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Patient satisfaction in the emergency department an empirical investigation into its measurement, antecedents, and consequences
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ABSTRACT - The main purpose of this research is to investigate the relationships between patient satisfaction,
its antecedents (including global perceptions, perceived quality dimensions, and expectations), and its
impact on consequences (including confidence/trust, payment perception, and complaints), as well as
defining and testing a conceptual model for patient satisfaction and related constructs in the context of an
emergency department (ED).
The key focus of this study is thus to define key factors promoting patient satisfaction in the ED
which, in turn, influence a set of performance factors (such as payment perception, confidence/trust, and
complaints) that can be used for improved resource allocation and the definition of priorities by hospital
and health system managers. A further focus of the study is the investigation of the potential moderating
effect of a set of controlling factors (including specific patients’ characteristics, psychological state, social
and demographic attributes, and the state of health/health status) on the relationships between patient
satisfaction, its antecedents, and consequences.
First, an exploratory phase of research was necessary in order to examine the nature of EDs and
identify the major gaps that could be addressed in the quantitative phase of research. Thus, after finishing
the analysis of the qualitative phase of research, we proceeded develop the questionnaire. As a solid base
for our conceptual model and the questionnaire, we considered the methodology used in the Indice
Nacional de Satisfação do Cliente (ECSI–Portugal), which is based on structural equation modelling
(SEM) with latent variables, along with the American Customer Satisfaction Index (ACSI) model, which
consists of indices for drivers or causes of satisfaction (antecedents), satisfaction, and outcomes of
satisfaction (consequences) with cause-and-effect relationships. In developing the questionnaire, we also
took into account and reviewed the Instrumentos de Avaliação da Qualidade Hospitalar – Urgências
Adultos (IAQH-UA), the fourth National Health Interview Survey (Inquérito Nacional de Saúde), as well
as the survey used to investigate aging processes in Portugal. Our questionnaire was adapted, and other
questions were added that enabled us to identify important issues according to our conceptual model. The
appropriateness of the questionnaire was tested by administering the instrument to a small subset of the
study’s population by launching a pilot survey with 20 interviewees.
The investigation period for the study was January 1 through December 31, 2016. Data collection
was performed from May 18, 2017 through November 30, 2017 and took place in the public hospital
under investigation in Lisbon, Portugal. We chose the sample distribution with a 5% margin of error and
a 95% confidence interval. The total sample size was 382 patients. The questionnaire was sent either by
mail or e-mail, depending on the respondent’s preference. The data analysis included several steps:
descriptive statistics; correlation coefficients; ANOVA and T-test; multiple regression analysis; stepwise
multiple linear regression analysis; and SEM (path analysis).
Our results reveal that meeting expectations and the overall satisfaction with doctors are the main
patient satisfaction antecedents that primarily contribute to understanding the level of confidence/trust in
the ED and that influence it as the main patient satisfaction consequence, both directly and indirectly.
Even though there are more variables that influence confidence/trust in the ED through the perceived quality of healthcare rather than through satisfaction, we observe the strongest contribution in the
mediation model through satisfaction, which shows its dominant role over the perceived quality of
healthcare. In turn, controlling factors do not have a strong, significant impact on the relationship between
patient satisfaction, its antecedents, and consequences.
In our mediation model, we reveal that overall satisfaction with doctors can better explain
confidence/trust in the ED through perceived quality of healthcare; however, meeting expectations can
better explain confidence/trust in the ED through satisfaction.
Trust and expectations play an important role in the doctor-patient relationship. Several
researchers have noted that trust was more complex than expectations, as the older adults could be
satisfied but not trust providers, or they could trust providers but not be satisfied. Other researchers have
also emphasised the fact that patients may be satisfied with the visit but may not have a sense of trust and
vice versa. In our research, we considered confidence/trust to be an outcome; thus, our results showed
that a certain set of variables (overall satisfaction with doctors and meeting expectations) can bypass
satisfaction and perceived quality of healthcare and have a direct influence on confidence/trust, while
other sets of variables (qualitative perceived waiting time for triage and information about possible
delays) cannot bypass satisfaction; still others (qualitative perceived waiting time to be called back by the
doctor after the examinations and/or tests, privacy, and accessibility and availability) cannot bypass
perceived quality of healthcare without any chance of direct influence on confidence/trust.
By conceptualising patient satisfaction in the ED context based on our results, we may say that
the perceived quality of healthcare and satisfaction are integral to each other. Further, satisfaction and
perceived quality of healthcare play an important but distinct mediating role in strengthening the effect of
patient satisfaction antecedents on patient satisfaction consequences, where the strongest patient
satisfaction antecedents (the overall level of satisfaction with doctors and meeting patients’ expectations)
and the main patient satisfaction consequence (confidence/trust in the ED) form a connecting link
between two concepts (satisfaction and the perceived quality of healthcare).
Hence, this analysis demonstrates the complexity of the research topic under discussion and the
importance of investigating it further.
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Palavras-chave
Patient satisfaction Perceived quality of healthcare Emergency department Patient satisfaction antecedents Patient satisfaction consequences