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Hospital responsiveness and its effect on overall patient satisfaction: A cross-

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Article  in  International Journal of Health Care Quality Assurance · November 2017

DOI: 10.1108/IJHCQA-07-2016-0098

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IJHCQA
30,8
728
Received 1 July 2016
Revised 16 February 2017
Accepted 8 May 2017
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International Journal of Health
Care Quality Assurance
Vol. 30 No. 8, 2017
pp. 728-736
© Emerald Publishing Limited
0952-6862
DOI 10.1108/IJHCQA-07-2016-0098
The current issue and full text archive of this journal is available on Emerald Insight at:
www.emeraldinsight.com/0952-6862.htm
Hospital responsiveness and its
effect on overall patient
satisfaction
A cross-sectional study in Iran
Sadegh Ahmadi Kashkoli, Ehsan Zarei, Abbas Daneshkohan and
Soheila Khodakarim
School of Public Health, Shahid Beheshti University of Medical Sciences,
Tehran, Iran
Abstract
Purpose – Hospital responsiveness to the patient expectations of non-medical aspect of care can lead to
patient satisfaction. The purpose of this paper is to investigate the relationship between the eight dimensions
of responsiveness and overall patient satisfaction in public and private hospitals in Tehran, Iran.
Design/methodology/approach – This cross-sectional study was conducted in 2015. In all, 500 patients
were selected by the convenient sampling method from two public and three private hospitals.
All data were collected using a valid and reliable questionnaire consisted of 32 items to assess the
responsiveness of hospitals across eight dimensions and four items to assess the level of overall patient
satisfaction. Data analysis was performed using descriptive statistics and multivariate regression was
performed by SPSS 18.
Findings – The mean score of hospital responsiveness and patient satisfaction was 3.48 ± 0.69 and
3.54 ± 0.97 out of 5, respectively. Based on the regression analysis, around 65 percent of the variance in overall
satisfaction can be explained by dimensions of responsiveness. Seven independent variables had a positive
impact on patient satisfaction; the quality of basic amenities and respect for human dignity were the most
powerful factors influencing overall patient satisfaction.
Originality/value – Hospital responsiveness had a strong effect on overall patient satisfaction. Health care
facilities should consider including efforts to responsiveness improvement in their strategic plans. It is recommended
that patients should be involved in their treatment processes and have the right to choose their physician.
Keywords Patient satisfaction, Health system responsiveness, Non-medical aspect of care
Paper type Research paper
Introduction
The World Health Organization (WHO) evaluates the performance of health systems on three
main goals: improving health, fair financing and responsiveness (WHO, 2000). Responsiveness
of health systems pertains to one’s reasonable expectations of the non-medical aspects of health
care (Karami-Tanha and Fallah-Abadi, 2014); the way and the environment in which patients
are treated during their interaction with the health system (Valentine et al., 2015). Reasonable
expectations are the known and accepted principles, laws and standards of non-medical care
(Desilva and Valentine, 2000). The proposed model of responsiveness by WHO consists of eight
elements of non-medical aspects of health care; these falls into two important components:
(1) Respect for individuals (interpersonal): this includes maintaining patient dignity,
establishing clear communication (CO), upholding confidentiality of patient information
and autonomy of individuals and families to make decisions about their own health.
This study was conducted as a part of an MS thesis in the field of Health Services Management and
was conducted at the Shahid Beheshti University of Medical Sciences. The authors would like to thank
the directors and staff of Taleghani, Imam Hussein, Bahman, Iranshahr and Kian hospitals, for their
friendly cooperation in the implementation of this thesis.
 (2) Customer oriented (structural): this includes prompt attention (PA), access to social Hospital
support (ASS) networks during care, quality of basic amenities (BA) and choice of responsiveness
care provider (Murray and Frenk, 2000).
For patients, the responsiveness of the health system is an important component of their
overall experience while undergoing medical care. Patients understand and judge the
various aspects of their experiences throughout their time in a health care facility
(Adesanya et al., 2012). Successes in patient responsiveness can directly affect patient 729
welfare. Patient comfort is important and promotes and improves the overall health of
patients. Therefore, focusing on responsiveness is an important goal in health systems
(Gharai et al., 2013).
Patient expectations (medical or non-medical), as one of the important psychological
factors, are considered to influence their evaluation of care and satisfaction with the
treatment outcome (McKinley et al., 2002; Prudêncio et al., 2013; Yao et al., 2016). Patient
satisfaction is directly related to perceived performance and expectations (Sahoo et al.,
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2016). It is an effective response to the discrepancy between prior expectations and

perceived performance after consuming health services (Zarei et al., 2014). If the patient’s
experience of services inconsistent with his/her expectations, he/she will then be
dissatisfied (Zarei et al., 2015). In other words, unmet expectations could contribute to
dissatisfaction, which is likely to lead to poor compliance (Barlow et al., 2016; Yao et al.,
2016). However, if the received services meet the patient’s expectations, this will result in
his/her satisfaction (Zarei et al., 2015;Sahoo et al., 2016). Based on above, it is expected to
meet the reasonable expectations (responsiveness) of patients lead to their satisfaction.
Previous studies have documented the effect of responsiveness on patient satisfaction;
overall patient satisfaction is affected by the responsiveness of service providers (Bleich
et al., 2009; Messina et al., 2009; Faleh et al., 2015). Hospital responsiveness generally leads
to an increase in patient satisfaction with care providers, which in turn leads to an
increase in the utilization of health services (Naidu, 2009; Malhotra and Do, 2013).
Therefore, the hypothesis of study is as follows (Figure 1):
H1. Hospital responsiveness has a positive and direct effect on patient satisfaction.
Patient satisfaction has a direct and positive relationship with the number of admissions
and financial performance of hospitals; therefore, satisfying patients is a key component of a
hospital’s performance (Gharai et al., 2013). Satisfying patients is important, because
satisfied patients are more apt to comply with their physician’s orders than dissatisfied
patients, these patients recommend their hospitals to others and hospitals with satisfied
patients experience fewer complaints than those with unhappy patients (Wu, 2011).
Studies have shown that patient satisfaction is one of the strongest predictors of a patient’s
willingness to re-use the services of a particular hospital (Kim et al., 2008; Naidu, 2009).
Patients are the main consumers of hospitals, and patient satisfaction could to some extent
reflect that hospitals are properly delivering services (Hajian, 2007).
Studies conducted in Iran have shown that the level of hospital responsiveness of Iranian
hospitals ranges from moderate to low (Ebrahimipour et al., 2013; Karami-Tanha and
Fallah-Abadi, 2014). Enhancing the level of health system responsiveness and patient
satisfaction in the Islamic Republic of Iran with an emphasis on human identity and with
special attention given to the spirituality, biological, psychological and social needs of
patients is important. According to a study conducted in Tehran, more than 90 percent of
respondents considered responsiveness to be a very important issue (Rashidian et al., 2011).
Satisfaction and responsiveness have not been widely studied in developing countries
(Faleh et al., 2015). To our knowledge, these studies are lacking in Iran. Although few
studies have been done on the relationship between hospital responsiveness and patient
 IJHCQA Dimensions of hospital responsiveness
30,8
Dignity

Communication

730
Confidentiality

Autonomy
Overall patient
satisfaction
Prompt attention
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Social support

Quality of basic
amenities

Figure 1. Choice of provider

The research model

satisfaction, but the evidence for patients’ expectation and satisfaction is still questionable,
which needs much more empirical investigation (Barlow et al., 2016; Yao et al., 2016).
Moreover, the relationship between responsiveness and patient satisfaction in previous
studies has been investigated as a whole, and according to some researchers,
responsiveness is a multidimensional variable (Mishima et al., 2016). Therefore, the
impact of each dimension of responsiveness on patient satisfaction needs to be investigated
separately. This will provide useful information for policy makers. The aim of this study is
to investigate the relationship between the eight dimensions of responsiveness and overall
patient satisfaction in public and private hospitals in Tehran, Iran.

Method
Study design
This study was conducted in 2015. In total, 460 patients were selected from five public
and private hospitals in Tehran: 300 patients from two public hospitals and 160 patients
from three private hospitals. Financial and time constraints allowed for patients from
only five hospitals were to be included in the study; the hospitals were randomly
selected. The sample size from each hospital was proportional to the number of beds
in each hospital.
A convenient sample method was used for this study. Patients were asked to fill out
the study questionnaire on the day of their discharge from the hospital. The aim of the
study was explained to the patients and they were assured of their confidentiality.
A trained interviewer helped illiterate patients to fill out the questionnaire.
The researchers interviewed all discharged patients consecutively until the required
sample size of each hospital was met. If a patient did not wish to take part in the study
they were replaced by another patient. To be included in this study, patients were required
to be at least 16 years of age, have stayed at least one day in the hospital and were willing
to participate in the study.
 Instrument Hospital
All the data were collected using a questionnaire. The first part of the questionnaire responsiveness
consisted of items relating to socio-demographic characteristics, while the second part
included 32 questions designed to assess the responsiveness of hospitals across the eight
dimensions: PA, CO, patient dignity (DI), autonomy (AU), confidentiality of patient
information (CON), choice of care provider (CH), quality of BA and ASS. The third part
consisted of four questions (q33-q36) to assess overall levels of patient satisfaction as 731
adapted from Choi et al. (2004).
The questionnaire was designed by WHO and its validity and reliability have been
verified. The questionnaire has been translated and used in Iran before, and therefore, the
Farsi version of the questionnaire was already available. Cronbach’s α coefficient was used
to assess the reliability of the questionnaire. The coefficient for responsiveness and overall
satisfaction was 0.949 and 0.926, respectively, which indicates the questionnaire was stable
and reliable. To assess the perceived level of responsiveness and overall satisfaction, the
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Likert scale (where 1 ¼ strongly disagree and 5 ¼ strongly agree) was used. The mean score
of responsiveness was calculated by the sum of all items divided by 32 and the mean score
for overall satisfaction was divided by 4.

Data analysis
Data analysis was performed using descriptive statistics and multivariate regression was
performed using SPSS Statistics, V19.0 software (IBM Corporation). Linear regression was
used for assessing the relative importance of each aspect of responsiveness in predicting
levels of patient satisfaction. The purpose of this analysis was to examine the relationship
between the dependent variable (overall satisfaction) with the independent variables of this
study (aspects of responsiveness and demographic variables).

Findings
The mean age of patients was 47.7 ± 18.2 years. About 51 percent of patients (235 cases) were
female, the average length of stay was 6.7 ± 3.8 days. The detailed profile is given in Table I.
The mean scores of the eight dimensions of responsiveness varied from 3.0 (choice of
provider) to 3.76 (quality of BA) (Table II). The average score of hospital responsiveness was
3.48 ± 0.69 out of 5. Similarly, the mean score of the four items pertaining to overall satisfaction
varied from 3.26 (S4 – hospital services being ideal) to 3.75 (S1 – being satisfied with the services
in general); the average score of overall satisfaction was 3.54 ± 0.97 out of 5 (Table III).
Based on the regression analysis, the model was found to be statistically significant
(F ¼ 95.55, po0.001) and the value of adjusted R2 was 0.649; thus, around 65 percent of the

Demographic group Demographic sub-group Number Percent

Type of hospital Public 300 65

Private 160 35
Gender Male 225 49
Female 235 51
Educational qualification Under-graduate and below 321 70
Graduate and above 139 30
Insurance coverage Yes 430 93
No 30 7
Health status at discharge Excellent 36 8 Table I.
Good 199 43 Demographic profile
Moderate 185 40 of patients in
Bad 40 9 the sample
 IJHCQA variance in overall satisfaction can be explained by aspects of responsiveness (Table IV).
30,8 This indicates that the predictive power of the study’s model was strong. In our model, seven
independent variables had a positive impact on patient satisfaction and our hypothesis was
accepted. A one unit increase in the quality of BA yielded an increase of 0.33 in overall patient
satisfaction, 0.32 for dignity, 0.19 for CO, 0.17 for PA, 0.08 for autonomy, and 0.07 for the
choice of the health care provider. Based on these findings, the quality of BA and respect for
732 human dignity were the most powerful factors influencing overall patient satisfaction.
A patient’s access to a social support network and patient confidentiality did not significantly
affect the level of patient satisfaction with their health care facility. Among the demographic
variables, the type of hospital ownership had a significant effect on patient satisfaction as
patients in private hospitals were more satisfied than patients admitted to public hospitals.

Discussion and conclusion

This study was conducted to investigate the effects of responsiveness on overall patient
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satisfaction at selected hospitals in Tehran, Iran. Based on Cohen’s recommendations, any

Dimensions Mean ± SD

Prompt attention 3.28 ± 0.77

Clear communication 3.39 ± 0.86
Patient dignity 3.66 ± 0.74
Autonomy 3.31 ± 0.98
Confidentiality of patient information 3.48 ± 0.99
Table II. Choice of care provider 3.00 ± 1.06
Mean scores of Access to social support 3.75 ± 0.98
hospital Quality of basic amenities 3.76 ± 0.86
responsiveness Hospital responsiveness 3.48 ± 0.69

Items Mean ± SD

S1. Generally you are satisfied with the hospital and its services 3.75 ± 0.98
S2. This hospital and its services, to meet your needs 3.65 ± 1.00
Table III. S3. This was the hospital and its services meet your expectations 3.51 ± 1.06
Mean scores of overall S4. This hospital and its services are ideal for a hospital that is in your mind, was near 3.26 ± 1.21
patient satisfaction Overall satisfaction 3.54 ± 0.97

Statistics
Variables B SE p-value

Type of hospital (public*) −0.13 0.06 0.03

Prompt attention 0.17 0.04 o0.001
Clear communication 0.19 0.05 0.001
Patient dignity 0.32 0.06 o0.001
Autonomy 0.08 0.04 0.03
Table IV.
Choice of care provider 0.07 0.03 0.02
Regression analysis:
the impact of Quality of basic amenities 0.33 0.03 o0.001
responsiveness Confidentiality of patient information 0.01 0.04 0.80
dimensions on patient Access to social support −0.06 0.03 0.06
satisfaction Note: *Reference group: private hospital
 value more than 0.25 represents a large variance in the model (Cohen, 1988). This indicates that Hospital
our theoretical model was effective at explaining the relationship between responsiveness and responsiveness
overall patient satisfaction; this is consistent with the results of other studies conducted in the
European Union and Qatar (Bleich et al., 2009; Messina et al., 2009; Faleh et al., 2015).
Our findings suggest that responsiveness has a strong impact on overall satisfaction and that
patient satisfaction is affected by the type of hospital ownership, the ability of hospitals to give
patients PA, communication, dignity, autonomy, the ability to choose one’s health care provider 733
and quality of BA. Patients who were hospitalized at public hospitals were overall less satisfied
than those patients who were admitted to private hospitals. Varmaghani et al. (2012) also found
higher levels of satisfaction among patients in private hospitals compared to public hospitals.
Public hospitals are known for having high levels of customer dissatisfaction, long waiting
periods, poor and unclear communication and poor quality of services (Yaghoubi et al., 2011).
Thus, patients generally prefer private hospitals.
The quality of BA had the greatest effect on patient satisfaction, which is consistent with
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previous studies (Naidu, 2009; Sahoo et al., 2016). Danielsen et al. (2007) found a hospital’s
physical environment to be one of the most important factors influencing patient
satisfaction. Most medical care services are intangible in nature, while the first thing
customers receive are the tangible aspects of patient services that come from a hospital’s
physical environment. Therefore, it could be said that a patient’s first encounter with a
hospital is very important (Salehnia et al., 2013).
Respect of patient dignity had a positive impact on patient satisfaction. This parallels the
findings of other studies, which have shown that respecting the privacy and dignity of
patients is positively correlated with satisfaction of health services (Dadkhah et al., 2004;
Mobach, 2009). Respecting the dignity and privacy of patients is thought to improve one’s
sense of peace and security, while also quickening recovery times. Therefore, it is important
for medical and administrative staff to treat patients with respect.
CO was the third most important factor that affected patient satisfaction. Clear doctor-
patient communication leads to a more pleasant clinical experience and contributes to
accurate diagnoses and treatment compliance; CO influences patient satisfaction and is an
important consequence of the patient-doctor relationship (Zamani et al., 2004).
The relationship of patients with their doctors and nurses is the most important factor
affecting patient satisfaction with the health care system (Naidu, 2009; Mehra, 2016; Pai and
Chary, 2016). If a patient feels alienated, ignorance, uncertainty or ambiguity about the
consequences of their own health status, they might experience longer durations of
treatment and less satisfaction with the system as a result. In fact, when doctors spend more
time talking and communicating with patients, and promote a strong emotional and
personal relationship with them, patient satisfaction increases (Lin et al., 2010).
Receiving PA also had a positive effect on patient satisfaction. It is mentioned in the
literature that service promptness is one of the influencing factors on patient satisfaction
(Fahmi Khudair and Asif Raza, 2013). Patient waiting time is an important indicator of
patient satisfaction with the quality of health care they receive (Eldabi et al., 2002;
Mehra, 2016). Receiving an early diagnosis and treatment can decrease one’s length of time
in the hospital, therefore leading to an increase in patient satisfaction. Long waiting times
and a lack of immediate attention can contribute to a patient’s mistrust of the health system
before actual services are even received (Habibullah, 2012).
Patient autonomy and one’s right to choose their care provider resulted in a small
positive impact on patient satisfaction. Whelan et al. (2004) showed that the majority of
patients preferred to choose their own treatment and participated in the decision-making
process. Including patients in the decision-making process and respecting their rights
contributes to the acceleration of healing, reduction of hospitalization and treatment costs
and also increases patient satisfaction (Basiri Moghadam et al., 2011). Because of this,
 IJHCQA hospitals should pay more attention to executing a client-oriented approach, one that
30,8 involves patients in the discussion of their treatment options. Additionally, obtaining
permission and feedback from the patient and his/her family creates a sense of
self-involvement and increases patient satisfaction.
Patient confidentiality and patients having a social support system did not have a
significant impact on overall patient satisfaction; this contradicts the findings of previous
734 studies. For instance, Lin and Lin (2011) found a positive correlation between confidentiality
and patient satisfaction. One’s social network can also have an impact on one’s experience
with illness, treatment and outcome; having a social network is known to lead to a reduction
in deaths from chronic disease, faster recovery times, increased use of health care services
and patient satisfaction (Elal and Krespi, 1999). It appears that while confidentiality and
social support are important, they have little effect on patient satisfaction, but that having a
lack of these factors can result in dissatisfaction.
There were some limitations with this study. First, responsiveness and satisfaction are
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concepts associated with a patient’s rights and awareness of those rights. Therefore, a lack
of patient awareness regarding one’s rights might affect a patient’s assessment and
judgment of medical services provided to them. This lack of awareness generally leads to a
higher evaluation of reality. Second, a convenient sampling method was used in this study
and this might limit its applicability to other populations.

Conclusion
Hospital responsiveness had a strong effect on overall patient satisfaction. Hospitals should
not only focus on clinical aspects of care, but also consider including efforts to
responsiveness improvement in their strategic plans. Patient autonomy is an important
aspect of non-medical care, and the right to choose one’s care provider impacts overall
patient satisfaction. Hospitals should take actions to address these factors to increase their
patients’ levels of satisfaction. It is also recommended that patients should be involved in
their treatment processes and have the right to choose their physician.

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Corresponding author
Ehsan Zarei can be contacted at: zarei_1980@yahoo.com

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