Effect of patient-related factors on hospitalization service satisfaction and recommendation intention of medical institutions in Korea

The patient satisfaction emerged around 1980, as part of realizing customer-centered values in the health care sector worldwide. Until the 1980s, the medical field was dominated by doctors' specialized knowledge and authority, and there was a lack of interest in the emotions and psychology of patients. However, as hospital management professionals emerged in the United States in 1980, customer satisfaction, which is considered a core value in the general service industry, has also established itself in the medical industry [1]. In addition, Donabedian presented the concepts of structure, process, and performance for medical quality evaluation and suggested various methods to measure it [2], which established a "patient satisfaction survey" that subjectively evaluates patients' medical use services.

There are various factors that affect the satisfaction of patients using medical institutions. In general, medical technology for treatment and surgery, communication with medical personnel, and medical institution facilities are representative. On the other hand, patients who are satisfied with the service will be highly loyal to the medical institution, revisit the same medical institution, and recommend hospitals to others [3].

The most fundamental thing that can increase patient satisfaction is to provide patient-centered medical services. The Institute of Medicine (IOM) defines Patient-Centeredness as “a partnership between physicians and patients to ensure that decisions respect patients' wants, needs, and preferences and that patients are adequately educated and supported to make decisions and participate in their own care” [4, 5]. And the Agency for Healthcare Research and Quality (AHRQ) in the United States measures patient experience in a standardized framework from 1995 through the Consumer Assessment of Healthcare Providers and Systems (CAHPS) program (https://​www.​cms.​gov/​research-statistics-data-and-systems/​research/​cahps). The United States is currently using CAHPS surveys for pay-for-performance programs [6]. Specifically, the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is a tool to measure patients' perceptions of the hospital experience [7] and the survey results are regularly published on hospital comparison websites (http://​www.​medicare.​gov/​hospitalcompare/​search.​aspx). Through this, it is helping patient to choose a hospital, and medical service satisfaction surveys and evaluations have become very important socially. Furthermore, when patients are satisfied with the quality of medical services they have experienced, it carries the meaning that it can lead to positive word-of-mouth recommendations among acquaintances, which can be considered as acts of customer loyalty [8].

In line with this trend, each medical institution is naturally increasing its efforts to measure patient experience [9]. And they are trying to implement person-centered care to improve patient experiences, health outcomes, efficacy and quality of care [10, 11]. For example, patient-reported experience measures are being used for regulation and/or certification in Canada, the Czech Republic, Denmark, France, and the United Kingdom [12‐14]. And the US uses this to determine the reimbursement of value-based payment systems [12, 15, 16]. Meanwhile, the OECD has recommended member countries to collect patient experience information. Since 2013, the OECD has included patient experience indicators in OECD Health Statistics, and most of countries have submitted patient experience survey data (https://​stats.​oecd.​org/​Index.​aspx?​ThemeTreeId=​9). This movement of the international community became the basis for strengthening patient participation in the provision of medical services and ensuring the quality of medical care. Along with international discussions, the Ministry of Health and Welfare of Korea recognized the importance of confirming patient experiences and introduced a medical service experience survey for all citizens in 2017 [17]. And, the evaluation results of HCAHPS, which are frequently cited in discussions about patient experience, are published on the website. It helps patient choose hospitals by presenting comparative values such as the most positive response rate (response with 9–10 points) (http://​www.​medicare.​gov/​hospitalcompare/​search.​aspx) [18], is called Top-box. Although the scale and level to measure satisfaction will vary, in the United States, the Top-box value is determined to be important for patient to choose hospitals.

This study intends to examine changes in overall satisfaction and recommendation intentions, which are outcome indicators that are expected to influence patients' choice of medical institutions. To this end, we would like to analyze the experience of medical services using raw data from 2019 to 2021, the most recent data among the medical service experience surveys in Korea, based on the Top-box model. The analysis results will be used as basic data for establishing patient-centered policies, contributing to provision of better medical services to patients.

According to the distribution of subjects in this study, there were fewer inpatients in 2021 compared to the 2019 and 2020 surveys. In 2021, the number of hospitalized patients is estimated to decrease due to COVID-19. Meanwhile, over the past three years, those in their 60 s or older accounted for more than 60% of inpatients, and those with chronic diseases accounted for more than 60%, confirming the need for medical care of the vulnerable.

According to the analysis results, the recommendation intention and overall satisfaction with the medical institution corresponding to the patient-related factors showed a high level of satisfaction (Top-box rating) for those who judged their health to be good and those who used single-person rooms. And participants who responded positively to their subjective health status rated the overall satisfaction with the medical institution higher. This suggests that individuals who have a positive perception of their health status tend to evaluate the quality of medical services more positively [28]. On the other hand, it is thought that the single-person room would lead to a positive experience of inpatients in terms of less noise in environmental aspects and protection of personal privacy. As for the intention to recommend the medical institution used, the non-wage workers, those living in rural are, those who thought their health was good, and those who used the single-person room showed a high level of satisfaction (Top-box rating).

In addition, those who used the integrated nursing care service showed a higher level of satisfaction and recommendation intention (Top-box rating) than those who did not use the nursing service. In Korea, the integrated nursing care service is innovative change. Until then, households suffered mental and economic burdens by caring for their families or hiring personal caregiver privately. In particular, most of those who hired a personal caregiver complained of a high burden on cost [29]. Among these, the newly settled integrated nursing care service system was a good opportunity to increase patient satisfaction in terms of both time and cost.

In both patient satisfaction and recommendation intention, patients admitted to single rooms had higher scores than multi-person rooms. Several previous studies have also shown that single-person rooms are superior in both patient satisfaction and quality of care compared to multi-person rooms [30‐32]. In Korea, patients prefer single rooms to multi-person rooms [33, 34], but in terms of bed composition and price burden, they are practically hospitalized in multi-person rooms. This is because hospital beds are operated mainly in multi-person rooms. In addition, since single-room room fees are not covered by health insurance, the patient must directly pay the entire hospital room fee unless there is a special reason (infectious disease and deathbed, etc.). The government and medical institutions should come up with bed policies that reflect consumers' preferences, such as reducing multi-person rooms and lowering the cost of single rooms.

Overall satisfaction with medical institutions and the intention to recommend them are representative performance indicators for medical institutions, and are very important items to be checked by medical institutions. In this study, overall satisfaction and recommendation intention were higher in the 2021 survey than in the 2019 survey. The reason for this increase in satisfaction may be the result of quality interventions based on previously measured results [35]. This can be seen as the result of medical institutions' efforts to create a patient-centered medical culture and provide medical services from the perspective of patients despite the risk of COVID-19. Of course, there should be long-term review and microscopic confirmation, but the government's institutional intervention, such as the expansion of patient experience evaluation (Government-led, starting from 2017), also contributed to the efforts of medical institutions.

The main efforts to increase satisfaction with the use of medical services are made by individual medical institutions, but it is the role of the government to create such an environment. This is why the World Health Organization (WHO) has suggested that improving responsiveness is a major goal of the health care system [36]. It is important to have an institutional infrastructure so that patients can have a good experience even in the non-medical aspect. The government should establish stewardship of health and medical policies, such as presenting a desirable image of medical provision. When the government and medical institutions work together, medical quality improvement activities can create synergy. When the government and medical institutions work together, health care quality improvement activities can create synergy.

On the other hand, this study has some limitations. First, the basic data of this analysis are mainly characteristics of patients, and the influence of characteristics of medical providers such as the size of medical institutions and medical subjects on patients was not included in the analysis. In particular, physical resources such as facilities and medical personnel, along with the size of medical institutions, can have a significant impact on the patient's experience, but this study did not reflect this. This is because this survey does not collect information from medical institutions. There is a tertiary hospital in Korea, which has modern facilities to meet the needs of various patients. It is regrettable that there is no such information in the questionnaire.

Second, from the consumer's point of view, the experience may vary depending on the initial level of expectation for the medical institution that was not reflected due to the lack of survey questions. In addition, it is difficult to judge the value of experience in a medical institution only by the area where the patient lives. Because it is easy to move to other regions due to the nature of Korea, patients often move to large cities including the Seoul metropolitan area for medical treatment unless it is a mild disease. Therefore, not only the area where the patient lives but also the location information of the medical institution must be presented to prove the validity of the conclusion that patients living in the countryside are highly satisfied. As such, there are no major variables that affect the experience, so there are constraints on interpretation.

Third, because it is a cross-sectional survey data (different subjects for each time point), not a longitudinal survey data (individual follow-up survey at intervals of time), satisfaction and recommendation intention that can be changed by environmental improvement and policy intervention could not be confirmed.

Despite the above limitations, the medical service experience survey used in this study is the only survey that can comprehensively confirm the medical experience in Korea. And with the advantage of being composed of a sample that can be representative of the whole country, it was possible to derive representative results on the factors affecting the overall satisfaction with hospitalization services and the intention to recommend medical institutions used.

This study examined the changes in overall satisfaction with medical institutions and recommendation intention for inpatients using the raw data of the Medical Service Experience Survey (2019–2021) in Korea. In addition, various influencing factors were analyzed from the patient's perspective. Between July 1, 2018 and June 30, 2021, people who used inpatient services were divided into three periods, and it was confirmed that overall satisfaction with medical institutions and intention to recommend them were higher in the 2021 survey than in 2019. Overall, it can be said that this is a positive result that the provision of patient-centered medical services has been gradually activated.

In this trend, the government should expand the patient-centered system and improve the positive experience and satisfaction of medical institutions. From a policy point of view, the number of inpatients per bed should be reduced, such as reducing beds in multi-person rooms. And it should be changed to a structure in which the state is responsible for nursing and nursing together. As a result, patients will be able to concentrate on treatment with a comfortable mind, and the quality of medical care will be improved.

At the same time, it is hoped that the contents of the medical service experience survey will be expanded to build various grounds that can lead the people-centered health care system.