, admission
process, nursing care, physicians’ care, technicians’ care, and discharge process are all
strongly associated to overall customer satisfaction with the emergency encounter, with a
positive correlation at a 0.01 level of significance. Nursing care has the strongest
correlation with overall satisfaction, followed by physicians’ services, technical services,
admission process, and finally discharge process, which has a weaker correlation.
Tables I and II summarize the relationship between the studied factors and the
overall customer satisfaction in both medical settings. Strong associations exist
between satisfaction with service acts and overall satisfaction with the hospital. The
above findings support H1 and indicate that customer satisfaction with specific major
acts is positively related to overall customer satisfaction with the service encounter.

Overall satisfaction

Admission Pearson correlation 0.562 *

Nursing care Pearson correlation 0.678 *
Physicians Pearson correlation 0.584 *
Technicians Pearson correlation 0.583 *
Discharge process Pearson correlation 0.424 * Table I.
Correlations between
Notes: *Correlation is significant at the 0.01 level (two-tailed). All sig. (two-tailed) results were 0.000; service acts and overall
N ¼ 170 satisfaction in the ER
IJPHM H5 is also supported because, in the inpatient/consumer setting, the nursing act has the
2,1 highest correlation among all acts with r ¼ 0.731, which is much higher than the act
that follows (Physicians’ services) with r ¼ 0.638. In fact, it is generally clear that some
associations are stronger than others, which could imply that certain factors or acts
have greater influence than others on the overall customer satisfaction. For instance,
nursing care, which has the highest correlation coefficient in both settings, has a much
54 higher association with overall satisfaction, than other acts like food services or
discharge process. This information supports H7.

Inpatient/consumer setting correlation analyses

At the inpatient/consumer level, in Tables III-X, all events are strongly correlated to
their respective acts with a significance level of 0.01. In addition, except for parking
availability, all events are strongly associated to overall satisfaction with the
inpatient/consumer service encounter. The events that have the highest correlations in

Overall satisfaction

Admission Pearson correlation 0.600 *

Nursing care Pearson correlation 0.731 *
Housekeeping Pearson correlation 0.570 *
Food services Pearson correlation 0.570 *
Physicians Pearson correlation 0.638 *
Table II. Technicians Pearson correlation 0.630 *
Correlations between Orderly staff Pearson correlation 0.614 *
service acts and overall Discharge process Pearson correlation 0.608 *
satisfaction in the
inpatient/consumer Notes: *Correlation is significant at the 0.01 level (two-tailed). All sig. (two-tailed) results were 0.000;
setting N ¼ 215

Overall satisfaction Admission

Table III.
Correlations between Admission waiting time Pearson correlation 0.444 * 0.673 *
admission process events, Sig. (two-tailed) 0.000 0.000
admission process act, N 209 209
and overall satisfaction in Admission personnel courtesy Pearson correlation 0.529 * 0.691 *
the inpatient/consumer Sig (two-tailed) 0.000 0.000
setting N 209 209

Overall satisfaction Nursing care

Table IV. Skill of nursing staff Pearson correlation 0.642 * 0.792 *

Correlations of nursing Sig. (two-tailed) 0.000 0.000
events, nursing act, and N 215 215
overall satisfaction in the Responsiveness of nurses Pearson correlation 0.688 * 0.708 *
inpatient/consumer Sig. (two-tailed) 0.000 0.000
setting N 215 215
the admission process, nursing, housekeeping services, food services, physicians’ Patient
services, technical services, orderly services, and discharge process events are, satisfaction
respectively, admission personnel courtesy, responsiveness of nursing staff, hospital
room’s atmosphere, variety of meals, physicians’ communication and accessibility and
time spent with patient/consumer, lab testing waiting time, orderly staff punctuality,
and helpfulness of office personnel at discharge.
Since, for all events of all service acts in both hospital settings, customer satisfaction 55
with specific events are strongly associated to customer satisfaction with respective
acts, H2 is supported. In addition, H3 and H4 are supported since both admission

Overall satisfaction Housekeeping Table V.

Correlations between
Hospital room and bathroom cleanliness Pearson correlation 0.522 * 0.491 * housekeeping services
Sig. (two-tailed) 0.000 0.000 events, housekeeping
N 215 215 services act, and overall
Courtesy of housekeeping staff Pearson correlation 0.507 * 0.686 * satisfaction in the
Sig. (two-tailed) 0.000 0.000 inpatient/consumer
N 214 214 setting

Overall satisfaction Food services

Variety of meals Pearson correlation 0.535 * 0.769 *

Sig. (two-tailed) 0.000 0.000
N 207 207
Note: Correlations between food services events, food services act, and overall satisfaction in the
inpatient/consumer setting Table VI.

Overall satisfaction Physicians Table VII.

Correlations between
Physician’s communication Pearson correlation 0.535 * 0.769 * physicians’ services
Sig. (two-tailed) 0.000 0.000 events, physicians’
N 207 207 services act, and overall
Physician’s accessibility and time Pearson correlation 0.535 * 0.769 * satisfaction in the
Sig. (two-tailed) 0.000 0.000 inpatient/consumer
N 207 207 setting

Overall satisfaction Technicians

Lab testing waiting time Pearson correlation 0.505 * 0.512 *

Sig. (two-tailed) 0.000 0.000
N 195 195
Note: Correlations between technical services events, technical services act, and overall satisfaction in
the inpatient/consumer setting Table VIII.
IJPHM waiting time and physicians’ medical qualifications are strongly related to overall
2,1 satisfaction with the service encounter with r ¼ 0.503 and r ¼ 0.490, respectively.
Quality of communication with nurses is strongly correlated with overall satisfaction
in both the emergency and inpatient/consumer hospital settings with r ¼ 0.475 and
r ¼ 0.652, respectively, which supports H6. However, the strongest correlations exist
between overall satisfaction and speed and responsiveness of the nurses in the
56 emergency setting (r ¼ 0.574), and between overall satisfaction and responsiveness of
nursing staff in the inpatient/consumer setting (r ¼ 0.688).

Patient/consumer satisfiers and dissatisfiers

The results in Tables XI and XII support H8 since, in both settings, peripheral elements
were mentioned by respondents as satisfiers or dissatisfiers more than the core medical
elements. Moreover, peripheral elements are mainly dissatisfiers because they were
stated as the worst aspects of the hospital visit around 84 percent of the times, compared
to around 51 percent of the times for the best aspects at the hospital in the emergency
setting and around 78 percent compared to 61 percent, in the inpatient/consumer setting.
This result is somewhat dissimilar to Gabott and Hogg’s (1996) product dimensions’
evaluation theory, which states that the core medical service elements have a neutral

Overall satisfaction Orderly staff

Table IX.
Correlations between Orderly staff courtesy Pearson correlation 0.585 * 0.802 *
orderly services events, Sig. (two-tailed) 0.000 0.000
orderly services act, and N 196 196
overall satisfaction in the Orderly staff punctuality Pearson correlation 0.662 * 0.777 *
inpatient/consumer Sig. (two-tailed) 0.000 0.000
setting N 195 195

Overall satisfaction Discharge process

Table X. Billing process Pearson correlation 0.524 * 0.727 *

Correlations between Sig. (two-tailed) 0.000 0.000
discharge process events, N 195 195
discharge process act, Helpfulness of office
and overall satisfaction in personnel at discharge Pearson correlation 0.551 * 0.772 *
the inpatient/consumer Sig. (two-tailed) 0.000 0.000
setting N 198 198

Best aspect Worst aspect

Table XI.
Core clinical factors Clinical competence 49 (49.0) 19 (16.1)
versus peripheral factors Peripheral factors 51 (51.0) 99 (83.9)
as best and worst aspects Total (N ) 100 118
of the medical encounter
in the emergency setting Note: Figures given in parentheses are percentages
effect on satisfaction and can be high dissatisfiers if absent, while peripheral elements of Patient
the service constitute the main satisfiers and can be regular dissatisfiers. The results satisfaction
of this project show that clinical competence elements can be satisfiers more than
dissatisfiers and that peripheral elements are more related to dissatisfaction. It is
important to clarify that core medical service elements are related to medical competence
and clinical skills of physicians, nurses, and other medical staff; while peripheral
elements of the medical service are elements outside the professional medical service, 57
like waiting time, nursing care and friendliness, courtesy of staff, wheel chairs, billing,
cleanliness, and hospital atmosphere.

Customer satisfaction with major service acts and its effect on customer overall
satisfaction: a stepwise regression analysis
The effect that satisfaction with different service acts has on overall satisfaction is
uncertain from the values of correlation coefficients and therefore a stepwise regression
analysis was run on the data to check for the relevance of the servuction model used in
the methodology and to test the influence of each act on overall satisfaction. This
model attempts to find the best regression model that fits the dependent variable
without examining all the possible regressions. Stepwise regression was used rather
than hierarchical regression due to the facts that this research is exploratory rather
than confirmatory and not all possible regressions that could be run were run.

Emergency setting stepwise regression analysis

The results of the stepwise regression analysis in Tables XIII and XIV show that the
acts that influence overall satisfaction with the medical service encounter in the
emergency setting are nursing care, physicians, admission, and technicians, in that
order of importance. When testing for autocorrelation and collinearity, both turned to
be almost inexistent since the Durbin-Watson statistic is 1.934 (close to 2) and all VIF

Best aspect Worst aspect

Table XII.
Clinical competence 52 (39.1) 28 (21.9) Core clinical factors
Peripheral factors 81 (60.9) 100 (78.1) versus peripheral factors
Total (N ) 133 128 as best and worst aspects
of the medical encounter
Note: Figures given in parentheses are percentages in the inpatient setting

Change statistics
Model R2 Adjusted R 2 SD error of the estimate R 2 change Sig. F change

1 0.459 0.456 0.771 0.459 0.000

2 0.539 0.534 0.714 0.080 0.000
3 0.585 0.578 0.679 0.046 0.000
4 0.599 0.589 0.670 0.013 0.020 Table XIII.
Stepwise regression for
Notes: 1. Predictors: (constant), nursing care; 2. Predictors: (constant), nursing care, physicians; emergency setting with
3. Predictors: (constant), nursing care, physicians, admission; 4. Predictors: (constant), nursing care, overall satisfaction as
physicians, admission, technicians dependent variable
IJPHM
Unstandardized Standardized
2,1 coefficients coefficients Correlations
Model B SD error b t Sig. Zero-order

1 (Constant) 1.097 0.190 5.762 0.000

Nursing care 0.642 0.054 0.678 11.944 0.000 0.678
58 2 (Constant) 0.534 0.205 2.603 0.010
Nursing care 0.488 0.057 0.515 8.487 0.000 0.678
Physicians 0.304 0.056 0.327 5.386 0.000 0.584
3 (Constant) 0.157 0.214 0.737 0.462
Nursing care 0.335 0.065 0.353 5.137 0.000 0.678
Physicians 0.313 0.054 0.337 5.840 0.000 0.584
Table XIV. Admission 0.264 0.061 0.266 4.298 0.000 0.562
Coefficients for stepwise 4 (Constant) 0.061 0.215 0.285 0.776
regression model in the Nursing care 0.307 0.065 0.324 4.692 0.000 0.678
emergency setting with Physicians 0.257 0.058 0.276 4.414 0.000 0.584
overall satisfaction as Admission 0.228 0.062 0.229 3.644 0.000 0.562
dependent variable Technicians 0.149 0.064 0.153 2.347 0.020 0.583

values are less than 5. The model has an adjusted R 2 equal to 58.9 percent, which
implies that the acts used in the model, except for the discharge process, explain about
60 percent of the variation in the dependent variable (overall satisfaction). The
discharge process was excluded because it has no significant effect on overall
satisfaction, which is logical because in the emergency setting, most of the paper work
is done at the admission level.

Customer satisfaction with major service acts and its effect on customer overall
satisfaction: a stepwise regression analysis
The effect that satisfaction with different service acts has on patient/consumer
satisfaction is uncertain from the values of correlation coefficients and therefore a
stepwise regression analysis was run on the data to check for the relevance of
each service act on overall satisfaction. This model attempts to find the best
regression model that fits the dependent variable without examining all the possible
regressions.
The results of the stepwise regression analyses performed show that the acts of
services that influence overall satisfaction with the medical service encounter in the
emergency setting are nursing care, physicians, admission, and technicians, in that
order of importance. When testing for autocorrelation and co linearity, both turned to
be almost non-existent since the Durbin-Watson statistic is 1.934 (close to 2) and all
VIF values are less than five. The model has an adjusted R 2 equal to 58.9 percent,
which implies that the acts of services used in the model, except for the discharge
process, explain about 60 percent of the variation in the dependent variable
(patient/consumer satisfaction assessment of hospital service). The discharge process
was excluded because it had no significant effect on overall satisfaction, which is
logical because in the emergency setting, most of the paper work is done at the
admission level (Figures 2 and 3).
 Physicians
Patient
satisfaction
Technicians
Nursing
0.257

0.149
0.307 Discharge
59
Admission Figure 2.
Model for overall
0.228 patient/consumer
satisfaction with the
Overall Satisfaction emergency room
Adj. R2 = 0.589 encounter

Physicians

Technicians
Nursing 0.198

0.294 0.178 Discharge

Admission

0.142 0.208
Overall Satisfaction
Adj. R2 = 0.701
Figure 3.
Model for overall customer
Housekeeping satisfaction with the
Orderly
Food Services inpatient encounter

Consumer marketing implications

Dissatisfied patient/consumers are a costly burden to hospitals that must be controlled
by shaping patient/consumer perceptions and expectations. One major factor in shaping
these perceptions is “external communication” with potential patient/consumers. While
current strategic assessments remain core focused, the results of this study reveal that a
health care systems tactic would be a more effective alternative. The immediate
implications are that, to increase patient/consumer satisfaction, hospitals need to
develop strategies to empower employees. This would mean making employees more
customer-focused and responsive in an effort to improve the compassion and self-image
of the staff.
Hospital strategists must become more aware of the strategic drift that the industry
has taken and realize that health care delivery systems are highly centered on
the patient/consumer interactions. The importance of the human element in health care
delivery is both a great opportunity (if employees are trained and motivated to provide
consistently high-quality service) and a great threat and competitive weakness
IJPHM (if employees are not customer-oriented). Organizations need to bring managers close
2,1 to the customers by serving periodically in backrooms where they can have direct
contact with customers and employees to check for weaknesses and points to be
changed.
The fact that nursing care constantly comes up as the key determinant of customer
satisfaction gives more importance for health care organizations’ management to
60 monitor employee satisfaction, specifically nurses. Furthermore, training plays a
critical role in directing all employees towards the same goal of customer satisfaction.
Finally, employee training should not only focus on building up employees’ medical
and technical skills but more importantly on strengthening employees’ communication
skills and shaping their way in treating customers as human beings that have needs
rather than taking them for granted.

Future research
The importance of patient/consumer assessments in insuring hospital competitiveness
through the sharing of perceptions – as explained in this study – makes it necessary
for hospitals to focus on internal measures rather than merely building core
technology. Employee training, empowerment and enfranchisement strategies are the
basis for successful internal promotion, which depends on employee satisfaction and
their consequent performance in providing customer services. Accordingly, future
research should focus upon such issues as measuring employee satisfaction and how it
relates to customer satisfaction within hospitals. It is believed that future consumer
marketing research can use a similar model and apply it to other hospital services such
as outpatient/consumer treatment. Ultimately, a fundamental re-evaluation will need to
be made of how patient/consumer satisfaction is determined, transmitted, and
integrated into hospital health care delivery systems. Finally, exploratory statistical
testing methods were used in developing both in-patient and outpatient models
presented within this research. For this reason, the service categories presented here
consist of few components, which should be further refined through statistical methods
such as cluster analyses. The findings of these analyses should then further be refined,
with the relations among the resultant categories developed into a series of subsequent
hypotheses and theory. This would then allow theory testing and development through
confirmatory statistical tests such as hierarchical regression, which would yield more
accurate results with respect to causation.

Notes
1. Shared perception theory development.
2. Competence perception theory development.
3. Exploratory hypothesis for subsequent development.
4. Strategic drift theory development.

References
Berry, L.L. and Bendapudi, N. (2007), “Health care: a fertile field for service research”,
Journal of Service Research, Vol. 10 No. 2, pp. 111-22.
Budd, J. and Raber, D. (1996), “Discourse analysis: method and application in the study of
information”, Information Processing & Management, Vol. 32 No. 2, pp. 217-26.
Cone, D.C. (2007), “Knowledge translation in the emergency medical services: a research agenda Patient
for advancing pre-hospital care”, Academy of Emerging Medicine, Vol. 14, pp. 1052-7.
satisfaction
Craig, T.J., Perlin, J.B. and Fleming, B.B. (2007), “Self-reported performance improvement
strategies of highly successful veterans health administration facilities”, American Journal
of Medical Quality, Vol. 22 No. 6, pp. 438-44.
Deming, W.E. (1986), Out of the Crisis, Massachusetts Institute of Technology Center for
Advanced Engineering Studies, Cambridge, MA. 61
Gabbott, M. and Hogg, G. (1996), “Service dimensions and service quality: an asymmetric
approach”, Workshop on Quality Management in Services, Vol. VI, EIASM, Gothenburg.
Gandjour, A. (2007), “Changing the organization of health care”, Journal of the American Medical
Association, Vol. 298 No. 3, p. 286.
Gilligan, C. and Lowe, R. (1995), Marketing and Health Care Organizations, Radcliffe Medical
Press Inc., New York, NY.
Glass, G.V., McGaw, B. and Smith, M.L. (1981), Meta-Analysis in Social Research, Sage,
Beverly Hills, CA.
Glickman, S.W., Baggett, K.A., Krubert, C.G., Peterson, E.D. and Schulman, K.A. (2007),
“Promoting quality: the health-care organization from a management perspective”,
International Journal of Quality Health Care, Vol. 19 No. 6, pp. 341-8.
Hunter, J.W. and Schmidt, F.L. (1990), Methods of Meta-Analysis: Correcting Error and Bias in
Research Findings, Sage, Newbury Park, CA.
Hunter, J.W., Schmidt, F.L. and Jackson, G.B. (1982), Meta-Analysis: Cumulating Research
Findings across Studies, Sage, Beverly Hills, CA.
Jones, A.E., Shapiro, N.I. and Roshon, M. (2007), “Implementing early goal-directed therapy in the
emergency setting: the challenges and experiences of translating research innovations into
clinical reality in academic and community settings”, Academy of Emerging Medicine,
Vol. 14, pp. 1072-8.
Juran, J.M. (1988), Juran on Planning for Quality, The Free Press, New York, NY.
Kendrick, D.C., Bu, D., Pan, E. and Middleton, B. (2007), “Crossing the evidence chasm: building
evidence bridges from process changes to clinical outcomes”, Journal of the American
Medical Informational Association, Vol. 14 No. 3, pp. 329-39.
Laffel, G. and Blumenthal, D. (1989), “The case for using industrial quality management science
in health care organizations”, Journal of American Medical Association, Vol. 262 No. 20,
pp. 2869-73.
Leonardi, M.J., McGory, M.L. and Ko, C.Y. (2007), “Quality of care issues in colorectal cancer”,
Clinical Cancer Research, Vol. 13, pp. 6897s-902s.
Lilford, R.J., Brown, C.A. and Nicholl, J. (2007), “Use of process measures to monitor the quality of
clinical practice”, British Medical Journal, Vol. 335 No. 7621, pp. 648-50.
Lillrank, P. (2003), “Standard, routine and nonroutine processes”, Organization Studies, Vol. 24
No. 2, pp. 215-33.
Mintzberg, H., Quinn, J.B. and Ghoshal, S. (1998), “The strategy process: concepts, context and
cases”, Journal of Advertising, Vol. 27 No. 4, pp. 53-70.
Porter, M.E. and Teisberg, E.O. (2007a), “How physicians can change the future of health care”,
Journal of the American Medical Association, Vol. 297, pp. 1103-11.
Porter, M.E. and Teisberg, E.O. (2007b), “Changing the organization of health care – reply”,
Journal of the American Medical Association, Vol. 298, pp. 287-8.
IJPHM Pugh, M.J.V., Berlowitz, D.R., Montouris, G., Bokhour, B., Cramer, J.A., Bohm, V., Bollinger, M.,
Helmers, S., Ettinger, A., Meador, K.J., Fountain, N., Boggs, J., Tatum, W.O. IV, Knoefel, J.,
2,1 Harden, C., Mattson, R.H. and Kazis, L. (2007), “What constitutes high quality of care for
adults with epilepsy?”, Neurology, Vol. 69 No. 21, pp. 2020-7.
Puro, J.-P. (1996), Towards a Phenomenological Theory of Interpersonal Communication,
Gaudeamus, Helsinki.
62 Shortell, S.M., Rundall, T.G. and Hsu, J. (2007), “Improving patient care by linking
evidence-based medicine and evidence-based management”, Journal of the American
Medical Association, Vol. 298 No. 6, pp. 673-6.
Volpp, K.G., (2007), “Designing a model health care system”, American Journal of Public Health,
Vol. 97 No. 12, pp. 2126-8.
Wijnberg, N., van den Ende, J. and de Wit, O. (2002), “The relation between systematic
management and scientific management: two cases from the financial services”, Group &
Organization Management, Vol. 27 No. 3, pp. 408-29.
Wilson, I.B., Landon, B.E., Marsden, P.V., Hirschhorn, L.R., McInnes, K., Ding, L. and Cleary, P.
(2007), “D Correlations among measures of quality in HIV care in the United States: cross
sectional study”, British Medical Journal, Vol. 335 No. 7629, p. 1085.
Yang, B. (2002), “Meta-analysis research and theory building”, Advances in Developing Human
Resources, Vol. 4 No. 3, pp. 296-316.

About the authors

Imad Baalbaki, PhD, is a Director of Development at the American University of Beirut in
Lebanon. He has taught and conducted research globally and is the author of multiple articles
that has been published throughout the world.
Zafar U. Ahmed, PhD, is a Full Professor and Associate Dean, College of Business
Administration, and Director: MBA Program, Prince Sultan University, Riyadh, Saudi Arabia.
He is also a Tenured Full Professor of Marketing and International Business at the Texas A&M
University at Commerce, Texas, USA. He has got more than 100 scholarly publications to his
credit, has organized and presided more than ten global conferences, serves on the editorial
board of more than ten journals, serves as the President, Academy for Global Business
Advancement (www.agba.us), Editor-in-Chief, Journal for Global Business Advancement (www.
inderscience.com/jgba), Editor-in Chief, Journal for International Business and Entrepreneurship
Development (www.inderscience.com/jibed).
Valentin H. Pashtenko, PhD, is an Assistant Professor of Management at the Christopher
Newport University in Newport News, Virginia, USA. He is the author of over 20 articles, has
taught on three continents, and has had his work published throughout the world.
Suzanne Makarem is a doctoral candidate in Marketing at the Temple University in
Philadelphia, Pennsylvania, USA. She has presented her work globally and has been received
such honors as Best Paper for her outstanding academic research. Suzanne Makarem is the
corresponding author and can be contacted at: Suzannem@temple.edu

To purchase reprints of this article please e-mail: reprints@emeraldinsight.com

Or visit our web site for further details: www.emeraldinsight.com/reprints

View publication stats