What is new?
Key findings- •
There are few valid and reliable outcome measures assessing patient satisfaction with health care.
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The Short Assessment of Patient Satisfaction (SAPS) scale is a new instrument with initially demonstrated validity and reliability.
What this adds to what was known?- •
Based on a sound conceptual model of patient satisfaction, the SAPS scale meets several calls over the past 20 years for a modern, short generic measure of patient satisfaction.
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Initial validation tests suggested that it outperformed leading existing measures of patient satisfaction.
What is the implication and what should change now?- •
The SAPS scale needs to be tested in a variety of clinical settings.
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If validation studies support its psychometric properties, it will meet the need for a modern, psychometrically valid measure of patient satisfaction.
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It can be used in a wide variety of clinical settings in place of older instruments, which have known measurement problems.
During the past 30 years, the measurement of patient satisfaction has increased in popularity mainly owing to three changes in health care. First, the role of clinicians has changed from one of helping patients through their illness to one where the clinician is expected to either cure the patient or alleviate chronic symptoms. Second, the patient-centered care movement—which presents patients as consumers of health care—has changed the priority in health care from a belief in beneficence to autonomy and has led to patient views being taken into account during medical decision making. Third, patient perspectives are increasingly sought for inclusion in the monitoring of health care and the legitimizing of health policy [1], [2].
Despite this rise in the popularity of patient satisfaction assessment, there are conflicting definitions of it. The major patient satisfaction theories were all published during the 1980s; almost all research since then is based on these. Ware et al. [3] argued that patient satisfaction was a function of patients' subjective responses to experienced care mediated by personal preferences and expectations. Linder-Pelz [4] postulated that it was mediated by personal beliefs and values about care as well as prior expectations of the care. Fox and Storms [5] advocated that a person's orientation determined satisfaction; dissatisfaction occurred where there was transgression of the relationship between expectation and experience. Fitzpatrick and Hopkins [6] argued that expectations were socially mediated, reflecting the health goals of the patient and the extent to which illness and health care violated the patient's personal sense of self. Finally, Donabedian [7], [8] postulated that it was based on personal relationships within health care systems and health care outcomes from treatment, where these were mediated by the values of the patient. Consistent with this, subsequent research has shown that the dominant predictor appears to be the patient–practitioner relationship, mediated by expectations of this relationship, prior experiences, and health outcomes [9], [10].
The implication is that the construct of patient satisfaction covers all aspects of care quality, particularly the interpersonal processes. A review of the literature arising from these theories [1] revealed that although these theories have been operationalized in various ways, an overall inclusive model of patient satisfaction should cover the following key dimensions:
- 1.
Appropriate access to health services, including the environment within which treatment takes place and the level of care coordination [3], [5], [11], [12];
- 2.
The provision of health information [5], [8], [9], [11], [12], [13], [14];
- 3.
The relationship between the patient and health care staff, specifically empathy with the patient [3], [7], [9], [11], [12], [15], [16], [17], [18];
- 4.
Participation in making choices regarding health treatment, including the associated fears and sense of loss of control as well as the appropriate use of treatment therapies and medications [11], [19], [20], [21];
- 5.
Satisfaction with the treatment provided, that is, the technical quality of the care provided [3], [5], [11], [14], [18], [22];
- 6.
The effectiveness of treatment, including the extent to which treatment meets patient expectations of care and helps the patient in their daily life [3], [7], [9], [11], [12], [14]; and
- 7.
General satisfaction [23], [24].
Regarding assessing patient satisfaction, as this operationalized model implies, there is an obvious tension between condition-specific instruments, which cover just one or two of these dimensions and generic instruments, which cover all. Although condition-specific instruments are attractive, the limitations are that they may not be valid when used in other settings, with other conditions or provide estimates that are comparable. Generic instruments overcome these restrictions. Where their descriptive systems cover all the dimensions described previously, construct validity and generalizability may be claimed, although there may be a loss of discriminatory power in particular diseases or situations.
However, few generic instruments have been published to date for which adequate psychometric profiles are available, and there seems to be a general dissatisfaction with published instruments (especially in light of the fact that there are, literally, thousands of patient satisfaction measures available on the Internet). These judgments rest on the findings of review articles. Sitzia [25] reviewed the literature and found that just half of all reviewed articles reported any psychometric data; yet, 81% reported using a new patient satisfaction instrument and a further 10% reported modifying a previously existing instrument. Most of the instruments used had little evidence of reliability or validity; and of articles reporting a new instrument, 60% reported no psychometric data whatsoever. More recently, Hawthorne [1] reported similar findings; viz., that many studies reported patient satisfaction in a single sentence where it was offered as complimentary evidence of treatment success. Few articles reported the instruments used, their psychometric properties, or the actual results.
It is possible that this long-standing unsatisfactory situation is, in part, a function of available instruments. Available instruments may be culturally specific [26], [27], [28], they may be too long to be used in busy clinical or research settings [3], [29], they may be condition specific [30], [31], biased (eg, where there is over measurement of some dimensions and under measurement of others) [32], [33], or they may lack psychometric robustness in the sense that there is very little evidence supporting instrument validity or reliability [4], [28], [34]. Both the Sitzia and Hawthorne reports also suggested that there are no modern, generic patient satisfaction instruments that have been developed using contemporary psychometric practices, which are short and easy to use and for which robust psychometric data are available. In light of this situation, Hawthorne recommended the development of a short, valid, and reliable generic patient satisfaction instrument. Consistent with this call, this study reports the development of a new generic, short, valid, and reliable measure of patient satisfaction, the Short Assessment of Patient Satisfaction (SAPS) scale.
