Examining Relationships Between Hospital Inpatient Expectations and Satisfaction For PDF

Walden University
College of Management and Technology
This is to certify that the doctoral study by
Julie Becker
has been found to be complete and satisfactory in all respects,

and that any and all revisions required by
the review committee have been made.
Review Committee
Dr. Alice Denomme Gobeille, Committee Chairperson, Doctor of Business
Administration Faculty
Dr. Michael Ewald, Committee Member, Doctor of Business Administration Faculty
Dr. Cheryl Lentz, University Reviewer, Doctor of Business Administration Faculty
Chief Academic Officer

Eric Riedel, Ph.D.
Walden University
2013
Abstract
Examining Relationships Between Hospital Inpatient Expectations and Satisfaction for
Maximum Medicare Reimbursement
by
Julie A. Becker
MS, Upper Iowa University, 2011

BS, University of Wyoming, 1998
Doctoral Study Submitted in Partial Fulfillment

of the Requirements for the Degree of
Doctor of Business Administration
Walden University
December 2013
Abstract
Hospitals rely on Medicare reimbursement to cover the cost of some patients services.
Patient satisfaction scores became a health care industry priority in 2008 when The
Centers for Medicare and Medicaid Services initiated the Value-Based Purchasing
Program, basing 30% of Medicare reimbursement for hospitalized patients on patient
satisfaction metrics. The purpose of this correlational study was to examine the
relationship between hospitalized patients expectations of care received and satisfaction
with the overall experiences in the medical, surgical, and cardiac units of a 300-bed
hospital in southeast Wisconsin. Understanding predictors to high patient satisfaction can
provide opportunities for health care organizations to align financial strategies with a
patient-centered approach focused on individualizing care and meeting expectations. The
expectancy value theory served as the theoretical foundation describing personal beliefs,
values, and prior experiences as key components shaping patient expectations. Data were
gathered from 90 participants who completed a 20-question survey using a 5-point
Likert-type scale. Statistical analysis revealed a significant positive correlation between
meeting patient expectations and patient satisfaction. A positive correlation also existed
between factors related to previous physician, nursing, and hospital experiences and the
current level of satisfaction. No significant differences in expectations or satisfaction
existed between the medical, surgical, and cardiac units. Hospitals can strengthen
financial stability by meeting the patient satisfaction scores for maximum Medicare
reimbursement. Positive social change may occur when health care providers assess and
meet patients expectations, thereby influencing patients satisfaction through
individualizing services and supporting improved patient outcomes.
Examining Relationships Between Hospital Inpatient Expectations and Satisfaction for

Maximum Medicare Reimbursement
by
Julie A. Becker
MS, Upper Iowa University, 2011

BS, University of Wyoming, 1998
Doctoral Study Submitted in Partial Fulfillment

of the Requirements for the Degree of
Doctor of Business Administration
Walden University
December 2013
UMI Number: 3601243
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Dedication
My journey through this process felt difficult and challenging on numerous
occasions; however, I never felt alone. I first dedicate this study to my incredible
daughters, Lynsie Bloom and Taylor Bloom, who remind me of how proud they are of all
my accomplishments and assured me they could not ask for a better role model. I love
you both so much and feel blessed to be your mother. I also dedicate this study to my
Dad, William Becker. He encouraged me in all my endeavors in life, especially
endeavors related to education. He is a lifelong learner and values knowledge, believing
we should never stop striving to improve. Additionally, as a father of four daughters, he
witnessed that women often have to work harder to advance, but he told me that I could
stand toe-to-toe with anyone, man or woman. For that support and encouragement, I am
forever grateful.
Acknowledgments
I would like to acknowledge my outstanding committee members: Dr. Alice
Denomme-Gobeille, Dr. Michael Ewald, and Dr. Cheryl Lentz. I believe all members of
my committee dedicated themselves to assisting me in developing and implementing a
high-quality research study. The professional experience of each member was evident
through their reviews and suggestions throughout the process. This DBA process is a
journey I will never forget as I enjoyed significant growth, both personally and
professionally.
I would also like to acknowledge my female friends and role models who
encouraged me throughout this process, some of you throughout many of years of my
life. Specifically, I would like to mention Tracy Tennant (best friend and lifelong
supporter), Susan Wirtjes (my surrogate mother), Brenda Bowers (a fantastic boss and
role model), Susan Boland (a woman of great integrity and strength), and Connie
Slomczewski (we think alike and she always addresses me as Hi beautifulhow can
she not be one of my favorite people), as well as my numerous women friends from Iowa
who cheered me on every step of the way. I remain forever grateful for the love and
support showered on me over the past few years.
Table of Contents
List of Tables .......................................................................................................................v
List of Figures .................................................................................................................... vi
Section 1: Foundation of the Study......................................................................................1
Background of the Problem ...........................................................................................2
Problem Statement .........................................................................................................5
Purpose Statement ..........................................................................................................6
Nature of the Study ........................................................................................................7
Research Question .........................................................................................................9
Hypotheses .....................................................................................................................9
Survey Questions .........................................................................................................10
Theoretical Framework ................................................................................................11
Definition of Terms......................................................................................................15
Assumptions, Limitations, and Delimitations..............................................................16
Assumptions.......................................................................................................... 16
Limitations ............................................................................................................ 16
Delimitations ......................................................................................................... 17
Significance of the Study .............................................................................................18
A Review of the Professional and Academic Literature ..............................................21
Patient Expectations .............................................................................................. 24
Patient Satisfaction................................................................................................ 35
Relationship Between Patient Expectations and Patient Satisfaction ................... 48
i
Summary of the Literature Review ....................................................................... 61

Transition and Summary ..............................................................................................62
Section 2: The Project ........................................................................................................64
Purpose Statement ........................................................................................................64
Role of the Researcher .................................................................................................65
Participants ...................................................................................................................66
Research Method and Design ......................................................................................69
Method .................................................................................................................. 70
Research Design.................................................................................................... 74
Population and Sampling .............................................................................................78
Ethical Research...........................................................................................................84
Data Collection ............................................................................................................88
Instruments ............................................................................................................ 88
Data Collection Technique ................................................................................... 94
Data Organization Techniques .............................................................................. 96
Data Analysis Technique .............................................................................................98
Reliability and Validity ..............................................................................................103
Reliability............................................................................................................ 103
Validity ............................................................................................................... 105
Transition and Summary ............................................................................................106
Section 3: Application to Professional Practice and Implications for Change ................107
Overview of Study .....................................................................................................107
ii
Presentation of the Findings.......................................................................................109

Pilot Study........................................................................................................... 109
Research Questions and Hypotheses .................................................................. 111
Interview Questions ............................................................................................ 117
Relating Findings to Available Literature........................................................... 120
Expectancy Value Theory ................................................................................... 122
Business Practice ................................................................................................ 123
Applications to Professional Practice ........................................................................125
Implications for Social Change ..................................................................................128
Recommendations for Action ....................................................................................129
Recommendations for Further Study .........................................................................131
Reflections .................................................................................................................134
Summary and Study Conclusions ..............................................................................135
References ........................................................................................................................138
Appendix A: Becker Inquiry of Patient Expectations as Predictors for Patient
Satisfaction ...........................................................................................................156
Appendix B: Pilot Consent Form .....................................................................................157
Appendix C: Consent Form .............................................................................................159
Appendix D: National Institutes of Health Certificate ....................................................161
Appendix E: Sample Excel Spreadsheet ..........................................................................162
Appendix F: Histogram for Patient Expectation ..............................................................163
Appendix G: Histogram for Patient Satisfaction .............................................................164
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Appendix H: Histogram for Relationship Between Patient Expectation and Patient

Satisfaction ...........................................................................................................165
Appendix I: Comparative Box Plot Patient Expectation .................................................166
Appendix J: Comparative Box Plot Patient Satisfaction .................................................167
Appendix K: Comparative Box Plot Relationship Between Patient Expectations
and Patient Satisfaction ........................................................................................168
Curriculum Vitae .............................................................................................................169
iv
List of Tables
Table 1. Synopsis of Sources in the Literature Review .................................................. 222
Table 2. One-way ANOVA Sample Size Unit Totals ...................................................... 82
Table 3. Hypotheses and Corresponding Tests ............................................................... 102
Table 4. Mean and Standard Deviation for Survey Question Sections........................... 112
Table 5. Pearson Correlation of Patient Expectation Scores and Patient Satisfaction
Scores .................................................................................................................. 113
Table 6. Pearson Correlation of Patient Satisfaction Scores and Relationship between
Patient Expectations and Patient Satisfaction ..................................................... 114
Table 7. Mean and Standard Deviation for Medical, Surgical, and Cardiac Units......... 115
Table 8. Test of Homogeneity of Variances ................................................................... 116
List of Figures
Figure 1. Expectancy-value theory model and key components specific to patient
expectations and patient satisfaction ................................................................... 144
Figure 2. Literature review organization for examination of patient expectations and
patient satisfaction. ............................................................................................... 23
Figure 3. Patient centered graphic depicting the need to focus on the patient in order to
receive full reimbursement for healthcare services. ........................................... 711
Figure 4. Relationship between meeting patient expectations and patient satisfaction. . 766
vi
1
Section 1: Foundation of the Study
Consumers provide valuable patient satisfaction data used in determining
Medicare reimbursement. Patient satisfaction scores became an ongoing factor of the
reimbursement calculations beginning in 2008. Low patient satisfaction scores reduce
total reimbursement. The Centers for Medicare and Medicaid Services (CMS, 2012)
requires the random selection of health care consumers to complete surveys regarding
their experiences in the hospital settings. Health care organizations eligible for federal
reimbursement must report the resulting data. CMS began posting patient satisfaction
data for the public to review on the Hospital Compare website in 2005. The U.S. federal
government uses the results to define the level of reimbursement for health care services
(Centers for Medicare and Medicaid Services (CMS), 2012). Consequently, health care
consumer satisfaction is a key factor in the financial success of health care organizations.
Health care organizations benefit from acknowledging and addressing the amount
of income consumers spend on services. As consumers become more knowledgeable
about health care services through publically reported data, the priority is to find the best
value and highest quality of care. Finding publically reported data on services and
quality proved difficult for consumers prior to the initiation of Hospital Compare (CMS,
2012). Because of the additional information available to consumers through publically
reported health care, consumers viewed health care as a service, judging service value by
cost in relationship to quality of care. The pressures to provide quality services that meet
patients expectations at a lower cost raise the level of competition among health care
organizations. Patient satisfaction language is common; however, a less commonly used
2
phrase is patient expectation. Understanding how to identify patients expectations and
then meeting those expectations may improve satisfaction, thereby positively affecting
the financial reimbursements for health care organizations.
The purpose of this doctoral study was to examine the relationship between
patients expectations and their satisfaction for health care consumers in southeast
Wisconsin. The findings from this quantitative study provide additional information
regarding the relationship between hospitalized patients priority expectations and
satisfaction. As health care leaders define and meet the patients expectations, the quality
of care improves with a patient-centered approach, leading to improved satisfaction and
higher revenues (CMS, 2012).
Background of the Problem
Health care expenditures total more than $2.3 trillion per year, or nearly 20% of
the U.S. economy (Channing & DeVore, 2009). Leaders of health care organizations
realigned their priorities to address rising costs with the patient. In 2008, patient
satisfaction scores became a factor in reimbursement. The regulatory agencies
responsible for paying the health care organizations forced this realignment versus the
health care organizations voluntarily choosing to shift the focus (Blakley, Kroth, &
Gregson, 2011). Placing the patient at the forefront of health care means the patient
drives services as well as reimbursement. Health care consumers have the power to drive
reimbursement, which encourages a new level of competition among health care
organizations (Gruber, 2009). Patient loyalty is as important to the health care industry
as customer loyalty is for other service industries (Quader, 2009). Leaders in health care
3
organizations use patient satisfaction data to define and prioritize areas of improvement
in hopes of capturing loyalty and increasing the number of return customers; however,
the outcomes vary, ranging from minimal to great success.
Health care reimbursement is an additional factor related to patient satisfaction.
In a governmental effort to address the rising costs of health care, the CMS developed the
Hospital Value-Based Purchasing Program beginning with pilot programs in 2003 as a
means of improving the value and quality of health care services (U.S. Department of
Health and Human Services [USDHS], 2011a). This initiative, beginning in 2012, links
hospitals Medicare reimbursement to patient satisfaction scores and quality of care
measures. The calculation for reimbursement includes a formula in which 30% of acute
care reimbursement aligns with patient satisfaction scores using nine measures of patientexperience domains (USDHS, 2011c). The patient-experience domains are (a) nurse
communication, (b) doctor communication, (c) hospital staff responsiveness, (d) pain
management, (e) medication communication, (f) hospital cleanliness, (g) quietness, (h)
discharge information, and (i) overall hospital rating (USDHS, 2011c). The remaining
70% of reimbursement ties to quality measures (CMS, 2012). CMS (2012) holds 1% of
reimbursement for inpatient Medicare services, requiring the health care organization to
earn the 1% back through patient satisfaction and quality metrics with an incremental rise
to 2% by the year 2017. Considering this formula, if patients rate health care
organizations low on patient satisfaction, Medicare withholds reimbursement; therefore, a
priority for health care organizations includes understanding the expectations of patients
(USDHS, 2011a).
4
In this quantitative, correlational study, I defined and prioritized patients
expectations. If health care providers and leaders understand and prioritize patients
expectations, they can identify resources and initiatives to improve patients experiences.
Health care providers and leaders who plan new services and adjust existing services will
most likely benefit from the study. Health care providers increased knowledge of
patients expectations guides the processes and services supporting a patient-centered
approach. Services tailored to meet patients expectations improve patients experience
overall and lead to improved satisfaction. Patients are in a position to score their overall
experience, thereby defining their level of satisfaction. Financial reimbursement is linked
directly to the level of satisfaction (USDHS, 2011a). Ultimately, organizations
strengthen the customer base by meeting or exceeding expectations, increasing
satisfaction, and improving loyalty.
By improving patients experiences in health care, health care providers enact
positive social change as superior satisfaction aligns with a higher quality of care (Elliot
et al., 2010). The U.S. federal government mandated public reporting of patient
satisfaction and quality measures with two goals in mind. The first goal is to increase the
available information to health care consumers about the services they seek (Elliot et al.,
2010). If consumers have more information, they can make better health care decisions
by choosing the higher quality provider (Elliot et al., 2010). Second, public reporting
provides useful data for health care providers and organizations to focus on initiatives
that can improve the quality of care (Elliot et al., 2010). Lees (2011) claimed that the
objectives of patient-reported outcome measures and quality standards would increase
5
patients safety and improve patients experience. Improved quality of care positively
affects the population of health care consumers and society as a whole by supporting a
healthier population, increasing longevity, decreasing health care costs, and improving
quality of life. Findings from this study may contribute to health care organizations
performance by providing a means for identifying patients expectations and increasing
patient satisfaction. The studys findings may also be used by other health care
organizations and researchers interested in completing additional studies to support this
research area.
Problem Statement
Health care organizations participating in U.S. federal programs often rely on
Medicare reimbursement to cover a significant amount of the cost of services. In 2009,
over 7 million Medicare beneficiaries faced more than 12.4 million hospitalizations with
$4.4 million spent on care for patients harmed in the hospital and another $26 billion
spent on readmissions (USDHS, 2011b). In an effort to reduce health care costs and
improve the quality of care, the U.S. federal government implemented the Value-Based
Purchasing (VPB) initiative, withholding 1%, approximately $850 million, from 3,500
U.S. hospitals and using the money as incentive payments for meeting quality and patient
satisfaction measures (USDHS, 2011c). The general business problem was the negative
financial implications for health care organizations that fail to meet health care
consumers service expectations as measured through patient satisfaction data. The
specific business problem was the lack of information available to the leadership of a
6
300-bed hospital in southeast Wisconsin to identify patients priorities and those
priorities relationship to patient satisfaction.
Purpose Statement
The purpose of this correlational study was to examine the relationship between
patient expectations (independent variable) and patient satisfaction (dependent variable)
for health care consumers of a 300-bed hospital in southeast Wisconsin. The participant
group included a sample size calculated and validated after a pilot study of male and
female health care consumers who were over the age of 18 and considered physically
stable. The sample population represented patients admitted into the 300-bed hospital for
a stay of greater than 24 hours (Schoenfelder, Klewer, & Kugler, 2011). Purposive
sampling of patients over the age of 18 ensured a representative sample for patients of
legal age and varied health conditions as patients expectations were different based on
these factors (Holzer & Minder, 2011). An analysis of variance (ANOVA) tested the
expectations and satisfaction of a variety of ages and health conditions from the medical,
surgical, and cardiac units of the host hospital.
The finding from this study contributes to the body of knowledge on health care
patients expectations and experience. Health care organizations affected by the
regulations for health care reimbursement benefit through gaining information from this
study. Furthermore, health care organizations not currently affected by the
reimbursement changes benefit through information about the identification of patients
experience and expectations. Leaders of health care organizations gain an advantage
using the identified patients expectations when planning initiatives to improve patients
7
experience and deliver a higher quality of care. The public benefits from the study as
health care services change to reflect patients expectations. The patient-centered
approach leads to improved experiences, higher quality of care, and superior outcomes
for the general population.
Nature of the Study
In this study, examination of the research problem included analyzing the
correlational relationship between the studys variables, patient expectations and patient
satisfaction. A quantitative method with a correlational design provided an answer to the
research questions of whether a relationship exists between patients expectations and
their satisfaction. The quantitative method analysis and results included information for
health care organizations about patients satisfaction and quality of care; additionally, the
studys results included material helpful in developing initiatives to improve health care
services. Additionally, results from statistical testing included measures of significance
of the relationship between patients expectations and satisfaction.
I addressed the research questions through the application of the quantitative
methodology using correlation and one-way ANOVA to determine if a statistically
significant relationship exists between patient expectations and patient satisfaction. EllisJacobs (2011) reviewed the value of quantitative instruments in measuring patients
satisfaction. Through quantitative analysis, Ellis-Jacobs demonstrated a positive
correlation between patients satisfaction and a hospitals revenue. Chiang (2012) also
used a correlational design to understand prioritized variables related to happiness in
8
terminally ill patients. Therefore, use of a similar correlational design to examine the
relationship between patient expectations and patient satisfaction proved appropriate.
Quantitative methodology is more appropriate than other methodologies for
examining the relationship between the two variables. For example, qualitative
methodology does not provide a means for determining statistical significance, making
the method less desirable for this study. Marcinowicz, Chlabicz, and Grebowski (2010)
examined patients satisfaction through open-ended questions and theme identification
but did not address statistical significance. Owusu-Frimpong, Nwankwo, and Dason
(2010) implemented a mixed method approach for researching patients satisfaction
related to access through a deeper understanding of human descriptions with
supplemental concrete data. My study had no qualitative aspect, making a mixedmethods approach irrelevant as a research design.
The design for this study was correlational, used for determining and analyzing a
potential relationship and its significance. Experimental and quasi-experimental designs
are common in medical research but were not appropriate for this study as there was not
any manipulation or intervention required. I used the quantitative method to examine the
correlational relationship between patient expectations and patient satisfaction using
Likert-type scale data to answer the research questions. Quantitative data from patientsatisfaction surveys provided a scientific basis for the topic of patient satisfaction. The
data analysis tools used for this study were correlation and one-way ANOVA for
examination of the nature and significance of the relationship between the independent
and dependent variables, patient expectations and patient satisfaction. The statistical
9
analysis of the variables provided information about the relationship between the two
variables. Analyzing the results for statistical significance resulted in supporting the
existence of the relationship.
Research Question
The purpose of the study was to examine the relationship between the
expectations of the patients and resulting satisfaction of consumers of health care services
in a 300-bed hospital in southeast Wisconsin. Understanding patients expectations and
meeting or exceeding those expectations potentially improves patients satisfaction with
their experience as patients. A portion of health care organizations reimbursement is a
direct reflection of the consumers perception of their patients experience. The patients
experience is a culmination of the overall satisfaction with the care received within a
health care organization; therefore, health care leaders must understand patients
expectations and develop strategic and operational plans to meet their patients
expectations. The research questions were:
1. Does a relationship exist between patient expectations and patient satisfaction in
the 300-bed host hospital?
2. Do differences exist for patient expectations and satisfaction among the medical,
surgical, and cardiac hospital units?
Hypotheses
H10: Patient expectation is not correlated with patient satisfaction.
H1a: Patient expectation is correlated with patient satisfaction.
10
H20: No differences exist for patient expectations and satisfaction among the
medical, surgical, and cardiac hospital units.
H2a: Differences exist for patient expectations and satisfaction among the
Survey Questions
The data collected addressed the research questions through the use of a carefully
designed survey instrument. Each question included in the instrument resulted from an
exhaustive literature review of all current and available research for two variables, patient
expectation and patient satisfaction. The literature review also included a study of the
relationship between patients expectation and their satisfaction. The instrument, titled
Becker Inquiry of Patient Expectations as Predictors for Patient Satisfaction, is in
Appendix A. Questions 1 through 8 inquired about the level to which care providers met
patient expectations (independent variable), Questions 9 through 13 inquired about the
level of patient satisfaction (dependent variable), and Questions 14 through 20 addressed
the relationship between patients expectations and satisfaction. A 15 Likert-type scale
measured the participants degree of agreement with each statement. The questions on
the instrument were as follows:
1. The speed of your admission met your expectations.
2. Your comfort expectations were met during the admission process.
3. Your expectations for privacy were met during the admission process.
4. The doctors asked about your expectations for your hospital stay.
5. The nursing staff asked about your expectations for your hospital stay.
11
6. The skill of the doctors met your expectations.
7. The skill of the nursing staff met your expectations.
8. The promptness and responsiveness of the nursing staff met your expectations.
9. The doctor communicated with you in a way in which you were highly satisfied.
10. The nursing staff communicated with you in a way in which you were highly
satisfied.
11. The doctor listened in a way in which you were highly satisfied.
12. The nursing staff listened in a way in which you were highly satisfied.
13. You were satisfied with the level in which you were included in decisions about
your care.
14. Degree to which meeting your admission expectations reflects your satisfaction.
15. Degree to which meeting your doctor expectations reflects your satisfaction.
16. Degree to which meeting your nursing care expectations reflects your satisfaction.
17. You are highly satisfied with your overall hospital experience.
18. You have been highly satisfied with previous hospital experiences related to
doctor care.
nursing care.
20. You have been highly satisfied with previous overall hospital experiences.
Theoretical Framework
Health cares organizational leaders must understand patients expectations and
let the expectations guide efforts in defining and implementing initiatives to improve the
12
patients experience and satisfaction. Healthcare leaders need to understand how to
improve patients satisfaction for financial stability with the implementation of VBP
(Tompkins, Higgins, & Ritter, 2009). According to the expectancy value theory,
personal beliefs, values, and prior experiences shape the level of satisfaction (Gill &
White, 2009). Using the expectancy value theory as a framework, health care leaders
develop a process for assessing patients beliefs, values, and prior expectations related to
patients expectations. Health care organizations leaders must learn to anticipate
patients expectations to improve their satisfaction.
Patients enter into health care organizations with expectations developed over
time and reflective of personal beliefs. Gibbons, Houlihan, and Gerrard (2009) described
the expectancy value theory as an assumption based on attitudes of preceding factors
related to beliefs of outcomes, behaviors, and other peoples expectations. Defining
patients personal beliefs offers information about attitudes toward health care
expectations and behaviors. Oftedal, Karlsen, and Bru (2010) found that patients
expectations of success influenced the level of performing self-management of diabetes
when care providers offered individualized, empathetic, and supportive health care.
Considering the number of potential factors, defining patients expectations is a complex
task.
Addressing the complexity of patients expectations required a study of the
theoretical framework. The expectancy value theory provided a framework for
describing attitudes as a combination of personal values (Conley, 2012). Personal values
remain unknown to health care providers without inquiry, as personal values are unique
13
to the individual. Generalizing values to groups leave gaps in understanding patients
expectations; therefore, health care providers must strive to reach out on an individual
basis to define personal values. Additionally, health care providers must recognize the
effect of prior experiences on patients expectations.
Prior experiences influence personal perceptions about future activities, events,
and outcomes. Health care providers may suffer criticisms based on a patients past
experience. In the expectancy value theory, the evaluation of each event combines to
form a perception in direct proportion to the subjective probability that the event will
occur similarly to prior experiences (Savolainen, 2012). Health care providers must learn
how to capture information about the patients experience prior to providing services and
understand how to react to that information. See Figure 1 for an outline of the
expectancy value theory.
14
Figure 1. Expectancy-value theory model and key components specific to patient

expectations and patient satisfaction. Adapted from Expectancy-value beliefs and
information needs as motivators for task-based information seeking, by R. Savolainen,
2012, Journal of Documentation, 68, 492511. Copyright 2012 by Emerald Group
Publishing Limited.
The expectancy value theory pertains to studies about patient expectations and
patient satisfaction. Applying the theory to practice can influence decisions related to
patient care. The expectancy value theory, as applied to patients expectations, includes
three key components of patients expectations: personal beliefs, values, and prior
experiences (see Figure 1). Patients define the level of satisfaction after evaluating how
well care providers met their expectations. Ultimately, when the care providers meet or
exceed all expectations and the patient gives high scores on the satisfaction survey, the
value for health care organizations increases and maximum reimbursement then occurs.
15
Definition of Terms
The terms listed represent terms needing further description. For the purposes of
the research, the following definitions apply to the significant terms in the study.
Affordable Care Act (ACA): In 2010, the U.S. Congress approved the Patient
Protection and Affordable Care Act. The ACA defines comprehensive health care reform
measures intending to lower health care costs, guarantee choices, hold insurance
companies accountable, and improve health care quality (Patient Protection and
Affordable Care Act, 2010).
Expectancy value theory: A framework used to describe how a persons expected
outcomes for a particular activity derive from beliefs and values combined to form
personal attitudes and behaviors (Savolainen, 2012).
Inpatient: Patients experiencing a hospital stay of a minimum of 1 night (CMS,
2012).
Patient experience: The patient experience begins with the first interaction the
patient has with a health care organization and continues until services end (Schoenfelder
et al., 2011). The patient forms the experience based on current experiences with the
care, personal preconceptions, and previous health care experiences (Schoenfelder et al.,
2011).
Patient satisfaction: Patient satisfaction is an attitudinal response that patients
make about the health care experience based on individual values (Omondi et al., 2011).
Value-based purchasing (VBP): VBP is part of the Affordable Care Act. VBP
includes initiatives to manage the use of the health care system, reducing improper care
16
and using incentives to reward high-performing providers through application of
accountability measures for cost and quality of care (USDHS, 2011a).
Assumptions, Limitations, and Delimitations
Understanding patients expectations is a challenging task complicated by the
variation in health care services. Health care services exist in many different settings and
at different levels of complexity based on the health needs of the consumer. The purpose
of this study was to examine the expectations of patients admitted into the host hospital.
Given the study setting, the following discussion includes facts assumed true, weakness
that may limit the study, and boundaries that directed the scope of the study in the U.S.
host hospital.
Assumptions
As the researcher, I assumed several conditions were true to conduct this study,
including presuming the patients responses on the instrument were truthful and reflected
their perception of the expectations for the health care services rendered. An additional
assumption was that ensuring anonymity and confidentiality for all participants decreased
the level of concern about answering truthfully. Finally, an assumption existed regarding
leaving the survey with the patient provided anonymity and confidentiality for the
participants.
Limitations
In this study, I examined how health care organizations can improve the financial
outcome by understanding and meeting patients expectations. A limitation existed
because of the potential difficulty in understanding the expectations of all patients.
17
Patients expectations may vary based on different backgrounds, cultures, health status,
and personal beliefs. Expectations of patients may vary when collecting data over a
longer period. An additional limitation existed regarding the questions of the instrument.
Although the questions resulted from an exhaustive review of current literature and were
assumed appropriate for collecting data to assist me in understanding patients
expectations, the possibility existed that other appropriate questions may provide
additional information related to patients expectations. Finally, a limitation existed
regarding the timing of the survey. Patients received care and treatment during data
collection while still in the hospital, thereby potentially influencing the level of comfort
in answering questions truthfully. Patients may have had concerns about retaliation from
care providers if answers given were negative.
Delimitations
The delimitations of the study served as boundaries. The specific problem was
the lack of information available to health care organizations that fail to predict health
care consumers expectations effectively and deliver those expectations to ensure
maximum reimbursement (Tompkins et al., 2009). The research questions focused on the
existence of a relationship between patient expectations and patient satisfaction. The
sample population in this study consisted of inpatients of a 300-bed hospital in southeast
Wisconsin. The topics I assessed in the study were specific to admission and inpatient
services and did not include patients expectation regarding discharge satisfaction. The
data collection for the pilot study and the main study occurred over 2 weeks. The limited
time used in data collection only provided a snapshot of one group of patients in one 300-
18
bed hospital setting. The length of the study spanned a 2 week period to allow for
population selection, survey distribution, survey completion, and survey collection. The
assumptions and limitations specific to the population and the study assisted in
identifying factors potentially influencing the studys findings. Further, defining the
boundaries of the study solidified the scope and purpose of the study.
Significance of the Study
Health care leaders and providers need to understand and respond to health care
consumers expectations. Improved understanding adds value to the health care industry
and for the population as a whole (Elliot et al., 2010). Understanding and meeting
patients expectations contribute to effective practice within the medical field. Improved
practice positively affects society, thereby acting as a catalyst for social change (Ragan &
Quincy, 2012). Organizational leaders must understand the importance of providing a
positive patient experience, as the benefits to organizations and society are numerous.
Business and Social Impact
The landscape of health care continues to change. Patients are more aware of
options and choices than ever before because publically reported data for health care
organizations provide measurements on patient satisfaction and quality of care (Huppertz
& Carlson, 2010). Patients admitted into U.S. hospitals who also participate in Medicare
benefits receive surveys regarding their level of satisfaction with the hospital experience.
The scores from the surveys provide data used to calculate reimbursement to health care
organizations. On a quarterly basis, the Hospital Compare website lists the patient
satisfaction data. Cliff (2012b) reported that a higher level of patient satisfaction is
19
linked to improved clinical outcomes; therefore, the value of understanding the
expectations of the health care consumer may lead to improved patient outcomes and a
healthier population. An additional benefit to a healthier population is the cost savings of
shifting to prevention-based approaches often used by healthier consumers and
prevention-driven care providers (Meunier, 2009). There are far-reaching benefits of
meeting patients expectations and improving patients satisfaction.
Contribution to Effective Business Practice
Leaders in health care organizations do not have an understanding regarding
patients expectations (Rozenblum et al., 2011). The gap in understanding hinders
optimal patient outcomes through decreased patient satisfaction and patient compliance
(Rozenblum et al., 2011). In this study, inpatients in a health care organization provided
insights about their expectations and the relationship between patient expectations and
patient satisfaction. A consistent approach toward meeting patients expectations enables
health care organizations to strengthen collaboration through patient-centered care,
thereby improving satisfaction and quality of care (Boulding, Glickman, Manary,
Schulman, & Staelin, 2011; Rittenhouse et al., 2011). The value of defining,
understanding, and meeting patients expectations extends beyond an individual
encounter as best practice within the health care industry may change based on an
increased understanding. Potential best practice improvements include improved safety,
quality of care, and patient outcomes.
20
Implications for Social Change
Health care costs continue to increase, causing hardships for the consumers. A
CMS report indicated that consumers spent 27% of personal budgets on health care
expenses (as cited in Gruber, 2009). As consumers spend more money on health care
costs, less money remains to cover other costs of living, such as shelter, food, and
clothing. Individuals and families may not have enough money to meet basic needs. If
health care leaders and providers understand that patients increase compliance with
health recommendations when they experience high satisfaction, health care
organizations can positively affect a patients overall health. Healthier patients require
less complex and less expensive health care services. Consumers spend less
discretionary money for health care when individuals are healthier. Individuals can
adjust personal budgets to meet other needs as health care demands decrease; therefore,
the social impact of improving the health of the general population directly relates to the
financially stability of many individuals and families.
Health care organizations in the United States must engage in processes aimed at
identifying and responding to patients expectations. There are far-reaching positive
outcomes of implementing initiatives to improve patients satisfaction. The impact
begins within the organization through satisfied patients, compliant patients, financial
stability, and healthier outcomes. The positive outcomes extend to the community
through the improved general health of the surrounding population. A reduction in
money spent on health care through U.S. government programs allows diversion of funds
to other community programs previously underfunded. A population that is more health
21
conscious and responsive to health care recommendations has long-term impacts for the
individuals through better health and quality of life (Elliot et al., 2010).
A Review of the Professional and Academic Literature
Understanding and meeting patients expectations to improve patients
satisfaction overall in the health care industry is a priority. Health care organizations
must meet expectations to earn full reimbursement for Medicare inpatients, and soon
physicians may experience the same challenge as the CMS begins the process of
initiating a similar system for primary care providers (USDHS, 2011a). In the literature
review, I focused on the independent variable, patient expectations, and the dependent
variable, patient satisfaction. Further review included the related similarities and
differences between customer satisfaction and patient satisfaction to provide additional
insight on knowledge gaps around satisfaction in the health care industry. Also reviewed
were the past and current tools used to measure patient satisfaction and quality of care.
Numerous database searches provided literature to form the foundation of the
study. I used the following databases to locate peer-reviewed articles: ABI/INFORM
Complete, Academic Search Complete/Premier, Annual Reviews, Business Source
Complete/Premier databases, CINAHL Plus with full text, Cochrane Collection Plus,
Emerald Management Journals, MEDLINE with full text, Networked Digital Library of
Theses and Dissertations, Nursing and Allied Health Science, ProQuest Central, SAGE
Premier, and ScienceDirect. Websites included Agency for Health Care Research and
Quality, CMS, Institute of Medicine, and the U.S. Department of Health and Human
Services. The database searches used the following keywords and phrases: patient
22
satisfaction, patient expectations, health care quality, value-based purchasing, physicians
and patient satisfaction, hospital patient satisfaction, quality and satisfaction, customer
satisfaction, customer service, patient satisfaction surveys, and health care consumers.
Table 1 lists the sources in the literature review with the predominance of articles found
in peer-reviewed journals within the 5 years preceding publication of this study. Only
two of the 79 references exceeded the desired 5 years currency standard.
Table 1
Synopsis of Sources in the Literature Review
Reference Type
Research-based peer reviewed journals
Dissertations
Conference proceedings
Germinal and contemporary books
Websites
Total
79
0
1
2
2
Less than 5
years
77
0
1
1
2
Greater than 5
years
2
0
0
1
0
The literature review on the impact of patient expectations on patient satisfaction

was organized around two variables and the relationship between the two variables. The
variables included patient expectations, patient satisfaction, and the relationship between
patient expectations and patient satisfaction. The review of the patient expectation
variable included information about the emergence of the variable as well as why
patients expectations are important to health care organizations. Additional information
included the link between patient-centered care, patient expectations, and the impact of
physicians and nurses on the patients expectations.
23
The review of the literature for the other variable, patient satisfaction, included a
search for information about the emergence of patient satisfaction, background of patient
satisfaction, and customer satisfaction compared to patient satisfaction. Literature about
the measurement tools, past and present, completed the review of the second variable. In
the final discussion of the literature review, I focused on the relationship between patient
expectations and patient satisfaction. The literature included information about the
relationship, and additional information about the relationship of patient expectations and
patient satisfaction, to quality of care, cost of care, brand, and patient loyalty. The final
section of the literature review covered the gaps present in the available literature. A
diagram of the organization of the research topics is in Figure 2.
Figure 2: Literature review organization for examination of patient expectations and

patient satisfaction.
24
Patient Expectations
As leaders in health care organizations confront numerous changes in the care
delivery and reimbursement system, patients expectations are receiving increased
attention. Research on patients expectation emerged slowly. The health care industry
was slow to acknowledge patients expectations. A complex blend of experiences and
current knowledge develop patients expectations. The complexity involved in
developing individualized expectations results in a challenge related to predicting
expectations. The focus on patients expectations is two-fold: understanding how to
identify patients expectations and understanding how to meet the expectations once
identified. The available literature on patients expectations includes a generalized
approach or narrowed perspective on a certain type of procedure or treatment. Despite
the wide spectrum, gaps still exist in the available research about defining individual
expectations prior to receiving services.
Emergence of patient expectations. The health care industry faces a financial
disruption related to the ability to meet patients expectations and improve patients
satisfaction. Health care organizations must become educated about the importance of
assessing and meeting patients expectations. One key factor to understanding and
meeting patients expectations is patient-centered care. Defining patients expectations is
the first step in understanding. Definitions of patient expectations differ in numerous
studies yet, in broad terms, defining expectations reflects an anticipation of an event that
is likely to occur (Georgy, Carr, & Breen, 2009; Tejada et al., 2010). Beyond the
definition, health care organizations face complex challenges. For example, a barrier to
25
understanding patients expectations is related to the process for developing patients
expectations.
The expectancy value theory provides a framework for understanding patients
expectations. Fishbein and Atjzen (as cited in Savolainen, 2012) introduced the
expectancy value theory in 1975. According to the theory, attitudes develop through a
combination of beliefs (Conley, 2012). Expectations develop over time and may change
as an individuals experiences accumulate; therefore, expectations are a compilation of
personal beliefs, personal values, and prior experiences (Gill & White, 2009). Individual
expectations are unique and comprised of many factors. Ferrer (2009) reported that
expectations are a composition of needs, explicit promises, implicit promises, and the
experience of the individual. Furthermore, expectations include both cognitive and
emotional components (Kenten, Bowling, Lambert, Howe, & Rowe, 2010). Health care
organizations must understand the composition of the expectations for each individual
before they can accurately meet the expectations.
The complexity of the composition of patients expectations prevents a universal
approach. Additionally, health care workers expect terminology to be interchangeable,
yet definitions are different. Definitions of expectations include words such as needs,
hopes, predictions, and desires (Kenten et al., 2010). The term needs, as defined by
Polikandrioti and Ntokou (2011), is a concept that fluctuates and changes dependent upon
time and health condition, and is influenced by a patients culture. In addition, Needham
(2012) suggested that the health care industry has been slow to discover that, to improve
patients satisfaction, the focus should be on providing services that meet the needs of the
26
patients. Though Leung, Silvius, Pimlott, Dalziel, and Drummond (2009) discussed the
use of hope and expectations, they disagreed with using hope interchangeably with
expectations; rather, Leung et al. considered hope and expectations as independent yet
associated. Leung et al. explained that the delineation occurs because the determination
of hope relates to preference, whereas the determination of expectations relates to a sense
of probability.
Conversely, Brown (2011) suggested that hope and trust are associated with
expectations. Further, Brown claimed that expectations about outcomes align with the
experience; therefore, a high probability of a certain outcome results from trusting the
outcomes of previous experiences. Similarly, Kenten et al. (2010) used the term
prediction in place of expectation, where prediction related to the likelihood of a future
event. Yet another exchange occurred with expectations and desires when Singh and
Kaur (2012) studied the relationship between patient expectations and patient
satisfaction. The lack of consistent terminology poses an issue in defining patient
expectations. Using standardized terminology and definitions for patient expectations
allows for comparability of findings, thereby strengthening the body of knowledge.
Types of patient expectations. Beyond inconsistent terminology, researchers
have included a mixture of types of expectations. Georgy et al. (2009) outlined
probability expectations and value expectations as two types of expectations, defining
probability expectations as anticipation of the likelihood of an occurrence whereas value
expectations are reflected expectations of what a patient wanted. Bjertnaes, Sjetne, and
Iversen (2012) categorized expectations into three types: predictive, normative, and
27
comparative. Predictive expectations are those expectations likely to develop based on
attributes. Normative expectations are expectations that an individual believes should
occur. Finally, comparative expectations are expectations compared to similar services.
Constantino, Arnkoff, Glass, Ametrano, and Smith (2011) focused on outcome
expectations, defined as a patients expectation about the significance of receiving
treatment. Studies on patient expectations vary not only in terminology, but also in the
categorization of patient expectations.
Literature is available specifically about understanding expectations of patients
receiving a treatment or having a procedure. Mannion, Impellizzeri, Naal, and Leunig,
(2013) identified expectations for patients experiencing hip surgery for femoroacetabular
impingement. Howell and Rogers (2009) reported the importance of understanding
patients recovery expectations after total knee arthroplasty treatment to assist in
counseling patients on a realistic post-treatment course. Similarly, Tejada et al. (2010)
discussed the necessity of understanding patients expectations about total joint
replacement surgery and recovery time, as well as the resultant improvement in quality of
life. Although the literature for some treatments and procedures exists, there is an
opportunity for further research.
Each of the aforementioned studies is narrow in scope because of the focus on the
patients expectations for only one condition or procedure; however, the available
research is an indicator of the importance of individualizing assessments of patients
expectations. The focus on the individual aligns with the expectancy value theory in
which expectations identified for each specific procedure or subject is unique to the
28
individuals beliefs, values, and experiences (Gill & White, 2009). Nevertheless, limited
research exists on patients expectations for numerous health care settings, treatments,
condition specific cares, procedures, and classifications of patients.
Patient-centered care. The Institute of Medicine (IOM; 2001) focused on the
quality of care in the United States. Quality of care is inconsistent with overuse,
underuse, and misuse of health care services (IOM, 2001). The IOM included six
recommended health care service aims: (a) safe care, (b) effective care, (c) patientcentered care, (d) timely care, (e) efficient care, and (f) equitable care. One of the aims,
patient-centered care, is at the heart of positive patient experience. The IOM report
included information about patient-centered care through attention to patients wants,
needs, and preferences, thereby allowing patients to make individualized decisions about
their care. The basis for patient-centered care exists in meeting the expectations of the
patient.
Patient-centered care links back to the 1950s when Rogers (as cited in Hudon,
Fortin, Haggerty, Lambert, & Poitras, 2011) introduced a client-centered therapy concept.
From there, Balint, Hunt, Joyce, Marinker, and Woodcock (1970) introduced a new term,
patient-centered medicine. The patient-centered care terminology dates back to the 1980s
when the Picker Institute joined with a private foundation, the Commonwealth Fund, to
address health care needs (Balik, Conway, Zipperer, & Watson, 2011). One of the
focuses of the collaboration included identifying the value of providing care in which the
patient was the center of all activities.
29
The health care industry movement has been slow to place the patient at the center
of care for a multitude of reasons. Traditionally, physicians and other care providers
were the leaders of patient care, so shifting from care provider-centered to patientcentered may lead to discomfort and objections (Berwick, 2009; Cliff, 2012b). Health
care providers must be able to look at care through the eyes of patients, not through the
eyes of the providers (Guion, Mishoe, Passmore, & Witter, 2010). Furthermore, the
change in care model is often a significant change; therefore, it is necessary to have
careful planning to ensure proper implementation and sustainability. Embracing patientcentered care may require a complete organizational culture change. Any culture change
takes years to embed the change within the organization. Many organizations may avoid
implementing such a large change due to the level of commitment required. Some
barriers to implementation include an unclear definition of patient-centered care, a lack of
education and understanding of the importance of patient-centered care, a lack of
coordinated care, and resource shortages (Pelzang, 2010).
There are numerous benefits of patient-centered care. To fully implement patientcentered care, providers must engage with the patients to improve patient outcomes
(Cliff, 2012a; Levinson, Lesser, & Epstein, 2010; Pelzang, 2010). A key component of
patient-centered care is clear and ongoing communication with patients, which supports
shared decision-making (Levinson et al., 2010). Shared decision-making leads to patient
empowerment related to the care received (Pelzang, 2010; Poochikian-Sarkissian, Sidani,
Ferguson-Pare, & Doran, 2010). Encouraging patients engagement in the care decisions
through improved communication leads to improved patient outcomes and, ultimately,
30
improved patient satisfaction (Cliff, 2012a; Hudon et al., 2011; Pelzang, 2010;
Poochikian-Sarkissian et al., 2010). Communication influences numerous aspects of the
patients experience and is a factor of patient-centered care. Furthermore, patientcentered care affects the organizations financial outcomes through cost reduction for
services rendered (Cliff, 2012a; Hudon et al., 2011; Levinson et al., 2010; Pelzang,
2010). Implementation of patient-centered care benefits the patient and the organization.
Health care providers may use expectancy value theory to apply patient-centered
care where the care centers on the patient instead of the diagnosis (Cliff, 2011b). When
health care providers center the care on the patient, the providers view the patient from a
holistic perspective rather than from one area of illness or one part of the body (Bechtel
& Ness, 2010). From the holistic perspective, each patient is an individual who has
developed a set of beliefs and values from the experiences of their past (Pelzang, 2010).
Because the key components of patient satisfaction from the framework of the
expectancy value theory are personal beliefs, values, and prior experience, health care
organizations implementing patient-centered care may influence patient satisfaction by
understanding the patients expectations.
Healthcare industrys knowledge of patients expectations. The health care
industry has been slow to embrace the importance of understanding patients
expectations. Health care providers rely on the outcomes of the patient experience to
meet patients expectations. Physicians and nurses are the two groups within the health
care industry interacting at the highest level with patients; therefore, the relationships of
physicians to the patients experience and nurses to the patients experience are of
31
importance. Historically, providers health care services were payer-centered (Gruber,
2009). As of 2013, health care organizations continue to provide care for patients where
patients health care decisions are care-provider driven with the patient allowed limited
decision-making opportunities (Doss, DePascal, & Hadly, 2011). When the power of
decision-making resides with the care providers instead of the patients, care providers
may not take the time to understand the patients expectations. Lees (2011) found that
health care providers demonstrated a lack of listening skills and empathy regarding
interactions with patients. Lees further suggested that care providers expected patients to
adapt to the services versus the care providers individualizing care to meet the patients
needs. Hence, physicians and nurses continue to view care through the eyes of the care
providers, thereby negating the importance of understanding the patients perspective.
A lack of listening and empathy is not conducive to including patients in
decisions or patient-centered care. Hojat et al. (2010) identified a correlation between
patient satisfaction and the perceived level of empathy displayed by the physician.
Kliems and Witt (2011) considered shared decision-making a key component of patientcentered care, yet patients were comfortable having the physician direct the decisions. In
the same study, patients identified that the most important factor of a positive interaction
with physicians was the amount and quality of time spent with the physicians (Kliems &
Witt, 2011).
Patients relationship with the physician is an important factor in the overall
experience of care. Clucas and St Claire (2010) studied two groups of patients,
traditional and consumerist, focusing on the role of respect in the relationship between
32
the doctor and the patient. Both groups were more satisfied with care when the physician
demonstrated respectful behaviors; however, Clucas and St Claire found that variation
existed in other expectations between the groups. For example, consumerist patients
expected to be equal to the physician whereas the traditional patient expected to be in a
subordinate role to the physician (Clucas & St Claire, 2010). Furthermore, Miaoulis,
Gutman, and Snow (2009) found a disconnection between physicians and patients as the
patients wanted the physician to address their emotional feelings first and then address
the physical feelings; however, 90% of the time, the physicians addressed the physical
feelings first. Patients continue to become more educated as consumers of health care;
thus, the expectations for the relationship with physicians and nurses change.
Given the high level of interaction between nurses and patients, research about the
nursepatient relationship and patients expectations is relevant to patient satisfaction.
Nurses tend to spend the most time with patients in the hospital setting (Theofanidis,
Fountouki, & Pediaditaki, 2012). Relationship-based care is one care model that focuses
on the nursepatient relationship as a means of providing a caring and healing
environment (Woolley et al., 2012). The relationship between the nurse and the patient
can affect the patients entire experience. Nurses demonstrate positive connectedness, a
term aligned with the nursepatient relationship and a key factor of patient satisfaction,
when nurses engage in activities such as teaching, spending time with the patient, and
including the patient in the plan of care (Palese et al., 2011). When a positive nurse
patient relationship exists, nurses are able to gather pertinent information, including the
patients expectations. One Midwestern hospital recognized the overall improvement in
33
patient satisfaction after implementation of the relationship-based care model (Woolley et
al., 2012). When a nurse spends time getting to know a patient as a person versus simply
understanding the illness, the nurse can demonstrate a sense of respect and dignity while
promoting shared decision-making (Morrison & Symes, 2011). Despite these findings,
nursings relationships to patient expectations have not always been transparent.
Care providers who do not understand and meet patients expectations can
negatively impact patient outcomes. Schreuders, Bremner, Geelhoed, and Finn (2012)
reported that nurses delivering patient care and nurses with lower levels of education
were often limited in understanding the relationship between the nursing role and patient
outcomes. Morrison and Symes (2011) found that the nurses inability to identify the
impact of nursing care on patient outcomes could impede the extraction of patient
expectations. Without an understanding of patients expectations, nurses influence
limits patient compliance. Low patient compliance affects patient outcomes.
Furthermore, patients often found that nurses provided care with knowledge and skill, but
lacked the ability to build relationships with the patients, thereby failing to meet patients
expectations (Palese et al., 2011). The skill and knowledge of the nursing staff does not
supersede the importance of demonstrating the ability to identify and meet patients
expectations.
Physicians and nurses have opportunities to inquire about patients expectations
with every patient interaction. Bjertnaes et al. (2012) found that patient-reported
experiences with nursing care and the realization of expectations were the top two
predictors of overall patient satisfaction followed by the doctors services. Rozenblum et
34
al. (2011) found that both physicians and nurses felt an importance to inquire about
patients expectations; however, nurses felt asking about patients expectations was more
important than the physicians. Additionally, nurses were 8.6% more likely than
physicians to ask the patients about expectations, and the nurses appeared more skilled at
managing the identified expectations, yet physicians and nurses did not generally ask
patients about expectations (Rozenblum et al., 2011). In summary, identifying patients
expectations is important with the main responsibility for the inquiry resting with
physicians and nurses.
Physicians and nurses interact with patients more than any other member in the
health care team. Given the high level of interaction, health care organizations should
focus on improvements in assessing and meeting the expectations of the patients at the
physician and nursing level for the biggest impact on patient satisfaction. Additionally,
health care organization must increase the overall knowledge of the patients expectations
at all touch points of care, beyond the physician and nurse level, to ensure a
comprehensive approach to meeting patients expectations.
The health care industry has not kept pace with recognizing the influence patients
expectations have on the financial outlook for organizations (Manary, Boulding, Staelin,
& Glickman, 2013). As reimbursement reflects patient satisfaction scores, health care
organizations grapple with a knowledge deficit on the topic. The decrease in knowledge
is problematic for identifying patients expectations; therefore, meeting patients
expectations is valuable. If health care organizations want to affect the patient experience
by meeting patients expectations, initiating patient-centered care may be the first and
35
most important step. Furthermore, focusing on key interactions between physicians,
nurses, and patients would be equally important as physicians and nurses are the primary
care providers in health care organizations. Ultimately, any approach chosen must be
comprehensive and span the entire health care continuum. The following questions
reflect an analysis of the research located in the literature review on the first variable,
patient expectation, and are on the survey instrument as Questions 1 through 8 to guide
the data collection on this variable.
Patient Satisfaction
Health care providers commonly use the phrase patient satisfaction in the health
care industry in the 21st century; however, this phrase was not common before the 1980s
(Cohen, 2010; Gill & White, 2009). The amount of research on patient satisfaction
increased with the level of importance health care providers placed on patients
satisfaction within the health care industry. Additionally, researchers compared patient
satisfaction to customer satisfaction, thereby expanding the perspective of patients as
36
consumers of a service. The literature on patient satisfaction tools reflects a wide
spectrum beginning with simple surveys to more complex tools. As the focus on patient
satisfaction increased and the pressure to provide services that satisfy the patients
increased, health care organizations increased the number and quality of tools to
determine patient satisfaction (Abd Manaf, Mohd, & Abdullah, 2012; Bleich, zaltin, &
Murray, 2009; Coban & Kasikci, 2010; Hojat et al., 2010). A discussion on the factors
related to the emergence of patient satisfaction follows.
Emergence of patient satisfaction. The definition of patient satisfaction varies
in the literature. Welch (2010) offered a working, practical definition of patient
satisfaction as a combination of overall satisfaction, likelihood to recommend, and a
willingness to return. According to Miaoulis et al. (2009), measuring patient satisfaction
occurs to the extent to which the experience matches the patients expectation.
Moreover, in a qualitative study, Marcinowicz et al. (2010) indicated a lack of a common
definition of patient satisfaction. The variation in a universal understanding of patient
satisfaction impedes progression at the industry level as well as the research level.
Patient satisfaction research is important for the health care industry. However,
researchers have not examined patient satisfaction prior to the 1980s. After the 1980s,
more scholars reviewed patient satisfaction, possibly because of the consumer movement
of the 1960s through the 1970s (Cohen, 2010). Mayer (2012) claimed that President
Kennedys 1962 speech to the U.S. Congress was the start of the consumer movement.
In the speech, Kennedy identified four consumer rights: (a) the right to safety, (b) the
right to be informed and protected from fraudulent practices, (c) the right to choose
37
among a variety of products and services at competitive prices, and (d) the right to be
heard in the formulation of government policy. Since the speech, consumer and
governmental agencies developed to serve as consumer advocates (Cohen, 2010). Patient
satisfaction evolved into a consumer focus stemming from the consumers rights.
Health care is a service and, therefore, the consumer has the right to choose
services at a competitive price. One of the goals of the VBP was to improve the value of
health care through financial incentives to health care organizations as encouragement to
provide coordinated, efficient care (Tompkins et al., 2009). The value of health care
services is a relatively new consumer concept yet an important shift for the financial
outlook for health care organizations. The health care industry aligned consumer
satisfaction with quality of care through new regulations. In support of this concept,
researchers have linked high patient satisfaction to improved quality of care (Bechtel &
Nees, 2010; Ferrer, 2009; Friedberg, Steelfisher, Karp, & Schneider, 2011; Hudon et al.,
2011; Levinson et al., 2010). The federal government aligned quality and satisfaction
through two VBP measures. The two measures are (a) a quality indicator weighted at
70%, and (b) a patient satisfaction score weighted at 30% (Cliff, 2012a). Total
reimbursement is a combination of the two measures with the total reflecting the level of
reimbursement to health care organizations (Cliff, 2012a). Consumers directly affect
30% of reimbursement for care through patient satisfaction scores.
Patient satisfaction is a key factor in reimbursement; therefore, more research is
needed about the relationship care providers have on satisfaction. This research can
assist health care providers in understanding their role in the financial stability of an
38
organization. Adler, Vasiliadis, and Bickell (2010) discussed a systematic review of 12
studies completed from 1980 to 2007 and focused on the relationship of continuity
between doctors and patients and patient satisfaction. Researchers who studied
subjective measures indicated a significant association with satisfaction, whereas the
quantitative measures indicated a variable association (Adler et al., 2010). A variation
between qualitative and quantitative research has lead scholars to raise numerous
questions about the types of research and the value of the research.
Qualitative studies are subjective and are available in the literature on patient
satisfaction. For example, in a qualitative study, Marcinowicz et al. (2010) identified
common themes related to patient satisfaction. The themes consisted of six
characteristics aligned with positive patient satisfaction and included (a) favorable
doctor-patient interactions, (b) health improvement or resolution of health problems, (c)
fulfillment of prior expectations, (d) availability of health care, (e) a combination of
multiple characteristics, and (f) an absence of dissatisfaction (Marcinowicz et al., 2010).
Using themes to explain patient satisfaction data adds depth to the information whereas
quantitative data allow for a statistical approach without added context.
Researchers have numerous viewpoints about the strength and value of using
patient satisfaction as a measurement. Gill and White (2009) argued that patient
satisfaction is unpredictable, and therefore, the focus on using patient satisfaction as the
primary source of service outcomes is unsound. Similarly, Fenten, Jerant, Bertakis, and
Franks (2012) conducted a nationally representative, prospective cohort study in which
Fenten et al. found a lack of understanding of the factors correlated with patient
39
satisfaction. Additionally, numerous theories apply to patient satisfaction research. Gill
and White (2009) listed the five key patient satisfaction theories as (a) discrepancy and
transgression theories of Fox and Storms from 1981; (b) expectancy value theory of
Linder-Pelz from 1982; (c) determinants and components theory by Ware, Davies-Avery,
and Stewart from 1978; (d) multiple models by Fitzpatrick and Hopkins from 1983; and
(e) the health care quality theory of Donabedian from 1980. Theories provide a
framework for understanding patient satisfaction. Within these theories, patient
satisfaction language varies, and researchers often also vary the use of the term patient
experience.
The World Health Organization (as cited in Bleich et al., 2009) developed the
World Health Survey for 2003 to measure the responsiveness of a health care
organization through eight domains of the patient experience: autonomy, choice,
communication, confidentiality, dignity, prompt attention, quality of basic amenities, and
support. Furthermore, Dilworth, Higgins, and Parker (2012) used the term patient
experience and explored readmissions for older patients. Dilworth et al. included
interview questions addressing patients perceptions of care received during the previous
hospitalization and how they felt about readmitting to the hospital within 28 days of the
previous discharge. In this study, patients reported disappointing experiences related to
the readmission, listing poor communication, lack of proper consults, and poor care
management as the key factors of the disappointing experience (Dilworth et al., 2012). In
2006, in Massachusetts began publically reporting physician groups patient experience
data. In an effort to identify how the physician groups used the data, Friedberg et al.
40
(2011) studied the responses of 72 group leaders. The medical groups that demonstrated
integrated care were more likely to make use of the data to improve patients experience,
whereas the less integrated groups focused efforts on only the low-performing physicians
or groups (Friedberg et al., 2011). Additionally, the groups engaged in limited or no
improvement efforts were less likely to have payment incentives tied to patient
experience scores (Friedberg et al., 2011). Friedberg et al. (2011) posited a disregard for
improving patients experience because there were not any financial implications or
incentives linked to the measure with an additional suggestion that patient experience and
patient satisfaction cannot be easily interchanged.
Customer satisfaction versus patient satisfaction. Desai (2011) defined
satisfaction as an emotional feeling a consumer senses related to a precise experience.
Customer satisfaction, as defined by Reynolds and Harris (2009), is an emotional reaction
based on previous and current states of understanding related to use of a service. Ferrer
(2009) defined customer satisfaction as a physiological response based on personal
perception of reality. Ferrer further suggested that many factors comprise the overall
satisfaction for any customer such as the desired service level, services promises, and
past experiences. What the customer presumes the service will be and what the customer
wishes the service will be comprises the service level. Service promises include both
implicit and explicit information about the service. Patients use past experiences to shape
current expectations, and predictions and may not be based on experiences with similar
services if the current service was a new service for the customer (Ferrer, 2009).
Customer satisfaction is a complex phenomenon, much like patient satisfaction.
41
Customers used as a general term implies a use of some service whereas patients as
customers are consumers of health care services.
Some researchers termed patients as customers and consumers. Bechtel and Nees
(2010) defined patients as consumers interested in forming partnerships with care
providers to better support patient-centered care. Berwick (2009) addressed the link
between consumerism and health care, describing consumerism as a viewpoint from
which the patient is the customer guiding the quality and value of services through
decisions and feedback. Health care providers alignment of patient satisfaction with
value and quality of care is valid.
To further support the importance of patient-centered care, Gruber (2009)
reported consumers desire for individualized services designed through cooperative
associations based on trust and honesty. In patient-centered care, doctors and nurses
focus on the collaboration of the patient and care providers through ongoing and effective
communication. Additionally, Gruber discussed the shift in health care to a consumercentric model where the patients as consumers are empowered to be engaged members of
health care services. Similarly, Nazari, Divkolaei, and Sorkhi (2012) expressed the need
to implement a customer-based approach for customer satisfaction, recognizing that
meeting the customers expectations leads to better financial outcomes. Dehghan,
Zenouzi, and Albadvi (2012) discussed the importance of keeping services focused, and
centered on the customer for optimal customer satisfaction. In this way, traditional
customer satisfaction is similar to patient satisfaction as the health care industry touts the
benefits of providing health care using the patient-centered care model (Cliff, 2012a;
42
Levinson et al., 2010; Pelzang, 2010). As consumers indicate a desire for individualized
service in all industries, the health care industry meets this expectation through patientcentered care measures.
Health care providers should use models to gather additional information. The
Fishbein model is a customer satisfaction model used for measuring patient satisfaction
(Otani, Waterman, & Dunagan, 2012). In this models foundation concept, patients
combine prominent experiences with different weights to define the overall patient
satisfaction. Patients give varying weight to experiences, and because positive
experiences may counterbalance negative experiences, the model is a compensatory
model (Otani et al., 2012). In the use of a weighted model, patients are able to share the
effect of positive experiences on negative experiences, allowing analysis of patients
priorities. Additionally, a key component of the expectancy value theory is the influence
of experiences on expectations; thus, Fishbein supported the application of the
expectancy value theory as a framework for patient satisfaction.
Customer satisfaction is important in the ongoing efforts to measure patient
satisfaction. Nazari et al. (2012) recognized that measuring customer satisfaction
provides valuable information for implementing improvements based on the perceptions
of the customers. Health care providers should use customer satisfaction data to improve
the customer experience to mirror the patient-satisfaction regulations placed on the health
care organizations. According to Reynolds and Harris (2009), companies could improve
customer satisfaction by mitigating the customers perception of dissatisfaction and
inequity through efficient delivery of services, service recovery, and customer feedback.
43
Through VBP, the overall goals of the federal government are to increase value, improve
quality, and improve patient satisfaction (USDHS, 2011a).
Although patients are the health care industrys customers, the satisfaction
measurement methods used in other industries cannot always be replicated to the health
care setting. Welch (2010) argued that the emergency department has too many unique
factors that make adopting a model difficult for addressing straightforward factors often
found in nonpatient customer service industries. For example, patients may include an
emergency room visit as a part of an episodic illness involving other services when
defining the level of satisfaction; also, patients may report high satisfaction even when
the clinical care was poor or vice versa making evaluation of the scores difficult.
Health care industrys use of measurement tools. The health care industrys
research on measurement tools is rich with variations. Researchers have produced
quality tools to measure patient satisfaction; however, variability continues in the
reliability and quality of the tools. The Consumer Assessment of Healthcare Providers
and Systems (CAHPS) program launched through the efforts of the Agency for
Healthcare Research and Quality (AHRQ; USDHS, 2011b). The USDHS (2011c) used a
standardized survey tool to assess the consumers health care experiences. In 2006, CMS
implemented the Hospital Consumer Assessment of Healthcare Providers and Systems
(HCAHPS) survey program. To validate and test the survey prior to launching the
program, CMS (2012) collaborated with AHRQ. The CAHPS surveys are
multidimensional, measuring patient satisfaction and patient experience. Clancy, Brach,
and Abrams (2012) claimed that both dimensions served as a benefit as analysis of results
44
can lead to actionable opportunities. Publically reporting the CAHPS survey data
provides patients access to comparative information, allowing for informed decisions
about health care services (Huppertz & Carlson, 2010). Furthermore, physicians can use
the publically reported information to aide in making decisions when referring patients
(Tompkins et al., 2009). Publically reported data are useful to the consumers, care
providers, and health care organizations.
Prior to the CAHPS surveys, health care organizations used a wide range of
surveys. Gill and White (2009) reported that assessment of patient satisfaction in the
health care industry began in the 1970s with the development of a satisfaction scale
aimed at the physician and primary care and continued through the mid-1980s with a
progression of surveys and scales. A common tool for collecting patient satisfaction data
is surveys, often because of ease of use and cost. Presently, health care organizations
primarily use surveys. The first surveys contained a variability of reliability and validity.
Ware, Davies-Avery, and Stewart (1978) completed a review of patient satisfaction
instruments in the 1970s, focusing on defining the concept of patient satisfaction,
identifying dimensions of available surveys, evaluating the reliability and validity of the
reviewed measures, and evaluating the usefulness of the use of patient satisfaction as
dependent and independent variables in health care research. Regarding reliability and
validity, Ware et al. reported little confidence in the reliability and validity of many of the
surveys in use. The same concern exists in 2012 (Iversen, Holmboe, & Bjertnaes, 2012).
Over a period of 30 years, the proposed value of patient satisfaction data varies.
45
There is a need for reliable and valid patient satisfaction tools. For example, in an
effort to fill a gap in research related to cancer patients and evaluation of patient
satisfaction, Iversen et al. (2012) developed a questionnaire using rigorous testing to
ensure validity and reliability. Health care providers often adapt satisfaction tools from
original versions to meet the needs of a new population. When this adaption happens, the
tool must meet reliability and validity testing. Coban and Kasikci (2010) adapted an
English version of a hospital/patient experience survey tool for Turkish patients. The
adapted tool scored high on validity and reliability testing; therefore, the adaptions did
not affect the integrity of the intent of the survey. In the outpatient health care setting,
Abd Manaf, Mohd, and Abdullah (2012) used previous studies to assist in the
development of an instrument that met the commonly used reliability and validity
standards applied to surveys. The aforementioned researchers addressed the use of
patient-satisfaction measurement tools that meet rigorous reliability and validity testing to
improve the quality of data derived from surveys (Abd Manaf et al., 2012; Coban &
Kasikci, 2010; Iverson et al., 2012).
The SERVQUAL model is a proven, reliable, and valid service quality model
commonly used for measuring the differences between patients preferences and their
experience. The model originated as a tool to measure service quality in service and
retailing organizations (Parasuraman, Zeithaml, & Berry, 1988). Numerous researchers
have used the SERVQUAL model, which has five dimensions including tangibles,
reliability, responsiveness, assurance, and empathy (Dehghan et al., 2012; Desai, 2011;
Lin et al., 2009; Quader, 2009; Suki, Chwee-Lian, & Suki, 2009). Parasuraman et al.
46
(1988) created the five dimensions of what became 10 consumer criteria dimensions used
to evaluate the quality of a service. The SERVQUAL tool, intended for use in industries
outside of health care, is useful for the health care industry.
The tangible dimension of the SERVQUAL tool includes physical facilities,
equipment, and appearance of the employees. Health care providers use the reliability
dimension to measure the ability to perform the promised service in a dependable and
accurate manner. Responsiveness is a measure of the willingness to help customers and
provide the service in a timely manner. Health care providers use the assurance
dimension to measure the knowledge and courtesy of employees, as well as the ability of
the employees to encourage trust and confidence. Finally, health care providers can use
the empathy dimension to measure the level of caring and individualized attention the
organization provides the customers. The SERVQUAL model works for the health care
industry as well as other service industries because users can use the survey to compare
preservice expectations to postservice perception of the delivered service (Dehghan et al.,
2012). Furthermore, the dimensions translate to the health care environment, allowing
for transferability from one industry to another.
The best method for evaluating patient satisfactions varies with the intent of the
study; therefore, researchers must consider other methods. Lees (2011) posited that an
integrated approach including qualitative and quantitative information such as surveys,
questionnaires, interviews, and observation may be optimal for accurately capturing the
patients experience. Ahuja and Williams (2010) discovered value in moving patients
from a passive role to an active role through storytelling as a means of collecting
47
information about expectations and experiences. Storytelling is qualitative in nature and
extends the quantitative information generally gathered using surveys alone; therefore, a
mixed method approach can add depth to the data from the patients perspective.
The health care industry has a history of acknowledging the importance of patient
satisfaction dating back to the 1950s. The movement to implement tools to measure
patient satisfaction was somewhat slow with questionable quality of the tools. With the
development of the CAHPS program, the health care industry faced new regulations
requiring the implementation of tools to measure patient satisfaction. Accordingly,
health care organizations voluntary improvement efforts are no longer the norm for
health care providers. The following survey questions reflect an analysis of the research
located in the literature review of the second variable, patient satisfaction, and are on the
survey instrument as Questions 9 through 13:
satisfied.
your care.
48
Relationship Between Patient Expectations and Patient Satisfaction
Patient expectations and patient satisfaction represent two separate topics, yet
increasingly, researchers continue to evaluate the relationship between the two topics by
comparing and contrasting them (Ellis-Jacobs, 2011; Hojat et al., 2010; Kennedy, Caselli,
& Berry, 2011; Palese et al., 2011). Regardless of the amount of patient satisfaction
literature available, gaps still exist. The following section includes research information
realted to the aforementioned comparison.
Perspectives on the relationship. When comparing and contrasting the
relationship between patient expectations and patient satisfaction, three key themes
emerged. The three themes included the relationship to quality of care, the relationship to
cost, and the relationship to organizational brand and loyalty. A significant amount of
quality of care research exists with a decrease in availability related to cost of care. The
available research related to brand and loyalty is significant for general customer service
research but limited when searching for health care specificity. The decline in available
literature reflects the timelines of importance of each topic to the health care industry.
Relationship to quality of care. A wide range of research exists regarding
patients expectations, patients satisfaction, and quality of care. The IOM (2001) stated
that quality of health care should increase the likelihood of meeting the desired outcomes
of patients. The list of potentially desired outcomes include improved health, improved
quality of life, management of physical and psychological symptoms, attention to
concerns and expectations, dignity, shared decision-making, and spiritual well-being
(IOM, 2001). The available literature about the alignment of patient satisfaction and
49
quality of care is more prominent than the relationships related to patient expectations.
As patient expectations emerged later in the literature than patient satisfaction, the level
of literature available is not a surprise.
Quality of care is often an expected priority for health care organizations;
however, researchers have only recently examined the relationship patient satisfaction
has to quality of care. The CMS (2012) supported the positive relationship between
patient satisfaction, in which patient satisfaction is a quality indicator. The VBP
addressed the need to combine both clinical practice and patients experiences for the
highest level of quality of care for Medicare patients. Improved quality of care leads to
better outcomes. The clinical portion of the VBP includes 12 clinical-process care
measures while the remaining measures of the HCAHPS scores reflect patient experience
and patient satisfaction (CMS, 2012). Patients challenged the health care industry to
combine the patients perspective of care received to reconsider delivery of care as
patients directly affect the financial outcomes of health care organizations.
Physicians lead the delivery of health care; therefore, patient and physician
interaction demands attention. Kennedy et al. (2011) identified the strongest correlation
between patient satisfaction and quality of care as the perceived quality of the physician
providing the care. Additionally, Kennedy et al. found that seven characteristics affected
the patients perception of the quality of the physician. The seven characteristics
included (a) thoroughness, (b) spending adequate time with the patient, (c) listening, (d)
explaining, (e) using language the patient could understand, (f) patient involvement in the
care and decisions, and (g) demonstrating care and compassion (Kennedy et al., 2011).
50
Communication is an important part of providing care. Zolnierek and DiMatto (2009)
found a 19% higher treatment adherence for patients when the physician practices used
effective communication. The quality of care is enhanced when a patient adheres to the
recommended treatment (Palese et al., 2011). Omondi et al. (2011) found that satisfied
transplant patients complied with recommendations for follow-up care more often than
less satisfied patients. Equally important is the impact of poor communication on patient
outcome. Polikandrioti and Ntokou (2011) discussed how fractured communication
could lead to lost information, missed assessment for disease symptoms, and poor patient
outcomes. Physicians and patient satisfaction are inextricably linked. The relationship
between the patient and the physician is an integral factor in patient satisfaction and
health care outcomes of patients.
Trust is a central factor in patient and care provider relationships and can improve
the overall quality of care. Patients feel a sense of trust when the health care service
delivered has a value higher than the cost of the care provided (Owusu-Frimpong et al.,
2010). Patient satisfaction improves, as does patient compliance with physician
recommendations, when a high level of trust exists between patients and physicians
(Hojat et al., 2010). Respect is necessary when building a trusting relationship. Clucas
and St Claire (2010) evaluated the effect respectful interactions between patients and
physicians had on patient outcomes. When patients felt physicians showed respect,
patients increased adherence to the physicians recommendations for care, thereby
improving outcomes and quality of care. Consequently, patients expect care providers to
support an environment where services include attributes such as trust and respect
51
(Bechtel & Nees, 2010). Health care providers should strive to build relationships around
the priorities of the patients in a kind and compassionate manner for the best outcomes
for patients and as a means for improving patient satisfaction.
Patient satisfaction aligns in the literature with quality of care through an
understanding of patient expectations. Quader (2009) examined the gap between patient
expectations and health care managers and the impact on quality of care. In this study,
Quader defined expectations as beliefs in existence prior to receiving the services used to
evaluate the current service performance. Managers underestimated the patient
expectations for the tangible domain and overestimated the patient expectations for
reliability and responsiveness domains of the SERVQUAL survey tool. Quader argued
that the gap between patient and manager expectations could influence the quality of
care, as meeting the patients expectations is a key factor in patient satisfaction and
patient satisfaction links to an improved patient perception of care quality. In addition,
Rozenblum et al. (2011) suggested an improvement in patient satisfaction was contingent
upon identifying and meeting the patients expectations. When patients expectations are
met, the quality of care improves through better patient outcomes. Recognizing satisfied
patients follow care recommendations when expectations are met is a key piece of
information for the health care industry.
Some researchers have questioned the influence of patient satisfaction and
meeting patients expectations on the perception of the quality of care; for example,
trauma patients demonstrated an association between the interpersonal skills of nurses
and satisfaction with the quality of care versus an association to meeting the patients
52
expectations with quality of care (Berg, Spaeth, Sook, Burdsal, & Lippoldt, 2012). Ferrer
(2009) found that expectations did not influence the perception of quality. Furthermore,
Kenten et al. (2010) posited that there is minimal evidence regarding the impact of
patient expectations on patients perceptions of quality of care. Frjd, Swenne,
Rubertsson, Gunningberg, and Wadensten, (2011) found that 62% of patients reported
satisfaction with quality of care, yet in the same study, only 34% reported involvement in
shared decision-making, and only 35% reported receiving adequate information for selfcare. Patients can be satisfied even when there is a decreased level of patient
involvement and inadequate information. Welch (2010) suggested that patients might not
be reliable when evaluating the quality of care. Supporting this argument is Cetin, Ucar,
Gven, Atac, and zer (2012) who suggested that patients lack the technical knowledge
to assess the quality of the care services. The drivers of patient satisfaction may not
consider the quality of care, but rather the patients perceptions of the attitudes and
behaviors of the care providers. Altogether, patient satisfaction and patient experience
appear to affect the patients perceptions of quality of care; however, some researchers
have called this relationship into question, suggesting a need for further research.
Relationship to cost of care. Researchers examined the relationship of patient
expectations and patient satisfaction to the cost of care. In 2007, the United States spent
$1.13 trillion on care for over 300 million people (Conway, Goodrich, Machlin, Sasse, &
Cohen, 2011). Considering the United States has the highest health care costs in the
world and does not demonstrate improved outcomes for the cost, the amount of research
should continue to grow in an effort to identify measure to decrease cost (Darling, 2009).
53
Medicare reimbursement regulations through the VBP changed the cost of care for
hospitals. VBP promoted better clinical outcomes, improved patients experience of care
in the hospital, and reduced cost of health care for the hospitalized Medicare patients
through incentives (Tompkins et al., 2009; USDHS, 2011a). According to Ellis-Jacobs
(2011), when hospitals do not provide care that meets the patients expectations, patient
satisfaction scores are lower. Lower satisfaction scores for hospitals now affect
reimbursement for Medicare patients (CMS, 2012). The cost of care increases for the
hospitals when reimbursement decreases, because of low patient satisfaction scores;
therefore, Ellis-Jacobs argued that low patient satisfaction might challenge the small,
rural hospitals. The apparent implication for the rural hospitals is significant; however,
larger health care organizations suffer the impact of low patient satisfaction scores as
well.
Health care organizations priority for managing costs is now more important than
ever with the implementation of VBP. Fenton et al. (2012) found that higher patient
satisfaction correlated to an increase of inpatient use, overall increased health care
expenditures, increased prescription drugs, and increased mortality risk. Additionally,
physicians affected patient satisfaction to the extent that the physician met the patients
requests and expectations; however, physicians could deny requests and maintain high
patient satisfaction if the physician explained the reasons for the decline in a patientcentered manner (Fenton et al., 2012). Often the physician orders unnecessary tests,
treatments, referrals, and medications in response to patient demands and expectations
(Johnson, 2011). To manage resources appropriately and to control costs, the focus
54
should be on the patient versus focusing on providing unnecessary services per patient
requests as a strategy to improve patient satisfaction. Unnecessary health care costs
account for billions of dollars spent each year without appreciable improvement for
patient outcomes (Johnson, 2011). Misuse and overuse of health care resources increases
the cost of health care without improvement in patient outcomes. Aligning cost control
with patient outcomes provides the best approach for appropriate resource management;
however, there is a challenge to provide a service that leads to high patient satisfaction.
The cost of health care can benefit from additional initiatives. For example,
improving patient satisfaction can improve health care financial outcomes by decreasing
patient complaints, decreasing the amount of resources used to manage complaints, and
increasing return customer rates (Suki et al., 2009). When patient satisfaction increases,
there are naturally less complaints and patients are more willing to relay the positive
experience to others. Satisfied patients tend to return for services and the positive
comments to others could lead to new patients for the organization. Additionally,
Levinson et al. (2010) found that patients who were terminally ill required less health
care spending when the physician and the patient collaborated in shared decision-making.
Conversely, when the physician does not communicate effectively with the patient
regarding the patients condition and treatment options the cost of care increases because
of an increase in the laboratory and diagnostic testing (Cetin et al., 2012).
Communication with the physician is a key factor in patient satisfaction, which leads to
cost savings. Health care organizations should focus on improving communication with
55
patients in a patient-centered manner and encouraging shared decision-making to support
improved patient satisfaction and ultimately decrease costs.
Relationship to brand and loyalty. Patient movement from one organization to
another organization forces health care organizations into a competitive environment.
Organizations are vying for patient loyalty as a means to maintain financial stability. The
health care industry is starting to understand the need to capture customer loyalty.
Further, brand awareness has gained interest as a strategy to drive the value of health care
services through a differentiated promise to the patients (Weiss & Tyink, 2009). OwusuFrimpong et al. (2010) claimed that patients are consumers leading health care delivery;
therefore, patients can choose to move from one organization to another based on
satisfaction. Conversely, Weiss and Tyink (2009) viewed satisfaction as the lowest level
of acceptable customer service, and because satisfaction often results in reactionary
measures, satisfaction can be unstable and challenging to reproduce. The available
research is not clear if patient satisfaction should guide health care organizations efforts
to develop brand awareness.
Regarding patient expectations, Lin et al. (2009) reported a positive correlation
between perceptions and expectations and a positive correlation between loyalty and
perceptions; however, loyalty did not correlate to expectations. Lin et al. challenged the
idea that meeting patients expectations leads to increased satisfaction, which in turn
would lead to patients returning for future services. However, brand advertising
commonly focusing on the patients needs. To assist in managing patients expectations,
framing expectations of the service characteristics and attributes to consumers in an open
56
and honest manner remains helpful (Dagger, David, & Ng, 2011). Although the available
literature varies in the approach to brand awareness, the patient must be the focus of
services. The best approach for highlighting the patient as the focus is not well defined in
terms of positive outcomes for health care organizations nor in relationship to patient
satisfaction and patient expectations. Given the importance of communication, a first
step in building a positive relationship with customers could be providing effective
communication.
Building the relationship between the customer and the service provider is
important when striving to gain commitment and loyalty. Dehghan et al. (2012) stressed
the importance of individualizing customer services to strengthen relationships through
trust-building with an ultimate outcome of gaining customer loyalty. Dagger et al. (2011)
found an association between commitment and loyalty, but discovered that relationship
communication had a negative impact on commitment, possibly because of the variability
in perceptions of the intent of the communication. Further, Nazari et al. (2012) described
the loyal customer as a potential tenuous commodity for businesses because ensuring
customer commitment and loyalty by focusing on managing customer satisfaction is not
the normal process. Thus, researchers looked specifically at measuring patient loyalty
and did not focus on customer satisfaction. For example, Chahal and Kumari (2011) used
a five-factor model to measure patient loyalty. The five factors included using the
provider for different services, using the provider for the same services, price indifference
loyalty, dissatisfaction response, and recommending provider. Chahal and Kumari found
an association between the five factors and patient loyalty. If a patient would return for
57
the same or new services, seek the service regardless of cost, return even when some
dissatisfaction existed, and recommend the provider, the patient would then demonstrate
a higher level of loyalty. Patient loyalty is a different dimension of satisfaction, yet
patient loyalty influences the financial outcomes in a similar fashion as patient
satisfaction; therefore, further research to address the relationship between the two topics
could prove useful.
The loyalty commitment and brand promise suffer if satisfaction data and wordof-mouth are negative. The level of the health care organizations commitment to
maintaining a relationship with patients through attention, effort, and resources is of
significance to customer loyalty (Dagger et al., 2011). Huppertz and Carlson (2010)
found the strength of influence on the choice of the hospital to be high when patients
reported positive HCAHPS data and positive verbal information about the hospital. If the
information about the hospital were negative in the form of HCAHPS and verbal
information, patients would tend to avoid the hospital. More importantly, if HCAHPS
data and verbal information were contradictory, consumers weighed both forms of
information when making the decision to go to the hospital in question. The connection
between patient satisfaction data and loyalty is precarious because of the potential
influence of verbal information. Health care organizations should not rely on patient
satisfaction data as the primary indicator of patient loyalty. Knowing that patient loyalty
is important to the financial future of health care organizations, health care providers
must understand how to retain current patients. Ultimately, retaining customers is more
profitable versus obtain new customers (Quader, 2009). Optimally, health care
58
organizations should implement plans to retain customers as well as obtain new
customers. Patient satisfaction should be a key element in these initiatives.
Gaps in the literature. Patient satisfaction research is bountiful; however,
patient expectation research is more limited. The patient expectation literature steadily
increased because of recent regulations and financial impacts of the VBP (CMS, 2012).
The financial implications continue, as similar regulatory programs moves to other areas
of health care services such as home health and physician office settings. Messina,
Scotti, Caney, and Zipp (2009) discussed the impact patient satisfaction has on the
financial outlook and expressed a need to increase research focused on the patient
satisfaction and organizational performance because research specific to the relationship
is limited. Additionally, consumers access information through the public reporting of
patient satisfaction scores, further encouraging health care research in the areas of patient
expectations and patient satisfaction to improve publically reported scores.
A significant gap in the literature around patient satisfaction and patient
expectations exists because of the multitude of topics available in the health care setting.
Welch (2010) argued that research lacks in the areas of subpopulations of patients, agespecific, and disease-specific. Subpopulations of patients related to age-specific and
disease-specific is numerous. Indeed, each subpopulation could benefit from patient
satisfaction and patient expectation research specific to age or the disease as often,
satisfaction is variable when placed in a different context (Chahal & Kumari, 2011). The
variability within the subpopulations and disease states adds a layer of complexity to
achievement of high satisfaction.
59
Little research exists about the differences between race and ethnicity and patient
satisfaction. Npoles, Gregorich, Santoyo-Olsson, O'Brien, and Stewart (2009) studied
the relationship between patient satisfaction and interpersonal processes including
communication, patient-centered decision-making, and interpersonal style, by race and
ethnicity. Such studies are useful when applying patient-centered care strategies to health
care services as the findings may illuminate the priorities for different ethnicities. Health
care organizations can use the information to assess patients expectations and build an
individualized plan of care for patient of differing races; however, the limited number of
research studies on this topic impedes progress in this area. Initiation of research to
identify differences in expectations based on race, ethnicity, and language could assist in
decreasing health care disparities and improve patient satisfaction for the less studied
populations.
An additional opportunity exists in the area of research on chronic conditions and
patient satisfaction. Adler et al. (2010) researched the effects of continuity between
doctors and patients and the relationship continuity of care has on patient satisfaction.
Researchers specifically noted a gap in longitudinal studies. Continuity of care is
reflective of care received over a period. As patients invest more time in relationships
with providers, the relationship may change. In many cases, opportunities exist for
researchers identifying specific needs and expectations for patients suffering from
chronic conditions. As patients live longer, chronic conditions become more prevalent;
therefore, additional research to address the factors related to patient expectations and
60
patient satisfaction can provide information for development of services tailored to the
chronically ill patient.
A gap exists in the area of development and validation of tools. Health care
providers must use tools to appropriately capture patient satisfaction and patient
expectations. Though many tools are available in the research, the reliability and validity
of the tools varies. Health care providers should use different tools for different patient
populations and different diseases. Not all tools can successfully translate needs and
outcomes from one study to another. Researchers should produce and test new models,
theories, and tools related to patient satisfaction and patient expectations for a variety of
diseases, ages, languages, and health care settings. The following questions reflect an
analysis of the research located in the literature review on the relationship between
patient expectations and patient satisfaction, and listed on the survey instrument as
Questions 14 through 20:
doctor care.
nursing care.
61
Summary of the Literature Review
I examined the relationship between patient expectations and patient satisfaction
through a thorough review of the current literature. The literature review spanned
relevant information from the historical background of patient expectations, patient
satisfaction, and measurement tools through the importance of researching patient
expectations and patient satisfaction. Additional areas included in the literature review
were the physician and nurse relationship to patient expectations, relationship of patient
expectations and patient satisfaction to quality of care, cost of care, brand, and loyalty.
The final review involved examination of gaps in the literature to conclude the literature
review.
Health care organizations face a lack of understanding of patient expectations.
Researchers offered various definitions as well as numerous types of expectations such
as, probability expectations, value expectations, predictive expectations, normative
expectations, and comparative expectations (Bjertnaes et al., 2012; Ferrer, 2009; Georgy
et al., 2009; Tejada et al., 2010). Additionally, the emergence of patient expectations was
not a natural process; rather, regulatory and industry forces pushed the evolution. As
patients transitioned to a consumer perspective, health care leaders and providers had to
review the role of the service provider in a new light. The care could not be physiciandriven as patients expect patient-centered care. The expectations of patients are complex
and are based on a variety of factors not well understood by physicians and nurses
providing the care. Consequently, difficulty remains in meeting expectations.
62
Patient satisfaction research emerged in a similar manner as patient expectation
but preceded patient expectation research. The shift for patient satisfaction to a top
priority within the health care industry occurred because of the alignment to
reimbursement. Additionally, publically reporting of patient satisfaction data placed
pressure on health care organizations leaders to develop strategies to improve services
and improve patient satisfaction ratings. To that end, a key element of success for health
care leaders and providers includes recognizing patients expectations and patient
satisfaction continue to drive service.
Transition and Summary
Section 1 contained background information about the health care industrys
knowledge of patients expectations, patients satisfaction, and concepts related to
managing expectations and improving satisfaction. The purpose of this quantitative study
was to examine the relationship between patient expectations and patient satisfaction;
therefore, the research questions for the study inquired about the relationship between
patient expectations and patient satisfaction. The study adds value to the health care
industry by increasing knowledge about a national priority for the industry. Equally
important is the potential to effect positive societal changes through improved patient
outcomes.
In the literature review, I found a correlation between patient expectations, patient
satisfaction, and improved patient outcomes (Fenton et al., 2012; Lin et al., 2009; Suki et
al., 2009). Additional potential correlates included decreased cost in care and increased
level of brand and patient loyalty. When patients feel care providers meet expectations,
63
satisfaction improves. Understanding this correlation can change the approach to care in
the health care industry. A move to a patient-centered approach could positively affect
patient satisfaction and patient outcomes through shared decision-making and patient
empowerment (Cliff, 2012a; Hudon et al., 2011; Pelzang, 2010; Poochikian-Sarkissian et
al., 2010). The shift to improved satisfaction and improved outcomes could have positive
implications for health care organizations.
Section 2 contains the studys research methodology. The supporting sections
include the role of the researcher, study participants, research method, research design,
population and sampling, ethical research, data collection, data collection technique, data
organization techniques, data analysis, and reliability and validity. Section 3 contains the
presentation of findings, application to professional practice, implications for social
change, and further recommendations.
64
Section 2: The Project
In the project section, I provide a detailed account of the research study beginning
with an introduction to the problem statement to ground the context of the project details.
A description of the role of the researcher in the data collection process and a discussion
of the participants follows, including the population description, the total population,
sample population, type of sample, ethical considerations, data storage, and the informed
consent from participants. Another item reviewed is the chosen research method and
design: population, sampling, ethical research processes, data collection instruments, data
collection techniques, data analysis, reliability, and validity. In addition, Section 2
contains discussions addressing the questions surrounding the examination of the
relationship between patient expectations and patient satisfaction.
Purpose Statement
The principal objective for the correlational design study was to examine the
relationship between the patient expectation and patient satisfaction. Health care
consumers in a southeast Wisconsin hospital were the participants of this study. The
sample population consisted of admitted hospital patients over the age of 18 who were
considered physically stable (Holzer & Minder, 2011). Admitted patients must have
spent at least 24 hours in the hospital as a criterion to participate in this study.
Health care organizations within the United States may find the study results
beneficial where reimbursement by payers occurs through application of metrics based on
meeting patients expectations and providing services that lead to high patient
satisfaction. Organizations not affected by reimbursement issues may benefit from this
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study by understanding the relationship between meeting patients expectations and
patients satisfaction. Researchers examined the benefits of improved patient
satisfaction, with scholars supporting positive health outcomes and higher quality of care
(Cliff, 2012a; Hudon et al., 2011; Less, 2011; Pelzang, 2010; Poochikian-Sarkissian et
al., 2010). Understanding patients expectations could benefit all health care
organizations, regardless of the type of reimbursement. Future patients may receive
higher quality of care and improved outcomes.
Role of the Researcher
As the sole researcher in this quantitative, correlational study, I was responsible
for the research project, development of the survey instrument, and collection of the data
for the pilot and final participant survey. The project study components included the
development of the survey questions, planning the pilot study, and planning of the final
participant survey activities. Final tasks included analysis of the data, reporting the
findings, and providing conclusions derived from the data analysis.
I had a relationship with the host organization through employment as the vice
president for patient and family experience. The host organization includes a 300-bed
hospital, a physician medical group consisting of 27 sites with approximately 150
employed physicians, and numerous outpatient services. The vice president positions
responsibilities include patient and family interaction, patient satisfaction survey
management, patient satisfaction data analysis, and patient satisfaction strategy planning
and implementation. My role as vice president began in July of 2013, with a previous
role as a director in the patient and family relations department.
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Preceding the director position, I was in a role as care manager for 9 years in a
similar hospital system. The managers responsibilities included direct patient care as
well as management duties related to the care of pregnant mothers. During this time, the
host hospital began to be concerned about patient satisfaction; therefore, the management
role required development of a survey to assess the level of patient satisfaction with the
services provided to the pregnant mothers. Also included in the manger role was
management of educational programs, which relate to pregnancy and baby care, which
required development of satisfaction surveys.
To mitigate the risk of researcher bias, I developed a validated and reliable survey
instrument through a review of the available scholarly literature on the topic. Bias can
occur in any study and is a misrepresentation in the assessment of information or analysis
of the data (Healy & Devane, 2011). Contact with participants prior to the survey
implementation was not possible because no direct patient care occurred. By enlisting
the aforementioned measures, I remained professional and demonstrated integrity
throughout the research process.
Participants
The studys population consisted of all patients admitted to the hospital in the
fiscal year 2013, which extended from July 1, 2012 through June 30, 2013. The patients
considered part of the population were over 18 years of age, in a physically stable
condition, and admitted into the hospital for at least one overnight stay (Holzer &
Minder, 2011). The hospital units that house the potential patient population included
medical, surgical, and cardiac units. In the pilot study analysis, I calculated the sample
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size requirements using information necessary for the correlation sample size and the
ANOVA sample size, including statistical ranges for the estimated correlation coefficient
and estimated effect size. Additional information needed for the sample size calculation
was the average daily admitting census for the hospital units included in the population.
The daily admitting census, based on historical data from the fiscal year 2012, was 24;
therefore, the population of admitted patients for 1 year was 8,760.
The input parameters needed for the minimum sample size for correlation tests
include alpha level (), statistical power (1-), and correlation r. Three items needed for
the calculation of a minimum sample size for the one-way ANOVA test are alpha level,
statistical power (1-), and estimated effect size. The alpha level and the statistical power
are predetermined. For the study, the alpha level was .05 and the statistical power was
.80 (Field, 2009). The data collection for the pilot and the main study took place over 2
weeks and included a minimum sample size determined after analysis of the pilot study.
The main study sample size was the larger of the two samples sizes calculated from the
pilot study for the correlation test and one-way ANOVA test.
In the study, the sampling was purposeful sampling based on the identified
participant criteria with simple random sampling within the medical, surgical, and cardiac
units. Karpel (2009) used purposive, nonprobability sampling technique to choose
participants for a study related to patients experience with pain. Chiang (2012) used
purposive sampling to identify a participation pool of patients meeting criteria related to
terminal illness. Purposive sampling allows the researcher latitude to identify the
potential participants based on the purpose of the study (Chiang, 2012; Karpel, 2009).
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The participants in this study needed to meet certain criteria, including being 18 years or
older with a stable physical condition; therefore, the sampling technique was a purposeful
criterion sampling. The patients admitted into the host hospital had to be able to
understand the survey questions in order to achieve the data collection goals for the
study. These criteria allowed a sufficient pool of patients to meet the required number of
participants for the study for the anticipated 2-week period.
The participants came from a population of inpatient admissions in a southeastern
Wisconsin hospital from the medical, surgical, and cardiac units. Data collection for the
pilot study and the main study occurred within a 2-week period, surveying patients
meeting the criteria on a daily basis, to ensure I met the required sample size. The
participant pool excluded patients admitted because of an atypical event as the study
reflects commonly admitted patients in the medical, surgical, and cardiac units of the host
hospital. An atypical event included any rare incident considered uncommon to the
providers at the host hospital. Additionally, each opportunity for a patient to complete
the survey reflected one admission; therefore, patients had one opportunity for survey
completion.
The number of patients seen daily may have needed to increase if there was a
50% or more rate of refusal to complete the survey as the goal was to complete surveys
for the minimum sample size in 2 weeks; however, refusal rate was minimal with the goal
sample size met within 2 weeks. On each unit, I met with the charge nurse for review of
the daily admission list to define patients meeting criteria for inclusion in this study. All
potential participants received a personal visit in which I explained the study, placing an
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emphasis on the option to volunteer for the research study or to decline inclusion in the
study without any negative outcomes as well as emphasizing strict confidentiality of the
participating patients to ensure ethical research processes. Each patient received a code
number ensuring confidentiality of his or her identity throughout the survey and study
process.
Participants received and reviewed a letter of informed consent (see Appendix B)
prior to the initiation of any data collection. Once collected, I stored electronic data on a
private, password-protected computer with paper copies locked in a file drawer in my
home. After 5 years, I will destroy all electronic information and all paper data through
deleting, shredding, and disposal.
Research Method and Design
This study is quantitative with a correlational design. The efficacy of the research
study hinges on the quality of the research question, which the researcher derives from a
focused problem statement (Polit & Hungler, 1983). The research question and problem
for this study examined the relationship between patient expectations and patient
satisfaction because health care leaders face a financial risk to the organization related to
patient satisfaction (USDHS, 2011a). The quantitative method provided useful
information for health care organizations through correlational, statistical analysis of the
variables patient expectations and patient satisfaction. Health care organizations may use
the results of this study to expand knowledge on the level of influence patients
expectations have on patient satisfaction. Process improvements may increase the
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likelihood of hospitals gaining full reimbursement for services meeting patients
expectations.
Method
The quantitative method addresses the research problem in this study through
numerical results. The discussion includes the reasoning for choosing the quantitative
method over the qualitative method with supporting research from three similar
quantitative studies. In the health care setting, quantitative research is common because
the results often change health care practices; therefore, researchers must offer statistical
significance to ensure accuracy (Peat, Mellis, Williams, & Xuan, 2002). Quantitative
statistical analysis involves the use of numerical data to describe occurrences or describe
the significance of a relationship between or among variables (Polit & Hungler, 1983).
The variables in the study are patient expectations and patient satisfaction. Quantitative
researchers analyze and explain the statistical relationship between variables (Maxwell,
2013); therefore, quantitative methodology is appropriate for this study. Surveys are one
tool for data collection for quantitative studies. A survey instrument for this study is
appropriate, as the goal is to identify any relationship between two variables versus
manipulation and control of the variables of a treatment or intervention as in a true
experiment or quasi-experimental study. Ex post facto quantitative researchers use
surveys while recognizing the research occurs after the organic occurrence of the event
(Polit & Hungler, 1983). The patients in this study provided information related to
services already received through the completion of a 20-question survey instrument.
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In this research study, I examined the relationship between patient expectations
and patient satisfaction. In Figure 3, the patient is at the center of the bulls-eye as a
depiction of where the focus must be to move successfully to the outer ring of the bullseye with a goal of maximizing reimbursement. The patient is the only person identifying
his or her individual expectations, the second ring of the target. Once the care providers
identify the patients expectations, the care providers must define measures to meet the
expectations, thereby increasing the likelihood of a high degree of patient satisfaction. If
the patient experiences a high degree of satisfaction, the health care organizations
maximize reimbursement by increasing the likelihood that patients rate satisfaction
higher on the surveys used to determine reimbursement.
Figure 3. Patient centered graphic depicting the need to focus on the patient in order to
receive full reimbursement for health care services.
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A wide range of quantitative health care studies are in the literature. Ellis (2011)
addressed the relationship between customer satisfaction in rural health care and revenue
generation in a quantitative, ex post facto, correlational study using quantitative analysis
to delineate departments and their relationship to revenue. Ellis found that three
satisfaction ratings from the emergency department were significant, whereas none of the
inpatient ratings proved significant. Larson (2012) studied, through a quantitative
method, the relationship between a providers cultural competence and Hmong pregnant
womens neonatal outcomes using a survey instrument as the primary data collection
vehicle. Although Larson reported no significance between the overall patient
satisfaction and the providers cultural competency scores, three areas of the survey
related to the providers communication and cultural competent behaviors that forecasted
early and ongoing prenatal care leads to decreased preterm and low birth weight births.
In a similar quantitative study, Chiang (2012), using a survey to gather data, used
multiple correlational, statistical analyses to identify the relationship between factors and
the degree of happiness and quality of life for 82 terminally-ill patients. Chiang found
that psychological factors were significant in which p < .001. Each of the
aforementioned researchers successfully employed a correlational design and used
statistical analysis of numerical data specific to the health care setting and patient
satisfaction, offering support for the use of the quantitative methodology and a
correlational design for this study.
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The quantitative method was one of three options for this study. The other
methods include qualitative and mixed method designs, each of which appear in health
care research; however, I used the research questions for the study to guide the choice of
the quantitative methodology. Qualitative researchers employ a procedure in which the
focus is on people, circumstances, experiences, and processes that link the three together
(Maxwell, 2013). In the health care setting, researchers use qualitative studies to collect
information about behaviors from the perspective of the patient, using descriptive
measures versus numeric measures for quantitative methods (Peat et al., 2002). For
example, Johnson, Goodacre, Tod, and Read (2009) completed a qualitative,
phenomenological study using interviews to explore patient satisfaction with care related
to chest pain. Using a qualitative method, patients described the experience in their own
words and provided rich, personal descriptions of experiences for the study. My study
examined if a relationship existed between the variables using numeric data; therefore,
inclusion of personalized perspectives was an unnecessary element. Mixed-method
research, a combination of quantitative and qualitative methods, provides benefits
through triangulation, complementary data gathering, and advanced depth of information
(Maxwell, 2013); however, the information gathered for this study was specific to the
relationship between two variables to quantify the statistical significance of the results. A
mixed method did not meet that need.
This study was a quantitative study examining if there is a relationship between
patient expectations and patient satisfaction. The review of all available methods led to
this decision based on the goal of answering the research questions by testing the
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derivative hypotheses through statistical analysis. Similar researchers provided
additional support for the choice of quantitative method. In quantitative studies,
researchers explore a relationship through the demonstration of statistical significance,
which is highly regarded in the medical field as a strong research indicator.
Research Design
This subsection contains information related to the rationale for employing a
correlational design over other designs for examining the relationship between patient
expectations and patient satisfaction. In three doctoral studies of a similar nature,
researchers provided validation for the correlational design choice for their problem and
research questions (Chiang, 2012; Ellis, 2011; Larson, 2012). Correlational analysis does
not provide causal information. Correlational analysis does provide information about
existing relationships, which can provide foundations for further, potentially more
rigorous research (Polit & Hungler, 1983). Accordingly, correlational research does not
require manipulation or intervention on the part of the researcher.
As a correlational design is quantitative, researchers use the results from statistical
analysis of numeric data to support or reject the null hypotheses. Scholars cannot use
correlation or one-way ANOVA to address cause-and-effect; rather, researchers must
examine the relationship between the independent and dependent variables. The
correlational design is appropriate for a health care study, as researchers use evidencebased practice, the most rigorous scientific evidence available, and significance levels
identified through the statistical procedures (Peat et al., 2002). Though the focus is on
nonclinical practices related to patient satisfaction in the health care setting versus
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clinical practices related to health care outcomes, statistically valid analysis remains the
highest standard for health care studies.
The two variables studied were patient expectations and patient satisfaction.
Figure 4 depicts the correlation between the two. The independent variable was patient
expectations. The dependent variable was patient satisfaction. The study results showed
a positive relationship between the variables; therefore, care providers should initiate
measures to identify patients expectations and meet the expectations as a means to
improve patient satisfaction. The highest level of success in meeting patients
expectations would raise the level of patient satisfaction. If there is a positive
relationship between meeting expectations and patient satisfaction, health care
organizations can increase reimbursement revenues as the level of patient satisfaction is
driving the size of reimbursements (USDHS, 2011a).
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Figure 4. Relationship between meeting patient expectations and patient satisfaction.

Ellis (2011) analyzed patient satisfaction in two departments, the emergency
department and the inpatient department, including correlational analysis of the
relationship between patient satisfaction and revenue for the hospital. Ellis used the
Pearson correlation to determine the degree the two variables were dependent on one
another. The findings included statistically significant p values less than .05 in one area,
the emergency department, providing valuable information about customer service skills
that resulted in improved satisfaction and increased revenue (Ellis, 2011). Employing the
findings and initiating similar skills in the inpatient area may also improve revenue for
hospitals. Larson (2012) used multiple linear regressions to examine an association
between multiple independent and dependent variables related to the providers culturally
competent behaviors and prenatal care practices of Hmong women. In the study results,
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Larson indicated a lack of overall significance with p < .01 between the cultural
competence scores of the two groups yet indicated an association between
communication and adequate prenatal care. Chiang (2012) used multiple regression
analysis to explore the relationship among four variables: physical symptoms,
psychological state, existential beliefs, and social factors, with the level of satisfaction of
life for terminally ill patients. The ability to recognize each area is significant for
patients, and such information drives changes in care pathways provided to terminally ill
patients. Correlational design, as evidenced from previous researchers, proves useful for
statistical analysis of data driven by research questions specific to patient expectation and
patient satisfaction in a health care setting.
Other designs are useful in health care research; however, they were not
appropriate for this study. For example, an experimental study uses the model of
scientific research, which encompasses three properties: (a) manipulation of some
participants, (b) control over some portion of the experiment, and (c) randomization of
participants (Polit & Hungler, 1983). The tight control and randomization of an
experimental study decrease the influence of many external factors, resulting in minimal
bias and limiting confounding results, and provides the uppermost category of
substantiation for best practice in medical research (Peat et al., 2002). In quasiexperimental studies, researchers employ nonrandomization and, because of the loss of
randomization, lack the same level of rigor as the experimental studies. In this study,
there is not any treatment or intervention; rather, the primary data gathering tool is a
78
survey instrument for obtaining data on admitted patients perceptions about the care they
received in the subject hospital.
Correlation analysis is a quantitative methods design. Researchers of three
similar studies using a correlational design provided support for the design choice.
Correlational design aligns with exploration of relationships; therefore, the correlational
design is appropriate for the study because the study examines the relationship between
patient expectations and patient satisfaction (Chiang, 2012; Ellis, 2011; Larson, 2012).
The data gathered through survey implementation is numeric and allows for analysis of
significance of the relationship through the correlational design.
The method and design for this study is a quantitative method with a correlational
design. The quantitative method and the analysis of data using correlational tools
provided statistical information about the relationship between patient expectations and
patient satisfaction. Because this study examined the relationship with a goal of
determining its statistical significance, the qualitative method is unnecessary.
Additionally, researchers use other design methods such as experimental and quasiexperimental to focus on the use of interventions. Methods requiring interventions are
not appropriate as this study does not use interventions. Study analysis of the results of
the quantitative correlational study for statistical significance provides information for
support or rejection of the null hypotheses.
Population and Sampling
The sample population is a representation of the total population; therefore, the
process used to define and choose the sample population was important if the study
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results are to reflect the total population. The sample-size process description includes
the sampling method, sampling size, the criteria used for participant selection, and the
significance of the criteria to the study. The following discussion includes details of the
aforementioned processes.
In this study, all patients admitted into the medical, surgical, and cardiac units of a
300-bed, southeast Wisconsin hospital within a calendar year comprise the study
population. The total population represents inpatient units receiving reimbursement from
Medicare through the VBP. Medicare reimbursement for services provided in the
inpatient medical, surgical, and cardiac units aligns with 30% of reimbursement defined
by patient satisfaction metrics from CMS (USDHS, 2011c). Consequently, hospital
administrators suffer pressure to identify and understand factors influencing patient
satisfaction scores for admitted patients to receive full reimbursement for services
provided to the patients.
Defining the correct sampling method for the study ensures that the chosen
sample is appropriate for the research question. Researchers of two health care studies
support the choice of purposive sampling method for this study. Karpel (2009) studied
the correlation of the mind body connectivity and patients experience with pain using a
purposive, nonprobability sampling technique to choose participants. Karpel indicated a
purposive method helps guide the purpose of the study. Additionally, Karpel claimed
that a nonprobability sampling technique does not employ random selection. Chiang
(2012) used purposive sampling to determine the participants for a quantitative study on
the level of happiness for terminally ill patients. Purposive sampling allows the
80
researcher the opportunity to ascertain potential participants based on the purpose of the
study. The sample population appropriately reflected the purpose of this study by
employing purposive sampling in the hospital setting as the purpose of the study
examined the relationship between patient expectations and patient satisfaction.
Calculation of the sample sizes for the correlation and one-way ANOVA tests
require different estimation techniques. Determining the required sample size is
important for ensuring that a priori sampling risks are considered and addressed in testing
for significant differences between two groups or variables (Peat et al., 2002). Key input
parameters needed for the calculations include the average daily admitting census of the
study hospital, a predetermined alpha level and power, and effect size. The average daily
admitting census for the study hospital includes admission into the medical, surgical, and
cardiac units using historical data from the previous fiscal year. Based on the historical
data from the fiscal year 2012, average daily admissions are 24. Applying the number for
1 calendar year, the population of admitted patients computes to 8,760. The pilot study
analysis results determined the sample size calculation for the main study, including the
mean and standard deviation for the sample size calculation. The pilot study sample
population included 10 participants from the medical unit, 10 from the surgical unit, and
10 from the cardiac unit for a total sample size of 30 participants to ensure sufficient data
are available for accurate computation of the mean and standard deviation (Field, 2009).
The mean and standard deviation are two values needed to accurately calculate the effect
size used in the final sample size computation.
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Sample size calculation for the correlation test requires specifying desired values
for alpha, statistical power, and effect size. Chiang (2012) defined a sample size of 89 as
an appropriate sample size for the correlational study, as the results would reflect the total
population related to a patient satisfaction with the level of happiness for terminally ill
patients. In the calculation, Chiang included a power level of .80 at a significance level
of .05 with an effect size of .15 for a minimum sample size calculation of 82. Such
calculations are common for calculating a sample size for multiple regression studies.
Predetermined values for alpha and the statistical power include an alpha of .05 and a
power of .80 (Burkholder, 2012). Effect size for the correlation test is a result of the
correlation coefficient (r) from the pilot study analysis. The next sample size calculation
step for the correlation test required the use of a table in which the correlation coefficient
from the pilot study and the predetermined power of .80 intersect, defining the sample
size requirement (Burkholder, 2012). Final calculations for the correlation sample size
required comparison to the one-way ANOVA sample size calculation before defining the
final main study sample size.
As for the correlation test calculation, one-way ANOVA sample size calculations
also required specifying the desired values for alpha, beta, and effect sizes. The pilot
study analysis of the three different units, medical, surgical, and cardiac, provided the
mean and standard deviation values needed for the required effect size estimation.
However, the medical units required different representation in the final sample size
related to the daily admission variation among the units. For example, if the required
final sample size were 100, the medical unit representation in the sample would be 54
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participants, the surgical unit would be 15, and the cardiac unit would be 31 as
represented in Table 2.
Table 2
One-way ANOVA Sample Size Unit Totals
Unit
Annual Total
% of Total
Sample
Medical
4727
.535
54
Surgical
1354
.153
15
Cardiac
2756
.312
31
The final sample size calculation step for the one-way ANOVA test required the use of
an analysis of variance table in which the effect size from the pilot study and the number
of groups, three in this instance, intersect, defining the sample size requirement
(Burkholder, 2012). Comparison of the calculation outputs from the correlation sample
size computation and the one-way ANOVA sample size computation defined the final
sample size for the main study using the larger required number from the two
calculations.
Selection criteria for participants included at least 18 years of age, admitted into
the medical, surgical, or cardiac unit for a minimum of 1 night, and a stable physical
condition. A physically stable patient is capable of communicating with me in a manner
demonstrating an understanding of the instrument questions with an ability to answer the
questions; additionally, the patients medical record must indicate a stable condition. The
survey setting was the patients hospital room. All rooms in the host hospital are single
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occupancy; however, closing the door when in the room during any discussion about the
study protected the participants privacy. Family members could not answer questions
for the patient because the study topic is specific to the individual patients expectations.
According to the expectancy value theory, a persons attitudes about an activity, event, or
object depends on beliefs about those activities, events, or objects based on preceding
factors (Gibbons et al., 2009). Family members may not be able to define another
persons expectations based on personal beliefs; therefore, patients selected for
participation must be able to answer the questions on the instrument to provide accurate
information for the study.
The inpatient units previously identified are reflective of the research problem
related to reimbursement for Medicare patients in the hospital setting; therefore, they are
the appropriate population pool. For example, the host hospital also had inpatients in the
womens and childrens unit, but because the reimbursement withhold does not apply to
nonacute patients or non-Medicare patients, the patients in this area do not align with the
purpose of the study; therefore, they were not included. Additional excluded inpatient
units included pediatrics and neonatal intensive care, as they do not support the purpose
of the study. To ensure a diverse patient population, there was not any disease, nor health
condition exclusion to the criterion to participate. The various units cater to specific
illnesses and conditions; therefore, minimizing exclusions ensured the sample population
was a cross section of the patients in all units.
Using the specified criteria, the final sample pool reflects a similar number of
participants from each identified unit to ensure proper representation of a variety of
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patients and conditions. A daily inpatient admission list guided data collection. An
additional measure used to guide the purposive sampling was the inclusion of a meeting
with the charge nurse to identify patients meeting the criteria. Upon possible participant
identification, I met with the patient, taking the time to explain the data collection
process, including an emphasis on the option to decline and participant confidentiality. If
the daily goal of patients fluctuated, time adjustment to the time length of data collection
occurred.
The population and sampling of the study embodies key components of the study.
The sample population must be a size capable of providing accurate results, reflective of
the total population. In this case, the total population is a 300-bed, southeast Wisconsin
hospital with over 8,000 acute care inpatient admissions a year. Calculating a minimum
sample size required using an alpha level of .05 and a power of .80 and the numbers for a
range of possible effect sizes derived from the pilot study analysis (Field, 2009). Sample
criteria further defined the sample population. The sample criteria included 18 years of
age or older, admission into an acute care unit with a minimum of 1 night stay, and a
stable physical condition. Ultimately, implementing appropriate criteria with a
representative sample population ensures that the studys findings and conclusions
objectively and accurately address the research problem and provide information to
further the knowledge on the influence of patients expectations on patient satisfaction.
Ethical Research
The participants in the study were over the age of 18 and did not fall into the
vulnerable participant category. Additionally, the risk associated with this study was
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minimal; meaning, the likelihood of suffering harm or discomfort was not greater than
the risk associated with daily activities (Morris, 2012). The likelihood of suffering harm
was low because the primary activity for the quantitative study was completion of a
survey tool.
Prior to conducting research, per requirements of Walden Universitys
Institutional Review Board (IRB), I completed an IRB form as well as ethical research
training through The National Institute of Health (NIH). Located in Appendix C is the
NIH certificate of completion for the ethical research training with the corresponding
certification number 884937. By providing IRB approval, Walden indicates the research
study benefits outweigh the risks. The host hospital required an additional IRB process
for this study before allowing any research study to occur within the health care
organization. An IRB review board from the host hospital reviewed the required
paperwork to determine approval. The host hospital accepted the same IRB paperwork
used for Walden University, reserving the right to request additional information to
provide approval if indicated. Furthermore, there were no incentives offered for
participating in this study. The Walden IRB approval number is 07-15-13-0297192.
I met face-to-face with each potential participant and reviewed, in detail, the
process for data collection, analysis, and reporting. If a patient agreed to participate in
the study, I reviewed the consent form as shown in Appendix B for the pilot study and
Appendix C for the main study. The consent form informed the participant on the
purpose of the research, the criteria used for selection, information about the procedures,
volunteer status, the privacy information, contact information, and information on the
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researcher. All consent reviews and survey completions occurred in the patients room of
the hospital. The participants kept the consent form as a measure of informed consent to
maintain privacy. Using this method avoided the need for a signature from the
participant.
All participants agreed to join the study on a voluntary basis with an
understanding that they would not suffer any negative effects for choosing to decline
participation in the study. Those choosing to participate in the study benefitted by having
an opportunity to express perceptions of the care received while in the hospital.
Participants could assist the host hospital and other hospitals on a larger scale through
participation in a study intended to increase information on the study topic. During the
review of the consent form, I emphasized the voluntary aspect of the study as well as the
ability for participants to withdraw at any time throughout the process. If participants
decided to withdraw, they could withdraw through a verbal or written request without
suffering any negative consequences. When participants withdrew, I omitted their data
from the results of the study and permanently destroyed the paper data and deleted
electronic data from the data collected.
As a measure to protect the rights of the participants, I followed a process for all
data collection and storage during the research study. The survey data collected from the
participants was in paper form. The additional information resulting from the analysis of
the data is in paper form and electronic form. The electronic information is kept on a
flash drive and on a private, password-protected computer. Additionally, the flash drive
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and all paper materials remain in a locked file drawer for 5 years. After 5 years, I will
destroy the paper and electronic information through deleting, shredding, and disposal.
I protected the names of the participants through two processes. In the first
process, I protected the participants identity by using codes instead of participants
names. At no time during the research study process were names of the participants
disclosed. I maintained sole access to a master list of participants names in the event a
participant wished to withdraw. Because I maintain sole access, there is a level of
protection related to a single person handling the participants information. The charge
nurses on the units had access to the initial list of potential participants but neither the
final list of participants nor the survey data gathered from the participants prior to
analysis. The quantitative specialist consulted for this study received data in coded form
to protect the participants identities.
Providing an ethical framework for the research study is important to the integrity
of the researcher and the integrity of the study process. Participants volunteered to join
the study, and each participant had the right to withdraw any time during the process
without concern for retribution. The information gathered during the study is
confidential and requires special steps to ensure ongoing protection. Furthermore, after a
period of 5 years, destruction of the paper and electronic information occurs through
deleting, shredding, and disposal. I am aware of the Health Insurance Portability &
Accountability (HIPPA) guidelines protecting patients personal information (USDHSS,
2013) and, accordingly, maintained confidentiality over the participants identities and
privacy.
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Data Collection
I prioritized three main areas related to data collection. The first topic considered
the details related to the study instrument; for this study, the instrument was a survey.
The second item considered the data collection techniques or processes I used to collect
the data with the identified instrument. Additional information included the need for a
pilot study to validate the instrument. The final topic considered the data organization
techniques used to save and organize the data during the study to ensure efficiency and
mitigate data loss.
Instruments
The studys instrument provided a mechanism for collecting patient expectation
and patient satisfaction data. The instrument used in this study, located in Appendix A,
was a survey titled Becker Inquiry of Patient Expectations as Predictors for Patient
Satisfaction. The survey had 20 questions with a 5-point Likert-type scale. In this
section, I discussed the instrument and resultant survey data assurance in detail including
(a) the theoretical concept measured by the instrument, (b) score calculation, (c)
reliability and validity assessment, (d) process for completion of the survey, and (e)
location of raw data.
Gibbons et al. (2009) claimed that the components formulating expectations
reflective of the expectancy value theory and applicable to patient expectations are
personal beliefs, values, and prior experiences. The expectancy value theory provided a
framework for understanding how individual expectations develop and how the
differences in expectations can influence a patients level of satisfaction based on
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whether the health care providers meet those expectations. The survey instrument
contained questions to measure the patients expectations in the areas of admission,
nursing care, and physician care. Additionally, I used patient satisfaction questions to
measure the degree of patient satisfaction with communication and listening skills of the
nurses and physicians and the level of satisfaction with patient inclusion in decisionmaking. Finally, seven questions addressed the relationship between patient expectations
and patient satisfaction, including three questions measuring prior hospital experiences
intending to evaluate the effect prior experiences may have on current perceptions of
patient satisfaction.
The survey instrument contained a 5-point Likert-type scale providing an
acceptable range of selection options for the participants. Sarvadikar, Prescott, and
Williams (2010) used a similar 5-point scale when evaluating the attitudes of health care
professionals about reporting medication errors. The Likert-type scale has the lowest to
the highest ranking as follows: (1) strongly disagree, (2) disagree, (3) neutral, (4) agree,
and (5) strongly agree. The participants chose one answer for each question by placing a
mark in the box beside the desired response.
Survey instruments must meet reliability and validity standards. The processes
for ensuring reliability included administration of the survey and data entry. The
administration of the survey instrument can increase reliability through a consistent
process. The participants received the same survey questions in the same format, and I
administered the survey in a consistent manner. Moreover, the participants were in the
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same hospital; therefore, the administration of the survey occurred in the same setting. A
second process warranting reliability assurance is data entry.
The transfer of respondents data from the survey instrument through the final
stages of analysis in SPSS version 21 was correct. The initial transfer of data entry was
from the survey instrument into an Excel spreadsheet available in Appendix E. I
completed a question-by-question recheck of the data to guarantee the transfers of data
were correct. The second transfer of data occurred when moving data from the Excel
spreadsheet into SPSS software. To ensure the integrity of the data, retests of all the
entries occurred. The sample population data from 30 participants, 10 from the medical
unit, 10 from the surgical unit, and 10 from the cardiac unit, validated the instrument
through the analysis of Cronbachs alpha, which is a commonly used measure of
reliability (Field, 2009). The data from the pilot study also provided the elements needed
to validate the sample sizes for the correlation and one-way ANOVA tests (Ke, Squires,
& Li-Ming, 2011). Data collection for the pilot study mirrored the process of the main
study. Multiple questions for each variable supported the validity of the instrument, as
numerous questions are available to answer each variable of the research questions.
The participants remained in the patient room during the administration of the
survey. A participant must have had a minimum of 1 overnight stay for inclusion and
limit of participation is one per individual, excluding readmissions from the sample
population. I introduced myself, and then introduced the intent of the study. If the
patient wanted to participate in the study, a reviewed of the consent form and the survey
instrument occurred. The survey instrument was a one-sided paper copy presented to the
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patient with a brief explanation of the Likert-type scale and an inquiry if the participant
had any questions before starting.
The participants understood that I planned to step out of the room during
completion of the survey to allow for privacy, returning to retrieve the survey at an
agreed upon time. The participants placed the survey in an envelope and sealed the
envelope upon completion to ensure an added measure of confidentiality. Each question
must have only one answer, made by a tick mark in the chosen response box. Upon
return to the patient room, an opportunity to ask questions occurred as well as retrieval of
the sealed envelope. At this point, the participant completed their portion of the study.
To ensure an opportunity to contact me if the participant so desired, a review of the
contact information on the consent form transpired prior to exiting the room.
Data retrieved through the survey process remained in a locked file drawer
accessible only to me, the researcher. The data, when entered into SPSS version 21 and
analyzed, included summarized tables, graphs, and appendices in the doctoral study;
however, the raw data remains in a locked cabinet and on a password protected personal
computer. Consideration of requests for raw data on an individual basis is an option if
providing the data does not threaten the privacy of participants.
The questions on the survey instrument reflect portions of the research questions
and more specifically align with the study variables. The survey questions align with the
expectancy value theory by addressing patient expectations and patient satisfaction by
eliciting information about perceptions of care. Perceptions are a combination of
personal beliefs and experiences (Conley, 2012). To further support the theory, I used
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three questions on the survey to inquire about prior hospital experiences. The following
questions guided the data collection for patient expectations related to admission, nurses,
physicians, and perceived responsiveness.
The second section of questions inform on the patient satisfaction. An additional
five questions align with the second variable, patient satisfaction. I used these five
questions to extract information from the participants to address the level of satisfaction
with the hospital experience related to communication, listening skills, and involvement
in decision-making.
satisfied.
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your care.
In the final set of questions, I addressed the relationship of the patient
expectations and patient satisfaction. The relationship question set consists of seven
questions. The focus of the questions is on the expectations for admission, nursing care,
physician care, and previous hospital experiences with patient satisfaction.
doctor care.
nursing care.
The questions for the study derived from an exhaustive review of the current
literature, thereby supporting the validity of the instrument. To address the test-retest
reliability and internal consistency, a pilot study ensued. Equally important, the pilot
study results provided data for analysis of the questions and responses to optimize an
opportunity to make adjustments necessary to increase reliability and internal consistency
if indicated. In addition, to minimize threats to data collection, I followed the specific
steps previously outlined in this section.
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The process of data collection is important to the validity and reliability of the
study. Many opportunities exist for degradation of the processes; therefore, putting
measures in place mitigates threats to validity, reliability, and internal consistency. The
instrument I used in this study is a 20-question, 5-point Likert-type scale survey
developed after the conclusion of an exhaustive literature review. Moreover, the
questions on the survey appropriately aligned with the three study variables: patient
expectations, patient satisfaction, and the relationship between the two in a manner that
answers the research questions.
Data Collection Technique
A survey instrument is the vehicle for collecting data for this study. The survey
was a 20-question instrument employing a 5-point Likert-type scale. I completed the
administration of the survey to all participants.
In the host hospital, over a 2-week period, I reviewed the daily census with the
charge nurses on the medical, surgical, and cardiac units to identify potential participants.
The inclusion criteria were 18-years-old or greater and in stable condition. Additional
considerations with the charge nurse included identification of other factors that would
impact the patients ability to provide competent consent such as medication side effects,
emotional issues, pain, and anxiety causing temporary or permanent cognitive challenges.
Patients with these factors became ineligible for the study.
Visits to the identified potential participants occurred at a rate aimed at meeting a
minimum of two to three patients per unit to provide a variation in the patient population.
Upon entry into the patients room, I identified myself and explained the intent of the
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study. The patient reviewed the consent form if he or she agreed to participate as well as
reviewed the paper copy of the survey. To ensure patient privacy, the patient completed
the survey privately, placing the completed survey in a sealed envelope for future
retrieval.at an agreed upon time. The participant needed to answer each question,
choosing only one answer with a mark in the box of the desired response. The survey
took approximately 10 minutes to complete. Addressing any potential questions occurred
at the time of retrieval of the sealed envelope containing the survey as did the reminder of
the contact information on the consent form in the event he or she would like to initiate
contact in the future.
In an effort to increase the internal validity of the instrument, a pilot study ensued.
Data collection for the pilot study occurred after IRB approval through Walden
University and the host hospital. The pilot study consisted of 10 participants from each
of the three units, reflecting the sample population. Ke et al. (2011) completed a pilot
study and used purposive sampling to identify 10 participants to validate patient
satisfaction questionnaires after translation to other languages. In a similar fashion, I
employed purposive sampling of the host hospital participants using the same inclusion
criteria as the main study with a goal of a minimum of two participants per each of the
following units: medical, surgical, and cardiac. Administration of the consent form and
completion of the survey followed steps for the main study as outlined previously. In
addition to administration of the survey instrument, after retrieving the survey during the
pilot study, I elicited responses from the participant related to the following questions:
1. Was the survey easy to understand?
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2. Were there any questions you had trouble answering?
3. Did the amount of time required to take the survey seem reasonable?
4. Was the time of day appropriate for this activity?
5. Did you have enough choices for your answers?
I analyzed the results of the survey to identify questions that seemed ambiguous
or questions needing elimination or revision. Additional questions provided an
opportunity for comments about whether the length of the survey was appropriate, if the
Likert-type scale provided a large enough range for the answers, and if the results
appeared to be able to answer the research question. If revisions occurred, completing
another pilot study verifying the changes were effective must follow. Because no
negative issues or concerns were noted in the pilot study, a second pilot study did not
occur.
Data collection techniques for this study included the administration of a paper
survey to the sample population in the host hospital. Prior to implementing the survey for
the main study, a pilot study ensured the internal validity of the instrument. I used the
pilot study to identify issues related to the content of the instrument. By early
identification, making appropriate changes strengthened the content and confirmed the
survey elicits information that answers the research questions.
Data Organization Techniques
Organization of the data retrieved through the survey administration is the topic of
discussion in this subsection. Data organization reduces the likelihood of lost data,
correctly categorizes data, protects participation identity, and increases study efficiencies.
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Data retrieval for this quantitative correlational study occurred with a survey instrument
that I personally handed to each participant. The participant pool encompassed three
inpatient units of the host hospital; therefore, the coding of the participants reflected the
different units.
The nomenclature for coding of participants included a letter from the unit and a
number. The medical unit participants followed the pattern M1, M2, M3, and so on. The
surgical unit participants followed the pattern S1, S2, S3, and so on. The cardiac unit
participants code followed a C1, C2, C3 pattern. I wrote the participant code on the
paper survey and wrote the corresponding code on the patient list from the hospital to
allow for identification of the participant in the event of a request for exclusion after
survey completion. The survey question coding reflected grouping of the questions
according to the variables patient expectations, patient satisfaction, and relationship
between patient expectations and patient satisfaction. The patient expectations section
had eight questions with the pattern PE1, PE2, and PE3 continuing through PE8. The
patient satisfaction section had five questions with each number preceded by a PS. The
last section had seven questions with an R before each number to reflect the word
relationship.
In the Excel spreadsheet, the patients codes are across the top with each
participant code placed as a column heading. Each row heading on the left side reflected
one question. Appendix E contains a sample Excel spreadsheet. Hard copy titles
included the three units to assist with organization when transferring the results daily into
an Excel spreadsheet. I secured the hard copies of the surveys in a locked file cabinet
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after data transfer. The items remain in a locked file drawer during the study and for 5
years post study, at which time destruction of the paper and electronic information occurs
through deleting, shredding, and disposal.
Data Analysis Technique
By design, the findings from this quantitative correlational study should answer
the research questions using the derivative survey questions to elicit responses from the
participants and provide data for analysis of the results resulting in a quantitative,
systematic approach for answering the research questions. The survey tool was a 20question paper form. The first set of questions included eight survey questions guiding
data collection for the independent variable, patient expectations. The questions elicited
responses related to admission, nurses, physicians, and responsiveness.
In the second section of five questions, I elicited responses related to the second
variable, patient satisfaction. More specifically, the questions provided data on the level
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of patient satisfaction with communication and listening skills of the doctors and nurses
and patient involvement in decision-making.
satisfied.
your care.
In the last group of seven survey questions, I addressed the relationship between
patient expectations and patient satisfaction. The key components of the questions
reflected the relationship of the expectations for admission, nursing care, physician care,
and patient satisfaction with previous hospital experiences.
doctor care.
nursing care.
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Using the SPSS software version 21, I analyzed each section of questions
producing an output of descriptive statistics measuring the central tendency and standard
deviation as a means for representing the distribution of the variables. SPSS software
provides a mechanism to transfer nonmeaningful numerical data reflective of the
independent and dependent variables into meaningful measures of significance through a
variety of testing options (Field, 2009). Additional outputs for each questions are
necessary beyond descriptive statistics; thereby, presenting a need for analyzing the data
through inferential statistics. Inferential statistics derived from hypothesis testing and
correlation testing allows inferences to a larger population regarding relationships (Field,
2009). Furthermore, testing for normality of the data ensures correct use of parametric or
nonparametric hypothesis testing. Finally, tables for descriptive statistics and other
statistical results provide a visual presentation of the data.
Correlation testing using the Pearson correlation coefficient as the statistic is a
logical analysis application for the study. The correlation coefficient reflected the
relationship between two variables and tests H10: Patient expectation is not correlated
with patient satisfaction. I addressed the significance and strength of the relationship
between the independent variable patient expectations and the dependent variable patient
satisfaction using a p value of .05.
One-way ANOVA tests check for a statistically significant difference in
participants data results among the different hospital units. The one-way ANOVA test
was an appropriate test for significance for H20: There were no differences in patient
expectations and patient satisfaction among the different hospital units. The results of the
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one-way ANOVA test had to support or fail to support the null hypothesis using a
probability p value of .05 to determine statistical significance.
Coding data is necessary to export data into the SPSS version 21 software for
analysis. I assigned codes for the individual questions, individual participants, and
demographic data. The codes for the questions correspond to the variable. The patient
expectations questions followed a nominal pattern of one through eight with the initials
PE preceding each number. For example, the first three questions were PE1, PE2, and
PE3 through PE8. Similarly, the patient satisfaction group of questions had the initials
PS preceding the question number. There are five questions; therefore, the pattern begins
with PS9, PS10, PS11, PS12, and PS13. The final section of questions related to the
relationship between patient expectations and patient satisfaction. The code for these
questions followed a R14, R15, and R16 through R20. Participation coding reflected the
admitted hospital unit. The medical unit patients had an M before a participant number,
the surgical unit had an S before a number, and the cardiac patients have a C before the
number. The order of participant number corresponded to the sequence of each survey
completed on each unit. For example, the first participant on the medical unit had a code
of M1, and the second participant completing a survey on the medical unit had a code of
M2, and so on. The first participant completing the survey on the surgical unit would
have a code of S1, the second S2, and so on.
The data provides further support for the theoretical framework of this study. The
expectancy value theory often correlates perceptions to individual expectations based on
past experiences (Oftedal et al., 2010). The study included survey questions illuminating
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expectations, satisfaction, and past experiences of patients in the host hospital. Using
hospitalized patients from a variety of units allowed for identification of relationship
differences by unit, as well as identification of relationships between previous hospital
experiences and current hospital experiences. If support exists for the relationships based
on questions reflecting the expectancy value theory, I support the theory by using
statistical analysis to define the existence of relationships as well as the strength of
relationships. Conversely, the analysis may support or refute the null hypothesis that
there is no relationship between patient expectations and patient satisfaction.
I entered the coded data from the patient surveys into the SPSS version 21
software, and then analyzed the data using statistical tests that provided descriptive and
inferential statistics. The statistics included measures of correlation coefficient and oneway ANOVA. Table 3 contains the hypotheses and the corresponding tests.
Furthermore, the results of the analysis answered the research questions by supporting or
failing to support the null hypotheses.
Table 3
Hypotheses and Corresponding Tests
Hypothesis
H10: Patient expectation is not correlated with patient satisfaction
H20: There are no differences in patient expectations and patient
satisfaction among the different hospital units
Test
Correlation
One-way ANOVA
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Reliability and Validity
The discussion in this subsection includes information about the reliability of the
instrument and processes referenced in this study. The second topic of discussion in this
subsection is the identification of internal and external threats to the validity of the study.
I review the controls and strategies used to mitigate the threats and to ensure the integrity
of the studys results.
Reliability
Assuring the reliability of the study begins with the instrument used to gather data
and progresses through the processes implemented when completing the study. The goal
provides a high degree of uniformity and dependability with a standardized instrument
(Polit & Hungler, 1983). The primary tool for collecting data for this quantitative
correlational study was a 20-question survey instrument. The survey instrument in the
study was a new instrument; therefore, I completed a pilot study to test the reliability of
the instrument. The pilot study included 10 participants from each of the three units
using the same criteria as the main study. The criteria for inclusion was18 years of age or
older, a stable physical condition, and a patient with at least 1 overnight stay in the
medical, surgical, or cardiac unit of the host hospital. A pilot study allowed participants
and the researcher the opportunity to identify ambiguous questions, time constraints, or
other issues with the instrument or with the administration of the instrument prior to the
main study.
Cronbachs alpha testing addressed the internal consistency reliability of the
instrument. The pilot study mirrored the main study process previously outlined in the
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instrument section. If identified needed changes arose related to the instrument or the
process, I recognized a need for another pilot study existed after seeking a new IRB
approval from Walden University and the host hospital; however, because revisions did
not occur a second pilot was unnecessary.
The administration of the survey was also a factor in reliability of the study. In
this study, I was the only person administering the survey instrument and the only person
extracting the information from the instrument. Daily transfer of information into an
Excel spreadsheet improved reliability through transfer of smaller amounts of
information, thereby decreasing the risk of data input mistakes. A further step supporting
reliability included completing a recheck for each answer entered into the Excel
spreadsheet to ensure the accuracy of data transfer. The same process for data transfer
into SPSS version 21 occurred with a double check of all the information reducing the
likelihood of errors. An additional process test for data transfer accuracy ensued during
the completion of the pilot study.
The overall reliability of the studys findings is reflective of the reliability of the
instruments and the administration processes. Conducting a pilot study improved the
reliability of the instrument by providing an opportunity to identify potential concerns or
issues. Researchers strengthen findings by employing consistent processes related to (a)
the administration of the survey, (b) data collection, and (c) data extraction. Equally
important to the integrity of the study is validity of the research.
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Validity
The results of the study must reflect the population studied within the correct
context. To validate the study, researchers rely on the data reduction, interpretations, and
conclusions. There are two types of validity to consider: internal and external (Peat et al.,
2002). The threat to internal validity exists when the wrong conclusion results from the
collected data. The threat to external validity exists through inappropriate generalization
of the results to a larger population. I reviewed the measures used to mitigate these
threats to this study.
Internal validity. Establishing internal validity assures that any claimed causal
relationship between the independent and dependent variables is true. The study was a
correlational design; therefore, I focused on a relationship and not causation.
Consequently, internal validity was not a relevant issue for this study.
External validity. The research study results may apply to a different population.
Such application to a broader population supports external validity (Peat et al., 2002).
Clearly defining the limitations and delimitations of the study mitigate inappropriate
generalizability. For example, in this study, I focused on an inpatient population of
patients in southeast Wisconsin; therefore, generalizing the results to an outpatient
population of patients in another region of the country may not be appropriate. Further,
use of the instrument in other nonhospital settings may not produce similar results, as the
instrument for this study specifically inquired on the inpatient population of a hospital.
Purposive sampling can threaten external validity, as it is not randomly controlled.
Providing criteria for the chosen sampling in the study assists future researchers
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attempting to replicate the study. Likewise, providing specific criteria for participation
sampling and providing descriptive data of the participants in the study may yield results
for other populations.
The reliability and validity of the study ensures the confidence in its findings and
conclusions. Reliability increases and threats to internal and external validity are
mitigated through pilot studies and process controls. Areas of control exist for the (a)
survey instrument, (b) study processes, (c) data interpretations, and (d) data conclusions.
Implementing the controls provides the necessary framework for appropriate analysis of
the data in support of answering the research questions.
Transition and Summary
Section 2 included details regarding the study beginning with the introduction of
the problem statement to identify the underpinnings for the study specifics. The key
areas reviewed included the role of the researcher, the participant population information,
the type of sample, ethical considerations, data storage, research method, research design,
data analysis, reliability, and validity. The study was a quantitative correlational design.
The data collection instrument was a 20-question survey prepared to collect data from a
sample estimated from the pilot study results. I used SPSS version 21 software to
analyze the data using descriptive outputs, correlation, and one-way ANOVA testing.
In Section 3, the discussion includes details of the study results. A review of how
the results apply to professional practice follows. Also reviewed are the implications for
social change and recommendations for further actions including indications for areas of
further study.
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Section 3: Application to Professional Practice and Implications for Change
In Section 1, I discussed the underpinning of the study by introducing the problem
and purpose statements. Additional foundational elements included the research
questions and hypotheses for the study variables, patient expectations and patient
satisfaction. The literature review encompassed existing research about key topics
related to the study including patient-centered outcomes, customer loyalty, patient
satisfaction, and financial benefits for healthcare organizations. Section 2 highlighted
procedures and processes used in the quantitative, correlational design study using a
statistical approach for answering the research questions. In Section 3, the discussion
includes an overview of the study, a detailed presentation of the study findings, the
application to professional practice, implications for social change, recommendations for
action and further study, and reflections of the research process.
Overview of Study
The purpose of this correlational, quantitative study was to study the relationship
between patient expectations (independent variable) and patient satisfaction (dependent
variable) for health care consumers of a 300-bed hospital in southeast Wisconsin. I
developed a 20-question survey tool to collect data and completed a pilot study to validate
the survey tool. The pilot study data included elements for the calculation of the final sample
size for the main study. Ninety patients completed the survey for the main study, providing
data to answer the research questions by testing the hypotheses for this study.
Health care consumers drive health care services and reimbursement through
scoring the level of satisfaction with services received. Patient satisfaction scores
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comprise 30% of the total reimbursement for Medicare patients experiencing at least an
overnight stay in hospitals across the United States (USDHS, 2011c). Consequently,
patient satisfaction is a significant factor in the financial success of health care
organizations as low patient satisfaction scores reduce total reimbursement. Patients
expectations factor into the process of defining the level of satisfaction for patients (Gill
& White, 2009). Health care leaders and providers need to identify the patients priority
expectations and then develop services and processes that meet these expectations to
maximize reimbursement. The purpose of this quantitative study is to provide
information about the relationship between patient expectations and patient satisfaction
for health care leaders and providers.
The research questions for this study inquired if a relationship exists between
patient expectations and patient satisfaction in the 300-bed host hospital and if
differences exist for patient expectations and satisfaction among the medical, surgical,
and cardiac hospital units. The hypotheses tested include the following
Correlation analysis examined the relationship between the independent variable, patient
expectations and the dependent variable, patient satisfaction. One way ANOVA analysis
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addressed the expectations and satisfaction of a variety of ages and health conditions
from the medical, surgical, and cardiac units of the host hospital as a means for
identifying variation in units.
Analysis of the study data included identifying a significant correlation between
patient expectations and patient satisfaction. Similarly, a significant correlation existed
between factors related to previous physician, nursing, and hospital experiences and the
current level of satisfaction. Conversely, no significant differences in expectations or
satisfaction existed between the medical, surgical, and cardiac units.
Presentation of the Findings
Data collected in this study provided information for analysis using a quantitative,
systematic approach for answering each research question. The findings from this
quantitative correlational study answered the research questions and addressed the
hypotheses using the responses from the participants completing the survey questions.
Details exploring the study outputs from the 20-question survey follow.
Pilot Study
This study included a pilot of the instrument ensuring internal validity of the
survey instrument. Additionally, the participants in the pilot study had an opportunity to
illuminate potential concerns about the instrument and the survey process. The pilot
study ensured an opportunity for identification of content issues of the instrument as well
as process issues through inquiry after completing the survey. The pilot study
participants did not indicate any issues or problems with the tool or the process.
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The pilot sample population contained 30 participants, 10 individuals from each
of the three units; medical, surgical, and cardiac. Using SPSS version 21, I analyzed the
data collected from the 30 participants testing for Cronbachs alpha and using correlation
and one-way ANOVA outputs to determine the final main study sample size. Cronbachs
alpha is a common measure of survey reliability of internal consistency using a value > .7
indicating a high internal consistency (Field, 2009).
I used the Cronbachs alpha test for each section of questions on the survey. The
first section of questions on patient expectations tested at .860, the second set of
questions about patient satisfaction tested at .902, and the final set of questions about the
relationship between patient expectations and patient satisfaction tested at .874.
According to Field (2009), a test result > .7 is acceptable and indicates strong internal
reliability; hence, each section of the survey tool exceeded the acceptable threshold
demonstrating reliable internal consistency.
Pearson correlation test at the .01 level indicated a significant correlation of .673
between patient expectations and patient satisfaction. Additionally, one-way ANOVA
tests resulted in a partial eta-squared output of .636. Pearson correlation coefficient and
partial eta-squared are measures of effect size (Field, 2009). Effect size is one of three
elements needed to calculate the final main study sample size. The other predetermined
elements include alpha ( .05) and power ( .80). Using the elements previously indicated I
calculated a final minimum sample size of 18. Because of the high correlation
coefficient, the minimum sample size was small; however, the pilot study sample size
was 30 and exceeded the final main study sample size. Knowing this result, the final
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determination of the main study sample size of 90 occurred by doubling the pilot study
sample size of 30 and adding the 30 data points from the pilot study to ensure the final
sample size exceeded the pilot study sample size. The final main study sample size was
five times greater than the indicated minimum sample size identified through calculation.
Research Questions and Hypotheses
Health care leaders face challenges related to understanding patients expectations
and the effect meeting or exceeding patients expectations has on patient satisfaction. I
developed two research questions for this research study that inquired about these
challenges.
1. Does a relationship exist between patient expectations and patient satisfaction in
the 300-bed host hospital?
2. Do differences exist for patient expectations and satisfaction among the medical,
surgical, and cardiac hospital units?
Additionally, two hypotheses reflect the research questions.
Correlation test results answered the first research question and the first
hypothesis. One-way ANOVA test results answered the second research question and the
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second hypothesis. Table 4 contains descriptive statistics for patient expectations section
of questions, patient satisfaction section of questions, and the relationship between
patient expectations and patient satisfaction section of questions. Histogram location for
each is in Appendix F, Appendix G, and Appendix H respectively. The scoring scale was
a 5-point Likert-type scale ranging from 1(strongly disagree) to 5 (strongly agree). The
sample size for the relationship between patient experience and patient satisfaction
section differs from the other two sections. The sample size is N = 88 because 2
participants did not answer questions about previous hospitals stays because this study
was their first experience.
Table 4
Mean and Standard Deviations for Survey Question Sections
Patient
Expectations (PE
(PS)
Relationship
between PE and PS
SD
90
32.82
5.17
90
21.97
2.97
88
30.02
403
First research question and hypothesis. The first research question and hypothesis
inquired about a relationship between patient expectations and patient satisfaction. I
computed Pearson correlation coefficients between the patient experience group of data and
the patient satisfaction group of data and between the patient satisfaction group of data and
the relationship between patient expectations and patient satisfaction group of data. The test
for the relationship between patient expectations and patient satisfaction addressed the
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theoretical framework which discussed the effect past experiences have on current
expectations (Gill & White, 2009). The third section of questions asks about past
experiences. Analysis revealed a statistically significant relationship between both
comparison groups. There was a significant positive correlation between the two variables
patient expectations and patient satisfaction (r = .623, p = .01) as listed in Table 5.
Table 5
Pearson Correlation of Patient Expectation Scores and Patient Satisfaction Scores
Patient
Expectations
1
Pearson Correlation
Sig. (2-tailed)
N
Pearson Correlation
Sig. (2-tailed)
N
Note. * Correlation is significant at the .01 level (2-tailed).
90
.623*
.000
90
Patient
Satisfaction
.623*
.000
90
1
90
There was also a significant positive correlation between the two variables patient
satisfaction and the relationship between patient expectations and patient satisfaction (r =
.680, p = .01) as listed in Table 6.
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Table 6
Pearson Correlation of Patient Satisfaction Scores and Relationship of Patient Expectations
and Patient Satisfaction Scores
Patient
Satisfaction
1
Pearson Correlation
Sig. (2-tailed)
N
Relationship
Pearson Correlation
Sig. (2-tailed)
N
Note. * Correlation is significant at the .01 level (2-tailed).
90
.680*
.000
88
Relationship
.680*
.000
88
1
88
These findings answer the first research question by providing results to indicate a
relationship between patient expectations and patient satisfaction, thereby rejecting the first
null hypothesis, in support of the alternative hypothesis, patient expectation is correlated
with patient satisfaction. Overall, there was a moderate to strong correlation between
patient expectations and patient satisfaction, suggesting that when patients believe health care
providers meet their expectations, satisfaction levels increase. Furthermore, the second
comparison group results suggest previous hospital experiences, including satisfaction with
the nurses and doctors, affects current hospital experience satisfaction.
Second research question and hypothesis. The second research question and
hypothesis inquired about possible differences in patients expectations and satisfaction
among the medical, surgical, and cardiac units in the host hospital. Table 7 contains the
descriptive statistics including number of data points, mean, and standard deviation for
each unit. As noted previously, the sample size for the medical group is 40 versus 42 as
the relationship section of questions contained questions about previous hospitalizations
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and two medical patients did not have any previous hospital experiences. The means and
standard deviations for the units are similar; however, the medical unit has a higher
standard deviation in all categories than the surgical and the cardiac units. The medical
units provide a wide variety of services that treat numerous diseases and issues, whereas
cardiac and surgical services are more specialized. Appendices I, J, and K contain the
comparative box plots for the descriptive statistics.
Table 7
Mean and Standard Deviation for Medical, Surgical, and Cardiac Units
Relationship Between
Mean
SD
Medical
42
31.90
5.98
Surgical
19
33.68
4.51
Cardiac
29
33.59
4.15
Medical
42
21.69
3.23
Surgical
19
22.53
2.50
Cardiac
29
22.00
2.89
Medical
40
29.55
4.51
Surgical
19
31.32
2.89
Cardiac
29
29.83
3.89
Analysis revealed that there was not a statistically significant difference between
the different unit mean scores as determined by one-way ANOVA. Results include
patient expectations [F (2, 87) = 1.250, p = .292], patient satisfaction [F (2, 87) = .517, p
= .598], and the relationship between patient expectations and patient satisfaction [F (2,
85) = 1.299, p = .278].
116
Although the overall results were not statistically significant between the groups,
the questions about speed expectations of admission and comfort expectations during
admission were significant at p = .029 and p = .021 respectively. Specifically, with
further analysis of these questions using the post hoc test, Tukey HSD, the cardiac unit
was different. The cardiac unit result compared to the medical unit was p = .037 and the
cardiac unit compared to the surgical unit was p = .953 regarding admission speed
expectations. The cardiac unit also differed for the question about comfort during
admission with a comparison of p = .015 to the medical unit and p = .318 to the surgical
unit. I completed a test of homogeneity of variances and listed the results in Table 8.
None of the three areas met significance in variance at p < .05; therefore, further tests
proved unnecessary.
Table 8
Test of Homogeneity of Variances
Patient
Expectation
Patient
Satisfaction
Relationship
Between
Levene Statistic
df1
df2
Sig
2.830
87
.064
0.983
87
.378
1.640
85
.200
In conclusion, the analysis of the data through correlation tests indicated a strong
relationship between patient expectations and patient satisfaction thereby rejection the
first hypothesis. The analysis of the data through ANOVA tests indicated no significant
difference between the units. The results failed to reject the second null hypothesis as no
117
differences existed for patient expectations and satisfaction among the medical, surgical,
and cardiac hospital units. Further analysis of individual interview questions follows.
Interview Questions
Study participants answered 20 survey questions. To assist in answering the
research questions and assist in testing the hypothesis, the survey contained three
subsections defined as patient expectations, patient satisfaction, and relationship between
expectations and satisfaction. The discussion of findings reflects the three sections of the
survey tool. In an effort to identify the relationships between the independent variable,
patient expectations and the dependent variable, patient satisfaction, I performed correlational
testing and one-way ANOVA testing.
Patient expectation was the independent variable considered in the first section of
the survey. The following eight questions informed on this topic:
I grouped the eight questions related to patient expectations together and
compared the questions to the patient satisfaction group of questions. Patient satisfaction
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was the dependent variable in this study. Five questions comprised the second section of
the survey tool and represent the patient satisfaction data when performing the
correlational testing.
satisfied.
your care.
Comparison of the two groups occurred by performing Pearson correlation tests.
As noted previously, the results indicated a significant relationship between patient
experience and patient satisfaction (r = .680, p = .01). Strong correlation results between
the first two groups suggest meeting patients expectations can positively affect patient
satisfaction. The two questions with the lowest scores were the questions inquiring if the
doctors and nursing staff asked about the patients expectations. The participants
answered agreed and strongly agreed only 53.2% of time for doctors and 57% for the
nurses. Conversely, participants answered agreed and strongly agreed for the skill of the
doctors 92.2% of the time and the skill of the nursing staff 99.2% of the time. Other
areas of strong agreement included communication with the doctor (82.1%),
communication with the nursing staff (94.7%), doctor listened (85.8%), and nursing staff
listened (92.8%).
119
The final section of the survey included seven questions. The questions reflected
the relationship between expectations and satisfaction, including questions about the
current and previous hospital experiences. Additionally, the questions inquired about
how the admission process, doctors, and nurses influenced satisfaction.
doctor care.
nursing care.
I compared the patient satisfaction group and the relationship between patient
expectation and patient satisfaction group by performing Pearson correlation testing. As
noted previously, the results indicated a significant relationship between the two groups
(r = .680, p = .01). A strong correlation between the second groups suggests previous
hospital experiences may affect current hospital patient satisfaction. Participants
answered agreed and strongly agreed 80.5% of the time when scoring the level of
meeting admission expectations reflected their satisfaction. The same question related to
the doctor meeting expectations (84.7%) and nursing staff meeting expectations (89.1%)
were higher than admissions.
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Relating Findings to Available Literature

Patient satisfaction scores are crucial to the overall financial success of health care
organizations. Understanding how to improve patient satisfaction is paramount as 30%
of reimbursement for inpatient Medicare services aligns with patient satisfaction scores,
(USDHS, 2011c). Of interest is the slow progress by health care organizations regarding
services that meet the needs and expectations of the patients as a means to improving
patient satisfaction (Needham, 2012). The findings from my study can add to the body of
knowledge supporting the value of meeting expectations and improving patient
satisfaction.
Patient expectation and patient satisfaction were the two variables in this study.
Correlation results indicated a positive correlation between the two variables. Other
researchers support these findings as Fenton et al. (2012), Lin et al. (2009), and Suki et
al. (2009), also identified correlations between patient expectations, patient satisfaction,
and patient outcome. An additional positive correlation between patient satisfaction
section and the relationship between patient satisfaction and patient expectations section
of the survey existed. The latter section asks questions about previous hospital
experiences; therefore, a relationship exists between previous experiences and scores
related to a current experience. If the patient had positive experiences in the past, he or
she was more likely to score the current experience higher.
Questions on the survey regarding the nurse and physician asking about
expectations scored low in comparison to the other questions in Section 1. The results
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are not surprising as literature indicates a lack of assessing for expectations is rather
common (Rozenblum et al., 2011). Meeting expectations can only happen if health care
providers assess individual expectations. Bowling, Rowe, and McKee (2013) found that
meeting expectations were predictive of positive satisfaction scores; thereby supporting a
need to consider appropriate evaluation about expectations.
Patient-centered care literature often mentioned a relationship between including
patients in their care and improved patient outcomes with resulting improved patient
satisfaction (Hudon et al., 2011; Pelzang, 2010; Poochikian-Sarkissian et al., 2010).
Often the improvement occurred because of improved communication between the care
providers and the patient. The survey for this study contained two questions relating to
communication and one question regarding satisfaction level for inclusion with care
decisions. The frequencies of agreed and strongly agreed were high in this study for the
communication question for the doctors (82.1%) and the nursing staff (94.7%). Manary
et al. (2013) discussed findings indicating nursing communication was more predictive of
patient satisfaction scores in the hospital setting than physician communication whereas
Zolnierek and DiMatto (2009) noted approximately 20% improvement in treatment
compliance when the physicians communicated effectively. The results of this study
indicate a higher satisfaction with communication with the nursing staff; however, a
positive correlation exists between both the physician and nursing questions in the patient
experience section and the patient satisfaction section. Though findings vary regarding
which care provider affects overall scores at a higher degree, the key element to
improving patient satisfaction for either profession seems to be effective communication.
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Another important element of patient-centered care is including patients in
decisions about care. Results from this study about inclusion in care decisions reflect the
data from one survey question. The question asks about satisfaction with the amount of
inclusion related to decision about their care. A positive, significant correlation at p = .01
existed between every other question on the survey. The correlation coefficients ranged
from r = .305 to r = .691 suggesting a strong relationship between inclusion and all
aspects of care addressed on the survey; conversely, Frjd et al. (2011) found patients
could indicate positive satisfaction even when reporting low involvement in decisionmaking.
In summary, the results of this study offer information suggesting patient-centered
care is an expectation for patients in the host hospital. Patient-centered care elements
identified as significant included communication between doctors and nursing staff and
the patient, inclusion in decisions, and listening the patient. As patient-centered care
research indicates a relationship to improved patient satisfaction, health care leaders
should consider incorporating the approach as one measure for improving satisfaction
scores.
Expectancy Value Theory
The theoretical framework for this study was the expectancy value theory in
which personal values, beliefs, and prior experience come together to form expectations
(Gill & White, 2009). Patients expectations are a key factor in defining the level of
satisfaction with health care services; therefore, understanding patients expectations can
influence the level of satisfaction if health care providers meet expectations. The results
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from this study further inform health care leaders and providers about the importance of
the aforementioned theory when trying to understand patients expectations. Patient
expectations, patient satisfaction, and past experiences are the key themes discussed in
this section.
The results of this study included a positive correlation between patient
expectations and patient satisfaction, suggesting meeting expectations could improve
satisfaction. Expectancy value theory describes expectation formation as a combination
of values, beliefs, and prior experiences (Gill & White, 2009). Given this description,
personal expectations could vary between individuals; therefore, generalizing
expectations for all patients could lead to an inability to meet expectations. If health care
providers do not meet individual expectations, satisfaction could decrease. Additionally,
the study results indicated a positive correlation between current patient satisfaction and
previous hospital experiences. In support of these findings, Brown (2011) posited that
previous experiences were a factor in expectations about future outcomes. As previous
experiences contribute to expectations, health care providers can benefit from inquiry
about individual previous hospital experiences. Once health care providers examine
previous experiences, the current delivery of services can adjust if necessary to ensure an
optimal experience.
Business Practice
Health care leaders and care providers can benefit from the results of this study by
applying patient-centered practices. Understanding individual expectations allows health
care providers an improved path to meeting expectations, as patient expectations are
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unique to the individual. The impact on business occurs through improving patient
satisfaction scores thereby securing full reimbursement as reimbursement aligns with
patient satisfaction scores.
The results of this study illustrated a positive correlation between patient
expectations and patient satisfaction indicating a relationship between the two variables
in this study. In fact, Miaoulis et al. (2009) suggested that patient satisfaction can be
measured as a comparison in which the experience matches the patients expectation. If
this result is true, best practice for health care providers would include assessing the
patients individual expectations related to the care provided as a precursor to meeting the
needs and expectations of the patient. Assessment practices could positively affect
patient satisfaction by identifying what the patient defines as priority expectations.
An additional element noted in this study is a relationship between patient
satisfaction with the current hospital experience and previous hospital experiences.
Similarly, Ferrer (2009) indicated patients consider past experiences when shaping
current expectations. Based on these findings, care providers may consider assessing the
patients previous experiences with health care as an opportunity to understand
perceptions about health care services. For example, if a patient suffered negative
experiences in the past when getting blood drawn for lab tests, the patient may believe
that all blood draws in the future will prove to be a similar negative experience. If the
care providers understand this prior to drawing blood for labs, additional education and
care can be a part of the current service thereby mitigating the patients anxiety and
worry. Using this pre-service assessment strategy provides an opportunity to improve
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patient satisfaction by addressing concerns in advance thereby providing a positive
experience. The next section addresses in more detail the applications of the study results
to professional practice.
Applications to Professional Practice
This study afforded one health care organization in southeast Wisconsin an internal,
real-time measure of patient expectation and patient satisfaction and illuminating
opportunities for improvement. Additionally, this study adds to the existing body of
knowledge on patient expectations, patient satisfaction, and prior experiences with health
care services. Implications for professional practice in the health care industry related to the
study findings align with understanding patient expectations, improving patient satisfaction,
improving patient outcomes, and supporting financial stability of health care organizations.
Health care organizations receiving Medicare payments must meet thresholds

established by the U.S. federal government as outlined in the VBP program for full
reimbursement. The intent of the program was to increase value, improve quality, and
improve patient satisfaction (USDHS, 2011a). A portion of the reimbursement reflects
the level of patient satisfaction with services provided to the patient. Because of this
measure, health care organizations are learning to refocus efforts on patient satisfaction.
The findings of this study are specific to the relationship between patient expectations
and patient satisfaction. Given the specificity, the findings apply to future practices
within the health care industry to improve patient satisfaction scores. Improving patient
satisfaction scores ensure full reimbursement and support financial success for health
care organizations.
126
Best practices in the health care industry may change based on increasing the
level of understanding regarding assessing patients expectations as a means to improving
patient satisfaction. An analysis of the results of this study included a finding of a
positive correlation between patient expectations and patient satisfaction. Health care
providers can establish individual priorities as defined through patient expectations by
including an assessment of patients expectations prior to delivering services. In order to
meet expectations, the health care providers must know what the expectations are for each
patient. Health care practice change could include adding one or two questions related to
expectations to the assessment phase of care. The addition of the questions allows for an
accurate understanding of individual expectations. Once providers define patients
expectations through individual assessment, individualizing the care to meet the identified
expectations is the next step.
Individualized patient care is an essential feature of patient-centered care. Patientcentered care has shown to improve patient satisfaction as well as improving the quality of
care and outcomes through improved communication (Cliff, 2012a; Hudon et al., 2011;
Pelzang, 2010; Poochikian-Sarkissian et al., 2010). In fact, Suhonen et al. (2012)

suggested a positive relationship between individualized nursing care and patient
satisfaction was a predictor of patient satisfaction. Hence individualizing care through
assessing patients expectations, communicating clearly about such expectations, and then
individualizing care to meeting those expectations can factor into better overall outcomes by
increasing the level of patient-centered care.
127
The two primary providers of care are physicians and nurses with both
professions affecting patient satisfaction in varied degrees. The findings from this study
indicated the doctors and the nursing staff had similar correlations to overall patient
satisfaction. Though both professions impact the patient experience, Bjertnaes et al.
(2012) posited that nursing care and meeting patients expectations were more powerful
predictors of overall patient satisfaction than doctors services. The results of this study
indicated patients scored the nursing staff higher than the doctors in the areas of asking
about expectations, communication, listening, and skill although the doctors scores were
high overall with the exception of asking about expectations in which the nursing score
was low, as well. Interestingly, Lpez, Detz, Ratanawongsa, and Sarkar (2012) reported
patient satisfaction with care providers suffers influences by accessory staff, access, and
convenience; therefore, patient satisfaction improvement must encompass numerous
factors beyond care provider assessments and behaviors.
In summary, the findings from this study could impact professional practice
through an increase in knowledge about the influence patients expectations and previous
patient experiences have on patient satisfaction. By recognizing the influence and
designing care and services to reflect patients expectations, financial stability can occur
through maximum reimbursement, as patient satisfaction improves. Additionally, the
application of individualized care as an element of a patient-centered approach can lead
to improved quality of care and improved outcomes. Improved quality of care evidenced
by improved outcomes is the central implication for the following section.
128
Implications for Social Change
Social change can occur on an individual level, organizational level, and
community level. The results of this study apply broadly to each of the aforementioned
levels. On the individual level, the results of this study support individualizing care
through recognition and realization of patients expectations. Individualized care is a
basic element of patient-centered care. When care providers take the time to assess
individual expectations and adjust care accordingly, patients benefit from services
tailored to their needs. This study identified a positive correlation between patient
expectations and patient satisfaction; therefore, meeting expectations appears to improve
patient satisfaction. Satisfied patients tend to comply with physician recommendations at
a higher degree (Omondi et al., 2011). Increased compliance leads to improved quality
of care and better outcomes. Accordingly, better outcomes lead to a better quality of life
for patients.
At the organizational level, the findings of this study support a need to recognize
the importance patients expectations and previous patient experiences have on patient
satisfaction. The results of this study indicated patient satisfaction has a positive
relationship with patient expectations and previous experiences. Reimbursement depends
on high patient satisfaction scores (USDHS, 2011c). Therefore, organizational leaders
must build strategies to secure financial stability that focus on patient satisfaction
improvements. Moreover, organizational leaders can affect patient outcomes through
practice changes aligned with meeting individual expectations as meeting patients
expectations can lead to improved outcomes (Manary et al., 2013). Health care
129
organizations benefit financially when satisfied consumers return for services.
Additionally, satisfied consumers share positive experiences with others in the
community. Positive comments may influence where other consumers choose to receive
care in the future; therefore, improving satisfaction can serve as a referral base for the
organization, which supports financial stability for the organization. Maintaining
financial stability ensures health care organizations continue providing needed health care
services for the community.
A community may experience positive social change through improved clinical
outcomes for the general population. For example, if an organization implements
strategies to increase patient-centered care through individualization, patients may feel
more satisfied with the improved experience and follow the health care recommendations
with a resultant improvement in health. Improved outcomes through improved
satisfaction can lead to cost savings for the health care organization and the individual,
which reflects positive resource management for both the organization and individual.
Moreover, health care organizations can prove to be a valuable community partners
through service improvements that lead to better health outcomes while sustaining a
positive influence on the health of a community.
Recommendations for Action
Researchers provide new or supportive information to the body of knowledge through
research studies. This study provides information that assists health care leaders in the
evaluation of current patient satisfaction strategies related to patient expectations. I present
recommendations for action for health care leaders in the following section.
130
The finding of a positive relationship between patient expectations and patient
satisfaction leads to the following recommendations. One action item is to evaluate if current
practices include assessment of individual patient expectations. If health care providers do
not inquire about patient expectations, I would recommend adding a question to the
assessment tool used at the beginning of care. For example, health care providers could ask a
question such as, What are your expectations for your care today? Asking a question about
expectations allows the patient to identify what is essential to the patient for that day. The
care for the day should include meeting the identified priority expectation if possible. If the
care providers cannot meet the expectation, then education as to other potential options
should ensue. Including the patient, through assessment and planning, is a patient centric
approach and patient-centered care leads to improved satisfaction.
A second recommendation aligns with the identified relationship between previous
hospital experiences and current satisfaction. I would recommend investigating previous
hospital experiences through an addition of a question in the assessment phase of care. An
example of a question might be, What information would you like me to know about previous
hospital experiences? Questions should be open ended to encourage interaction. Follow up
to mitigate negative perceptions about the current services should include individualized
attention to identified issues.
Health care leaders and health care providers should reflect on the findings of this
study. Leaders can focus on strategies for the organization, whereas health care providers at
the patient contact level need to address practices and behaviors that may improve patient
satisfaction. I will share the results of this study with the host hospital leaders providing
insight into the host hospitals patient responses to the survey questions. At the time of this
131
study in 2013, the host hospitals strategies included efforts toward improving the patient and
family experience and patient satisfaction. The host hospital leaders may find support in the
study findings for existing initiatives and may consider implementing supplementary
elements based on the results of this study.
Further options for use of the study results include professional conferences related to
patient experience, patient satisfaction, or patient-centered care. Health care providers
including physicians and nurses may find the information enlightening for the clinical setting
practice; therefore, another option for sharing study information is through submission and
publication in professional publications. Finally, elements of the study fit well in customer
service training for health care providers highlighting opportunities to identify and meet
patients expectations and inquire about previous health care experiences. The
recommendations for action presented in this section should encourage health care leaders to
take a closer look at current patient satisfaction efforts. Specifically, evaluation of the
processes used to elicit patients expectations seems critical to efforts intended to improve
patient satisfaction. Recommendations for additional study opportunities that can provide
added support for the existing body of knowledge follow.
Recommendations for Further Study

Previous research on patient satisfaction focused on factors other than patient
expectations (Adler et al., 2010; Dehghan et al., 2012; Kennedy et al., 2011; Omondi et al.,
2011; Polikandrioti & Ntokou, 2011; Welch, 2010). Because research on patient
expectations is somewhat limited, numerous opportunities for further studies exist. This
study examined the relationship between patient expectations and patient satisfaction thereby
132
adding to the limited body of knowledge on patient expectations; however, I provide
additional recommendations for further study in this section.
A positive correlation between expectations and satisfaction existed; however, the
findings reflected hospitalized patients with various disease states and various treatments.
Future research might explore additional individual expectations related to disease processes
or health related procedures that affect patient satisfaction. Health care organizations offer
numerous types of services. With each service, the potential exists for variation in patients
expectations. Therefore, additional research for the various services could lead to a deeper
understanding of expectations numerous levels of care. The value of defining expectations
specific to individual disease treatments or procedures assists health care organizations
striving to individualize care through meeting individual expectations. An opportunity for
further research also exists in the area of qualitative studies. Using a qualitative approach
allows research participants to engage in personal reflections about patient expectations in a
unique manner; whereas, a quantitative approach displays results in only a numerical manner.
Research lacks in the areas of subpopulations of age-specific patients although

some literature exists on gender (Stenberg, Fjellman-Wiklund, & Ahlgren, 2012). This
study only had one age criteria that the patients needed to be older than 18 years of age.
With only one criterion related to age, this study did not add to the literature on patient
expectations or satisfaction of any certain age group. Future research may include studies
based on identified age groups. Another research area of opportunity exists in the
differences between race and ethnicity and patient satisfaction as expectations could vary
within these groups. Finally, longitudinal studies related to the continuity of care may
prove useful as the population ages and advances in medicine continue to occur. The
133
aging population deals with chronic conditions and continuity of care for this population
may be a key factor in patient satisfaction. Limited research on chronic conditions exists
(Carlin, Christianson, Keenan, & Finch, 2012); however, as people live longer,
understanding the expectations of individuals managing chronic conditions could prove
beneficial to health care organizations developing of services tailored to chronically ill
patients.
Patient expectation assessment tools vary in scope of intent and types of questions.
The survey tool used in this study was a new tool; therefore, further research replicating this
study could lead to further validation of this original survey tool. Additionally, applying the
tool from this study to a larger sample size could support the findings of this study on a larger
scale. A possible alteration to my study tool aimed at decreasing bias of patients giving
survey information while still receiving treatment includes the use of reverse questions. The
addition of reverse questions prevents the likelihood of false perfect scores. For example, a
reverse set of questions is The nurse showed genuine concern and The nurse did not show
genuine concern. Finally, the sample size of this study was 90 and is relatively small when
compared to some larger studies with sample sizes greater than 1,000; however, the findings
of this study were significant at the .01 level (Bjertnaes et al., 2012; Carlin et al., 2012;
Fenten et al., 2012). Further research using sample sizes greater than this studys sample size
may prove useful when generalizing findings across other inpatient hospital populations as
generalization across populations proves questionable with small sample sizes.
The research findings from this study specifically address the relationship between
patient expectations and patient satisfaction. Although the findings provided meaningful
information for health care leaders and provided additional information for the current body
134
of knowledge, further opportunities for future studies exist. Researchers interested in the
topics of patient expectations and patient satisfaction can choose from the numerous
recommendations in this section when deciding on potential research options.
Reflections
Personal reflection of the research experience led to the evolution of two themes.
The first was my effect on the participants, and the second was personal biases and
preconceived ideas about patient expectations and patient satisfaction. A review of each
thematic area led to identification of new perspectives as well as personal and
professional growth.
An initial assumption was that a job title would not lead to bias in the study;
however, by the end of the data collection period it appeared there was potential to
influence the participants. Though the results are reflective of the majority of the
patients genuine perceptions, some patients behaved in a manner that caused concern.
These patients seemed as if they wanted to please me versus indicating any concerns
about the care through less than perfect survey scores. Behaviors intending to please
others may not reflect genuine perceptions; therefore injecting bias into the study.
Surveying patients while they are still in the hospital receiving care and treatment
proved a limitation of the study. Intuitively, some patients may feel a sense of concern
about future care if they express negative comments about the recent care. A more
optimal option could be surveying patients post-treatment. Additionally, some patients
seemed surprised that the Vice President of Patient and Family Experience took the time
to talk to them as they placed a high value on the role in the organization. Consequently,
135
such interactions were concerning as these patients seemed to want to confirm that they
would mark high scores on the surveys. To mitigate this potential behavior, I included
language ensuring the patients that survey scores were confidential and also encouraged
them to be honest as accurate responses provided a clear understanding of the current
practices within the hospital.
Acknowledging personal bias based on preconceived ideas about patient
expectations and patient satisfaction directed new insights. Patient experience is the
cornerstone of my current and previous professional roles since 2010. At the culmination
of this study, the discovery was that even with a strong foundation; there is a significant
amount of learning yet to achieve. An example of a preconceived idea was the belief that
there would be differences between the units as differences exist on a daily basis in the
patient satisfaction data reviewed in the host hospital patient experience position;
however, the study indicated a lack of significance in this area. Granted, the differences
noted on a daily basis may be at the micro level because of the nature of the work while
this study generalized on a broader scale using a different survey tool. Regardless, the
assumption did not hold true, at least with this study, leading to a challenge to continue to
inquire beyond current belief. Seemingly, this doctoral process improved my scholarly
inquiry about patient expectations and patient satisfaction.
Summary and Study Conclusions
Section 3 contains detailed information about the quantitative correlational design
study focused on the relationship between patient expectations and patient satisfaction.
Data collected reflected responses to a 20-question survey from 90 hospitalized patients
136
in southeast Wisconsin and answered the research questions and hypotheses. The
research questions and hypotheses centered on two topics. The first was the existence of
a relationship between patient expectations and patient satisfaction. The second central
topic focused on differences between the medical, surgical, and cardiac units.
Patients deserve exceptional care and a positive health care experience. Health
care leaders and providers strive to deliver exceptional care; however, the road to
excellence is complex and unique for each patient. Understanding individual
expectations is a key element of an exceptional experience resulting in high satisfaction
scores. Correlation testing illuminated a moderate to strong correlation between patient
expectations and patient satisfaction. Equally important, was a noted correlation between
previous hospital experiences and patient satisfaction. Recommendations based on the
study results emphasize the need to assess individual expectations and previous
experiences as a means to improve overall patient satisfaction. An individualized
approach to care supports a move to patient centric services, which can positively
influence patient outcomes.
Health care organizational leaders must implement strategies aimed at
maintaining financial viability. A portion of Medicare reimbursement for these
organizations depends on meeting patient satisfaction metrics defined by the U.S. federal
government. The findings of this study illustrated a relationship between patient
expectations and patient satisfaction. Consequently, health care leaders may want to
consider evaluating current practices related to patient expectation identification if patient
satisfaction scores are low to increase the potential of maximum Medicare
137
reimbursement. Understanding patients expectations makes it more likely that health
care providers could meet the expectations; thereby, positively affecting patient
satisfaction and positively affecting financial viability.
Even more crucial, health care leaders can engage in providing services that may
support social change through improved patient outcomes. Health care leaders can
positively influence patient outcomes by addressing the need to assess for individual
expectations. An additional opportunity exists for inquiry about previous hospital
experiences as a means to improving patient satisfaction. An improved patient outcome
was a primary goal of VBP and ultimately, improved patient outcomes are a goal of
health care organizations. This study concentrated on the relationship between meeting
patients expectations, previous hospital experiences, and patient satisfaction providing
valuable insight into the perceptions of health care consumers. Health care leaders
should view the results of this study as an impetus for evaluating current practices around
garnering information about patients expectations and identify opportunities to leverage
patient expectation information to bolster patient satisfaction scores.
138
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Appendix A: Becker Inquiry of Patient Expectations as Predictors for Patient Satisfaction
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Appendix B: Pilot Consent Form
PILOT CONSENT FORM
You are invited to take part in a research study that looks at the link between what
patients expect from hospital care and how happy they are with this care. I am asking patients
older than 18 years of age and who have stayed at least one night in the hospital. This form is
part of a process called informed consent to allow you to hear about this study before you
would decide whether to take part.
This study is being conducted by a researcher named Julie Becker, who is a doctoral student at
Walden University. Walden Universitys approval number for this study is 07-15-13-0297192
and it expires July 14, 2014. You may already know Julie as the Vice President of Patient and
Family Experience, but this study is different from that role.
Background Information:
The purpose of this study is to look at the link between what patients expect of health care while
in the hospital and how happy they are with the care.
Procedures:
If you agree to be in this study, you will be asked to:
x Complete a 20-question, one page paper survey.
x You would complete the survey in your room.
x The survey will take approximately 10 minutes to finish.
x Your identity will be protected.
x After you take the survey, I will ask the following questions about the survey event:
1.
2.
3.
4.
5.
Was the survey easy to understand?

Were there any questions you had trouble answering?
Did the amount of time required to take the survey seem reasonable?
Was the time of day appropriate for this activity?
Did you have enough choices for your answers?
Here are some sample questions:

Your expectations for privacy were met during the admission process.
The doctors asked about your expectations for your hospital stay.
The nursing staff asked about your expectations for your hospital stay.
Voluntary Nature of the Study:
This study is voluntary. Everyone will respect your decision of whether or not you choose to be in
the study. No one at Wheaton Franciscan Healthcare All Saints will treat you differently if you
decide not to be in the study. If you decide to join the study now, you can still change your mind
later. You may stop at any time.
158
Risks and Benefits of Being in the Study:
Being in this type of study involves some risk of the minor worries that can be happen in daily
life, such as stress or being upset. Being in this study would not pose risk to your safety or
comfort.
The benefits may include giving us useful information about patient expectations and patient
satisfaction and using the survey to voice your opinions about the care you are receiving in the
hospital.
Payment:
There is not any incentive payment for participating in the study.
Privacy:
Any information you provide will be kept confidential. The researcher will not use your
information for any reason outside of this project. Also, the researcher will not include your name
or other items that could identify you in the study reports. Data will be kept secure in a locked
private file drawer and on a password protected personal computer. Data will be kept for a period
of at least 5 years, as required by the university. If you would like a summary of the study
results, please use the researchers contact information below to request a copy.
Contacts and Questions:
You may ask any questions you have now. Or if you have questions later, you may contact the
researcher via juliea.becker@wfhc.org or by phone @ 262-687-3834. If you have any questions
or concerns regarding your rights as a subject, you are encouraged to contact the Wheaton
Franciscan Healthcare Human Research Protection Program at 414-465-3134. You may also
contact this office in writing or in person at Wheaton Franciscan Healthcare IRB, 400 W. River
Woods Parkway, Milwaukee, WI 53212.
The researcher will give you a copy of this form to keep.
Statement of Consent:
I have read the above information and I feel I understand the study well enough to make a
decision about my involvement. To protect your privacy, I will not ask for a consent signature.
Instead your return of the finished survey would be your consent, if you choose to be in the study.
159
Appendix C: Consent Form
CONSENT FORM
You are invited to take part in a research study to examine the relationship between
patient expectations and patient satisfaction. The researcher is inviting patients to be in the study
that are over the age of 18 years old and experiencing at least one night in the hospital. This
form is part of a process called informed consent to allow you to hear about this study before
you would decide whether to take part.
This study is being conducted by a researcher named Julie Becker, who is a doctoral student at
Walden University. Walden Universitys approval number for this study is 07-15-13-0297192
and it expires July 14, 2014. You may already know Julie as the Vice President of Patient and
Family Experience, but this study is different from that role.
Background Information:
The purpose of this study is to examine the relationship between patient expectations of the health
care received while in the hospital and patient satisfaction with the care received while in the
hospital.
Procedures:
If you agree to be in this study, you will be asked to:
x Complete a 20-question, one page paper survey.
x The survey is completed in your patient room.
x The survey will take approximately 10 minutes to finish.
x Your identity will be protected.
Here are some sample questions:
Your expectations for privacy were met during the admission process.
The doctors asked about your expectations for your hospital stay.
The nursing staff asked about your expectations for your hospital stay.
Voluntary Nature of the Study:
This study is voluntary. Everyone will respect your decision of whether or not you choose to be in
the study. No one at Wheaton Franciscan Healthcare All Saints will treat you differently if you
decide not to be in the study. If you decide to join the study now, you can still change your mind
later. You may stop at any time.
Risks and Benefits of Being in the Study:
Being in this type of study involves some risk of the minor discomforts that can be encountered in
daily life, such as stress or becoming upset. Being in this study would not pose risk to your safety
or wellbeing.
160
The potential benefits may include providing useful information about patient expectations and
patient satisfaction and using the survey to voice your opinions about the care you are receiving
in the hospital.
Payment:
There is not any incentive payment for participating in the study.
Privacy:
Any information you provide will be kept confidential. The researcher will not use your
information for any reason outside of this project. Also, the researcher will not include your name
or anything else that could identify you in the study reports. Data will be kept secure by keeping
all study materials in a locked private file drawer and on a password protected personal computer.
Data will be kept for a period of at least 5 years, as required by the university. If you would like a
summary of the study results, please use the researchers contact information below to request a
copy.
Contacts and Questions:
You may ask any questions you have now. Or if you have questions later, you may contact the
researcher via juliea.becker@wfhc.org or by phone @ 262-687-3834. If you have any questions
or concerns regarding your rights as a subject, you are encouraged to contact the Wheaton
Franciscan Healthcare Human Research Protection Program at 414-465-3134. You may also
contact this office in writing or in person at Wheaton Franciscan Healthcare IRB, 400 W. River
Woods Parkway, Milwaukee, WI 53212..
The researcher will give you a copy of this form to keep.
Statement of Consent:
I have read the above information and I feel I understand the study well enough to make a
decision about my involvement. To protect your privacy, I will not ask for a consent signature.
Instead your return of the finished survey would be your consent, if you choose to be in the study.
161
Appendix D: National Institutes of Health Certificate
162
Appendix E: Sample Excel Spreadsheet
D
W
W
W
W
W
W
W
W
Wd
W^
W^
W^
W^
W^
W^d
Z
Z
Z
Z
Z
Z
Z
Zd
D
D

^
^
^

163
Appendix F: Histogram for Patient Expectation
164
Appendix G: Histogram for Patient Satisfaction
165
Appendix H: Histogram for Relationship Between Patient Expectation and Patient
Satisfaction
166
Appendix I: Comparative Box Plot Patient Expectation
167
Appendix J: Comparative Box Plot Patient Satisfaction
168
Appendix K: Comparative Box Plot Relationship Between Patient Expectations and
169
Curriculum Vitae
Julie A. Becker
Education
Doctor of Business Administration 2013 (expected)
Leadership Specialization
Walden University, Minneapolis, MN
Masters of Business Administration 2011
Organizational Development
Upper Iowa University, Fayette, IA
Bachelor of Science 1998
Nursing
University of Wyoming, Laramie, WY
Associate of Science 1996
Nursing
Western Wyoming Community College, Rock Springs, WY
Professional Licensure
Wisconsin Board of Nursing, Registered Nurse
Professional Experience
Wheaton Franciscan Healthcare, Glendale, WI
Vice President Patient and Family Experience, 2013 to present
Wheaton Franciscan Healthcare, Glendale, WI
Director Patient and Family Relations, 2011 to 2013
Wheaton Franciscan Healthcare, Waterloo, IA
Patient Care Manager, 2002 2011
Nursing Facilitator, 2000-2002
Registered Nurse, 1999-2000
170
Castle Rock Convalescent Center, Green River, WY
Special Programs Coordinator, 1997 - 1999
Professional Affiliations
Beryl Institute
American Academy on Communication in Healthcare

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Walden University

College of Management and Technology

This is to certify that the doctoral study by

has been found to be complete and satisfactory in all respects,

Chief Academic Officer

MS, Upper Iowa University, 2011

Doctoral Study Submitted in Partial Fulfillment

Examining Relationships Between Hospital Inpatient Expectations and Satisfaction for

MS, Upper Iowa University, 2011

Doctoral Study Submitted in Partial Fulfillment

UMI Number: 3601243

All rights reserved

Summary of the Literature Review ....................................................................... 61

Presentation of the Findings.......................................................................................109

Appendix H: Histogram for Relationship Between Patient Expectation and Patient

Figure 1. Expectancy-value theory model and key components specific to patient

The literature review on the impact of patient expectations on patient satisfaction

Figure 2: Literature review organization for examination of patient expectations and

Figure 4. Relationship between meeting patient expectations and patient satisfaction.

Relating Findings to Available Literature

Health care organizations receiving Medicare payments must meet thresholds

Pelzang, 2010; Poochikian-Sarkissian et al., 2010). In fact, Suhonen et al. (2012)

Recommendations for Further Study

Research lacks in the areas of subpopulations of age-specific patients although

Data collected reflected responses to a 20-question survey from 90 hospitalized patients

Was the survey easy to understand?

Here are some sample questions:

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