WHAT ATTRIBUTES OF HEALTHCARE ARE THE MOST IMPORTANT TO IMPROVE PATIENT SATISFACTION IN LEBANESE PRIMARY CARE SETTINGS: THE CASE OF MOUNT LEBANON CLINIC

7/29/2019 WHAT ATTRIBUTES OF HEALTHCARE ARE THE MOST IMPORTANT TO IMPROVE PATIENT SATISFACTION IN LEBANESE PRIMARY CARE SETTINGS: TH

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GRENOBLE ECOLE DE MANAGEMENT

DOCTORAL SCHOOL

WHAT ATTRIBUTES OF HEALTHCARE ARE THE MOST IMPORTANT

TO IMPROVE PATIENT SATISFACTION IN LEBANESE PRIMARY

CARE SETTINGS: THE CASE OF MOUNT LEBANON CLINIC.

A thesis submitted in partial fulfillment of

the requirements for the degree of

Doctor of Business Administration

By

Karim Kobeissi

2012


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ACKNOWLEDGMENT

First and foremost, Id like to express my gratefulness to God, The Almighty, for giving me the

grace to accomplish this dream. All glory and adoration belongs to Him.

Id also like to show gratitude to my supervisor, Dr. Benoit AUBERT (Director of the Doctoral

School and of the Lebanese DBA program), for his invaluable contribution, guidance and useful

suggestions which kept me on track. He has been a great role model and friend.

Moreover, Id like to thanks Professor Jean-Jacques CHANARON (Associate Dean Scientific

Director Doctoral School at Grenoble Ecole de Management, France), Dr. Laurent TOURNOIS

and Dr. Franois DESMOULINS-LEBEAULT who were abundantly helpful.

I cannot end without thanking my wife Rania and our three children, on their constant sustain

and love. It is to them that I dedicate this work.

No one cares how much you know,

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until they know how much you care - Don Swartz.

Table of Contents

Table of Contents ............................................................................................................................4

List of Tables ................................................................................................................................... 6

List of Figures ................................................................................................................................. 7

ABSTRACT ..................................................................................................................................... 8

INTRODUCTION ........................................................................................................................ 10RESEARCH BACKGROUND ..........................................................................................................13

RESEARCH OBJECTIVES AND PERSPECTIVES ...................................................................... .15

................................................................................................................................................ .............15

DELIMITATION OF SCOPE ...........................................................................................................17

RESEARCH ORGANIZATION ........................................................................................................17

PART 1 - LITERATURE REVIEW .............................................................................................19

Introduction .........................................................................................................................................19

Chapter 1: Patient Satisfaction ....................................................................................................201. 1 Conceptualization of Satisfaction ........................................................................................ ..... ...22

1.2 Conceptualization of Patient Satisfaction ........................................................................... ..... ..45

1.3 Measurement of Patient Satisfaction ...........................................................................................58

1.4 Patient Satisfaction: Conclusion ......................................................................................... ..... .....64

Chapter 2: Drivers of Patient Satisfaction ...................................................................................66

2.1 Care Variables ...............................................................................................................................67

2.2 Patient Variables ...........................................................................................................................72

2.3 Drivers of Patient Satisfaction: Conclusion ................................................................................83

CONCLUSION LITERATURE REVIEW .......................................................................................84

PART 2: HYPOTHESES, METHODOLOGIES AND OUTCOMES ........................................88

Introduction .........................................................................................................................................88

Chapter 3: Research Model and Hypotheses ...............................................................................91

3.1 The Qualitative Pilot Study .......................................................................................................... .93

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3.2 Design of the Research Model ....................................................................................................109

3.3 Research Hypotheses .................................................................................................................. .116

3.4 Research Model and Hypotheses: Conclusion ...................................................................... ..123

Chapter 4: Methodologies & Outcomes .....................................................................................127

4.1 Characteristics of the Quantitative Study .................................................................................128

4.2 Measurement and Scaling ......................................................................................................... ..133

4.3 Scales Validation ..........................................................................................................................143

4.4 Testing the Hypotheses ............................................................................................................... .154

4.5 Methodologies and Outcomes: Conclusion .............................................................................. ..193

Chapter 5: Managerial Contributions ....................................................................................... 196

5.1 Direct Implications for Primary Care Providers ................................................. ..... ..... ..... ..... .197

5.2 A Holistic Process of Patient Satisfaction ..................................................................... ............202

5.3 Managerial Contributions: Conclusion ......................................................................................207

CONCLUSION HYPOTHESES, METHODOLOGIES AND OUTCOMES ...............................208

CONCLUSION ........................................................................................................................... 210

Glossary of Statistical and Technical Terms .............................................................................216

Appendix 1 .................................................................................................................................. 252

Appendix 2 .................................................................................................................................. 253

Appendix 3 .................................................................................................................................. 255

Appendix 4 .................................................................................................................................. 259

Appendix 5 .................................................................................................................................. 260

Appendix 6 .................................................................................................................................. 261

Appendix 7 .................................................................................................................................. 262

Appendix 8 .................................................................................................................................. 263

Appendix 9 .................................................................................................................................. 264

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List of Tables

Table 1: Conceptual & operational definitions of satisfaction...................................................24

Table 2: Differences between service quality & satisfaction......................................................42

Table 3: Differences between perceived value & satisfaction ....................................................44

Table 4: Key definitions of patient satisfaction that are considered as references in the

literature........................................................................................................................................49Table 5: Key definitions of healthcare quality that are considered as references in the

literature........................................................................................................................................55

Table 6: Meta analysis of patient satisfaction.............................................................................60

Table 7: Observed impact of socio-demographics variables on patient satisfaction............. ....78

Table 8: Overview of the Interviewees ........................................................................................97

Table 9: Definitions & Operationalization of the different variables, included in the research

model ..........................................................................................................................................114

Table 10: Hypotheses of the present study................................................................................124

Table 11: Measurement of formative scales..............................................................................140

Table 12: Measurement of patient satisfaction.........................................................................142

Table 13: Results of the first order confirmatory factor analysis (distributive justice)........ ...145

Table 14: Results of the first and second order confirmatory factor analysis (SERVPERF) 145

Table 15: Reliability of the distributive justice & SERVPERF scales....................................147

Table 16: Distributive Justice and SERVPERF models estimates...........................................150

Table 17: Strong evidence of convergent validity......................................................................151

Table 18: Multicollinearity of items measuring patient satisfaction with healthcare dimensions.....................................................................................................................................................152

Table 19: Multiple regression analysis results (All predictors)................................................158

Table 20: Items used for measuring the mediating variables of the model.............................164

Table 21: Regression results of service quality mediating the relationship between physician

care and patient satisfaction.......................................................................................................165

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Table 22: Regression results of distributive justice mediating the relationship between price of

care and patient satisfaction.......................................................................................................167

Table 23: Regression results testing the moderating effect of age...........................................171

Table 24: Regression results testing the moderation effect of income ....................................174

Table 25: Correlations between access to care and patient satisfaction for both groups........176

Table 26: Regression results of testing the moderating effect of gender.................................179

Table 27: Summary of hypotheses testing results.....................................................................183

Table 28: Classification of factors related to the physician care dimension along with their

impacts on patient satisfaction...................................................................................................186

Table 29: Classification of factors related to the price of care dimension along with their

impacts on patient satisfaction...................................................................................................187

Table 30: Classification of factors related to the access to care dimension along with their

impacts on patient satisfaction ..................................................................................................189

Table 31: Classification of factors related to the atmospherics of care dimension along with

their impacts on patient satisfaction .........................................................................................190

List of Figures

Figure 1: Organization of Part 1.................................................................................................20

Figure 2: Expectancy Disconfirmation Paradigm......................................................................34

Figure 3: Organization of Part 2.................................................................................................90

Figure 4: Research Model and the Hypotheses........................................................................123

Figure 5: Diagram of Reflective and Formative Measurement Models .................................138

Figure 6: An Unmediated Model...............................................................................................162

Figure 7: A Mediated Model......................................................................................................162

Figure 8: A Moderator Model....................................................................................................168

Figure 9: Plots of correlations between access to care and satisfaction for both groups... ....176

Figure 10: A Holistic Process of Patient Satisfaction...............................................................206

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ABSTRACT

Patients view about healthcare service delivery is a neglected subject in many developing

countries such as Lebanon. Patients are viewed as passive beneficiary of healthcare service with

muted voices. However, the patients perceptions of service quality and satisfaction with

healthcare services can assist management and policy makers in the design, implementation and

evaluation of services which in turn assist to better improve and deliver qualitative healthcare to

the populace. Thus, the present research study aims to contribute to the development of

knowledge on patient satisfaction. More specifically, it attempts to distinctivelyidentify the key

healthcare dimensions that impact patient satisfaction with primary care services in Lebanon.

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To achieve this goal, a literature review is conducted in order to provide an original

conceptualization of patient satisfaction and its drivers. Based on the literature review, an

exploratory qualitative study is undertaken to gain insight into specific influencing factors which

are incorporated into the conceptual satisfaction model. An original model is developed that

illustrates the effects of four influencing factors (physician care, price of care, access to care, and

atmospherics of care) on outpatient satisfaction and tested a set of hypotheses covering the

mediating and moderating effects.

In order to explore effects and to transfer gained knowledge into management guidelines the

empirical study is designed. The research is conducted at Mount Lebanon Clinic (which is the

property of the researchers family and a typical case of clinics in Lebanon) on a sample of 385

outpatients. Multiple regression analysis is used to test the hypotheses.

The results of this research are twofold. First, a model which details relationships between

influencing factors and patient satisfaction is proposed and validated in the Lebanese context.

Second, an advanced model of patient satisfaction is developed. It is designed to view patient

satisfaction more holistically and to provide guidelines for healthcare providers. The existence of

two mediating variables is unveiled: distributive justice and perceived healthcare quality. The

moderating role of age, income and gender is also examined.

Keywords: Customer Satisfaction, Patient Satisfaction, Healthcare Service Quality, and

Lebanon.

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------------------------------------------------------------------------------------------------

INTRODUCTION

------------------------------------------------------------------------------------------------

The strategy for patient satisfaction in healthcare service requires effective marketing plans,

policies, and practices to genuinely meet the needs of different strata of population

(MacAlexander, Becker, & Kaldenberg, 1993). This concept drew the attention of the service

providers since early 70s and the healthcare providers in advanced countries became conscious

of satisfying patients (Cooper, Maxilla, & Rhea, 1979; P. Kotler & Zaltman, 1970; Woodside &

Frey, 1989; Zaltman & Vertinsky, 1971). The major reasons that have necessitated a shift

towards marketing approach are competitive pressures, alternate healthcare delivery

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mechanisms, changing cost structures, monitoring by public and private groups, and a markedly

better-informed clientele (Andaleeb, 1988). The progress of service unit depends on the patient

satisfaction and service quality in all developing and developed countries (Cronin & Taylor,

1992). Accordingly, patient satisfaction is no longer simply the nice or right thing to do; it is the

only good business choice in the current highly competitive environment (Dingman, Williams,

Fosbinder, & Warnick, 1999).

Indeed, there are multiple returns from improving patient satisfaction:

For one, patient satisfaction is a profitable competitive tool because studies have shown that the

public is inclined to pay more for care from quality institutions which are better disposed to

satisfy customers needs (Boscarino, 1992; Hays, 1987). Also, Hospitals that are patient focused

have been able to enhance their images, which in turn translate into increased capacity utilization

and market share (Andaleeb, 1988; Gemme, 1997; Gregory, 1986). Moreover, it has been shown

that satisfied patients demonstrate greater compliance with their medical care than do dissatisfied

patients (Bell, Krivich, & Boyd, 1997). They spend less time in the hospital and have improved

outcomes that can result in cost savings to the healthcare facility. In addition, satisfied patients

tend to remain loyal to that particular facility and are likely to use the hospitals services again

(Atkins, Marshall, & Javalgi, 1996; Taylor, 1994).

In contrast, patient dissatisfaction can result in lost revenue (Bell, et al., 1997). For example,

negative word of mouth can occur (J. E. Howard, 2000). Dissatisfied patients often do not return

to the same hospital and will avoid using other services associated with that facility, such as

outpatient1 care, home care, or physician services (Press, 2002). Furthermore, dissatisfied

1 The technical terms used in this dissertation are precisely defined in the glossary at the end.

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customers tend to complain to the establishment or seek redress from it more often to relieve

cognitive dissonance and failed consumption experiences (Nyer, 1999). In fact, dissatisfaction

can have serious ramifications: patients are unlikely to follow treatment regimen (Bell, et al.,

1997) and may fail to show up for follow-up care (Kahan & Goodstadt, 1999). The level of

patient satisfaction affects contracts renewals between employers or managed care organizations

and healthcare providers. Zimmerman et al. found that when patient satisfaction ratings fell

below the expected standards, employers and managed care organizations failed to renew

contracts with 50 percent of healthcare organizations (Zimmerman, Zimmerman, & Lund, 1997).

Delivering patient satisfaction is imperative because todays buyers of healthcare services are

better educated and more aware than in the past (Vuori, 1991). These buyers carefully study and

monitor the options available to them; they are, therefore, more discerning buyers, knowing

exactly what they need. These changes are being driven by the abundance of information that is

available to them from public and private sources. According to Kurz and Heistand, customers

are relying less on doctors to choose the right hospital (Heistand, 1986; R.S. Kurz &

Wolinsky, 1985). Reflecting on the importance of the patients point of view, Petersen suggests

that: It really does not matter if the patient is right or wrong. What counts is how the patient felt

even though the caregivers perception of reality may be quite different (Petersen, 1988).

Medical settings that fail to understand the importance of delivering patient satisfaction may be

inviting possible extinction.

The abovementioned importance of patient satisfaction and the fact that no previous research

was conducted on outpatient satisfaction in the Lebanese context led us to address such a topic in

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the present thesis, even if its primary focus is not to compare Lebanon to other countries but to

add additional knowledge to the existing literature on patient satisfaction.

To specify the nature and the merit of this work, the background to the research is presented

hereafter. Especially, the role of patient satisfaction in modeling health related behaviour and

treatment outcomes is discussed. Then, the research question and objectives are presented and

their academic and managerial relevance are justified. Finally, the scope of this research is

delimitated and the research organization is presented.

RESEARCH BACKGROUND

The Nature of Healthcare Services

Healthcare is a people processing service which involves tangibles actions to patients bodies

(Lovelock, 2001). Healthcare services are by nature credence purchases (Butler, Oswald, &

Turner, 1996). Originally touted by Nelson, purchases may be classified as having search,

experiential and credence properties. Purchases high in search properties can be evaluated prior

to consumption by a consumer (P. Nelson, 1974). Zeithaml notes that these are mostly physical

goods such as furniture and automobiles. Purchases high in experience properties are more

difficult to evaluate prior to purchase because they must be consumed before assessment is

possible (e.g. restaurant meals, child care). At the extreme end of this continuum are purchases

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high in credence properties. These are the most difficult to evaluate prior to consumption

because the consumer may be either unaware or lack sufficient knowledge to appraise the

purchase adequately (V. Zeithaml, 1981). Healthcare was noted to be at the extreme end of the

purchase continuum with the highest level of credence properties (Butler, et al., 1996). As such,

a better understanding of the way in which healthcare service dimensions affect satisfaction is of

crucial importance and will be at the heart of our research.

Role of Satisfaction in Modeling Healthcare

The satisfaction construct may be analyzed in two ways. It may be considered as an independent

variable that predicts consumer behaviors (with the assumption that differences in satisfaction

influence what people do) (Donabedian, 1988; G.C. Pascoe, 1983; J. E. Ware, Davies-Very, &

Stewart, 1977). For example, the degree of satisfaction is seen as contributing to subsequent

patient commitment to, and compliance with, recommended treatment as well as affecting the

likelihood of returning to the same provider and healthcare delivery program (Strasser, Aharony,

& Greenberger, 1993). It may be also studied as a dependent variable to evaluate provider

services and facilities (based on the assumption that patient satisfaction is one core service

quality indicator) (Heinemann, Lengacher, VanCott, Mabe, & Swymer, 1996). This last

approach is the one that we investigate in this research. Actually, such research is meaningful

from a managerial perspective because for patients who have some choice of their provider and

healthcare system, the degree of satisfaction with their current utilization and clinical progress

should have differential effects on how often they use a health service or recommend it to other

people and whether or not they will seek care elsewhere (C. W. Nelson & Niederberger, 1990).

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RESEARCH OBJECTIVES AND PERSPECTIVES

Objectives of the Research

The ambition of this study is to add to the limited knowledge and empirical evidences on the

drivers of patient satisfaction in Lebanese primary care settings.

The specific objectives are:

1. Identify the key healthcare dimensions that impact patient satisfaction with primary care

services.

2. To better understand the mechanisms linking healthcare dimensions to patient satisfaction

by:

Identifying what dimensions are most significant to improve patient satisfaction with

primary care services in Lebanon.

Investigating unexplored, but relevant, mediating variables, identified in the

satisfaction literature as well as in the healthcare literature.

Investigating relevant moderating effects.

Academic Relevance of the Research

More than a decade ago, Bernhart et al. called for additional research on patient satisfaction in

developing countries, flagging the importance of such research in the design, implementation and

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evaluation of healthcare services in such countries (Bernhart, Wiadnyana, Wihardjo, & Pohan,

1999). Unfortunately, while this appeal had been abided by many scholars in various developing

countries [e.g., (Al Tehewy & Salem, 2009; Andaleeb, Siddiqui, & Khandakar, 2007; Bernhart,

et al., 1999)], it didnt have any echo in Lebanon where the literature doesnt mention the

presence of any methodological study on outpatient satisfaction. The present study was

undertaken to fill this gap in knowledge. Accordingly, it attempts to distinctively identify the key

drivers of patient satisfaction with primary care services in Lebanon and investigate the

mechanisms through which and the conditions under which care dimensions affect patient

satisfaction. Thereby, results deepen existing knowledge on patient satisfaction.

Managerial Relevance of the Research

Findings of this research imply two main managerial contributions. First, the identification of the

key dimensions of healthcare that influence patient satisfaction with primary care services in

Lebanon. Such contribution will help the providers to redesign creatively their quality and

satisfaction programs. Second, the development of the holistic process of patient satisfaction. It

is a more practical and advanced process for approaching patient satisfaction implementation. Its

applicability and potential advantages go beyond this study and its particular context. Local and

international providers throughout the healthcare sector should be able to follow the proposed

steps. In the course of its application, healthcare settings could be taken to a higher level, helping

to serve patients more proficiently.

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DELIMITATION OF SCOPE

To accurately answer the research question and in order to meet the objectives, the scope of this

thesis has been clearly delimited. An inclusion of all possible influencing factors would have

made the research model too complex (Licata, Chakraborty, & Krishnan, 2008). Accordingly,

only a limited number of factors that were identified from the literature review and the

qualitative pilot study were included in the conceptual research model. Within a specific research

context, four influencing dimensions of healthcare (physician care, access to care, price of care

and atmospherics of care), three moderating variables (age; gender; income), and two mediating

factors (service quality; distributive justice) are chosen.

Theoretically, the study is situated within the wider area of services marketing. In terms of

classification, the project falls in the customer satisfaction part of services marketing. More

precisely, it is in the intersection of multiple influencing factors on outpatient satisfaction. In

other words, the relative importance assigned to different healthcare dimensions by primary care

patients and the possible effect of physician care, access to care, price of care and atmospherics

of care is explored. From a context point of view, this study relies on the case of Mount Lebanon

Clinic (MLC) which structure and portfolio of customers is quite typical of clinics in Lebanon.

Thus, this is a representative case.

RESEARCH ORGANIZATION

Following the INTRODUCTION, this research paper is divided into two parts covering five

chapters.

Part 1: Literature Review

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The objective of CHAPTER 1 is to provide an extensive literature review on PATIENT

SATISFACTION. This chapter aims to provide a comprehensive examination of the

conceptualization and measurement of the patient satisfaction construct. Then, CHAPTER 2

aims to elaborate on the drivers of patient satisfaction and situate them with respect to their

theoretical foundations.

Part 2: Hypotheses, Methodologies and Outcomes

The literature review and the pilot study were helpful to finalize the RESEARCH MODEL and

develop the RESEARCH HYPOTHESES presented in CHAPTER 3. As the main study is based

on a quantitative approach, CHAPTER 4 METHODOLOGIES AND OUTCOMES presents both

the measures carried out and the results identified. Especially, the validation of existing scales

and the construction of healthcare dimensions indexes is detailed. Then, the successive results of

each hypothesis are presented. Multiple regression analysis is used to highlight the impact of the

different dimensions and factors of healthcare on outpatient satisfaction. CHAPTER 5

MANAGERIAL CONTRIBUTIONS describes the practical consequences of the empirical

results. The discussion centers on direct management implications and an advanced process of

patient satisfaction.

Finally the CONCLUSIONS of the research are drawn. First, a synthesis of the key results of the

research is presented. Then, the key contributions of the research are pinpointed from theoretical

and managerial perspectives. The limitations of the research and the paths for future research are

also presented.

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PART 1 - LITERATURE REVIEW

---------------------------------------------------------------------------------------------------------------------

Introduction

Part one which forms the theoretical framework for this dissertation scans previous work in the

field of patient satisfaction. Its objective is to find and present the pertinent work from the

primary literature in a logical, critical, and organized manner and to bring the reader as up-to-

date as possible.

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Figure 1: Organization of Part 1

Chapter 1: Patient Satisfaction

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-

The single most important thing to remember about any enterprise is that there are no results

inside its walls. The result of a business is a satisfied customer" - Peter Drucker.

Practically every organization is nowadays concerned with satisfying the users of its products are

they known as clients, customers, consumers or patients. However, the concept of customer

satisfaction is nothing new. It was management guru Peter Drucker who wrote long ago that

PART 1: LITERATURE REVIEW

Part 1 is organized in two chapters:

CHAPTER 1: PATIENT SATISFACTION

Contributions of chapter 1:

- Provides a comprehensive examination of the conceptualization and measurement of the customer/patient

satisfaction construct.

CHAPTER 2: DRIVERS OF PATIENT SATISFACTION

Contributions of chapter 2:

- Provides a comprehensive examination of the drivers of patient satisfaction.

The findings of part 1 will discover the knowledge gap and help to frame the research model

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there is only one valid definition of business purpose - to create a customer'. Having created

customers, the next step is to satisfy them (Drucker, 1954).

Similarly, in the marketing discipline which has been defined as the delivery of customer

satisfaction at a profit (P. Kotler, 2002) and customer satisfaction engineering (Philip. Kotler

& Levy, 1969), there is probably no concept that is at once more fundamental and pervasive than

satisfaction (Czeplel & Rosenberg, 1977).

Customer satisfaction with healthcare has gained widespread recognition as a measure of service

quality (Harris, Swindle, Mungai, Weinberger, & Tierney, 1999). This has arisen partly because

of the desire for greater involvement of the customer in the healthcare process and partly because

of the links demonstrated to exist between satisfaction and patient compliance in areas such as

appointment keeping, intentions to comply with recommended treatment and medication use

(Willson & McNamara, 1982). Since high quality clinical outcome is dependent on compliance

which, in turn, is dependent on patient satisfaction the latter has come to be seen as a legitimate

healthcare goal and therefore a prerequisite of quality care (Vuori, 1987).

Consequently, this review assumes that satisfying patients is an essentially sound principle and

that an understanding of the nature of satisfaction is required if healthcare providers are to

deliver quality care and succeed in today's rapidly changing business and economic environment.

Section one of this chapter presents an overview of the way satisfaction is presented in the

marketing literature. Then sections two and three present a comprehensive view of the way in

which the concept of satisfaction is conceptualized and measured in the healthcare environment.

Finally, section four presents the conclusions and implications of this chapter.

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1. 1 Conceptualization of Satisfaction

1.1.1 Etymology of Satisfaction

When I use a word, Humpty Dumpty said in a rather disrespectful tone, it means just what I

choose it to mean neither more nor less (Carroll, 1865).

The word satisfaction first appeared in English during the thirteenth century. The word

satisfaction itself is derived from the Latin satis (meaning enough) and the Latin ending -faction

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(from the Latin facere to do/make). Early usage centered on satisfaction being some sort of

release from wrong doing. Later citings of the word emphasize satisfaction as a release from

uncertainty (The Oxford Library of Words and Phrases, 1993). Modern usage of the word has

tended to be much broader, and satisfaction is clearly related to other words such as satisfactory

(adequate), satisfy (make pleased or contented) and satiation (enough).

The difficulty faced when trying to define any word is that the meaning often depends on the

context in which the word is used. In a marketing context, satisfaction is used to have a more

specific meaning.

1.1.2 Definitions of Satisfaction

Before analyzing the definitions of consumer satisfaction, it is important to note that discrepant

terms are used interchangeably in the literature, such as "consumer satisfaction", "customer

satisfaction" or simply "satisfaction" (Giese & Cote, 2000). Researchers have used discrepant

terms to mean satisfaction as determined by the final user: consumer satisfaction (e.g., (Cronin &

Taylor, 1992; Spreng, MacKenzie, & Olshavsky, 1996; Tse & Wilton, 1988)), customer

satisfaction (e.g., (G.A Churchill & Surprenant, 1982; C. Fornell, 1992; Smith, Bolton, & Wagner,

1999)), or simply, satisfaction (e.g. (Kourilsky & Murray, 1981; Mittal, Kumar, & Tsiros, 1999)).

These terms are used somewhat interchangeably, with limited, if any, justification for the use of

any particular term. In this study, the term "customer satisfaction" will be used.

In spite of considerable investigations (e.g.(LaTour & Peat, 1979; Oh & Parks, 1997; Ross,

Frommelt, Hazelwood, & Chang, 1987)) through the years since Cardozo's classic article

(Cardozo, 1965), researchers have yet to develop a consensual definition of customer

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satisfaction. Cochran addressed this definitional issue by summarizing the emotion literature,

recording that "There are as many definitions of customer satisfaction as there are customers "

(Cochran, 2003) .

This ambiguity is due to the fact that when discussing and testing theory it is critical to explicate

the conceptual domain which unfortunately most satisfaction researchers dont: Without a

clear focus, any definition of satisfaction would have little meaning since interpretation of the

construct would vary from person to person (Giese & Cote, 2000). Consequently, "While

everyone knows what satisfaction means, it clearly does not mean the same thing to everyone"

(R. Day, 1980).

Table 1 presents the main definitions that are considered as references in the literature and which

will be further discussed in sections 1.1.3 and 1.1.4.

Table 1: Conceptual & operational definitions of satisfaction

Source Definition

Nature of

the

response

Nature of

the

experience

(V.A.

Zeithaml,

Bitner, &

Gremler,

2009)

The customers evaluation of a product or

service in terms of whether that product or

service has met their needs and expectations.

Cognitive

and

affective

Consumption

(Giese &

Cote,

2000)

A summary affective response of varying

intensity, with a time specific point of

determination and limited duration directed

toward focal aspects of product acquisition

and / or consumption.

Affective Acquisition

and

consumption

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(Garbarino

& Johnson,

1999)

Transaction specific customer satisfaction is an

immediate post purchase evaluative judgment or

an affective reaction to the most recent

transactional experience with the firm. Overall

satisfaction is a cumulative construct, summing

satisfaction with specific products and services

of the organization & satisfaction with various

facets of the firm such as the physical

facilities

Cognitive

and

affective

Post

purchase (in

the case of

transaction

satisfaction

) Overall

evaluation

(cumulative

satisfaction

(R. L.

Oliver,

1997)

Satisfaction is the consumer's fulfillment

response. It is a judgment that a product or

service feature, or the product or service

itself, provided (or is providing) a pleasurable

level of consumption-related fulfillment,

including levels of under- or over fulfillment.

Cognitive

and

affective

Consumption

(E. W.

Anderson,

Fornell, &

Lehmann,

1994)

An overall evaluation based on the total

purchase and consumption experience with a good

or service over time.

Cognitive Cumulative

(=

relational)

(Halstead,

Hartman, &

Schmidt,

1994)

A transaction-specific affective response

resulting from the customers comparison of

product performance to some prepurchase

standard.

Affective Consumption

(C.

Fornell,

1992)

An overall post purchase evaluation. Cognitive Post

purchase

(Richard

L. Oliver,

1992)

It is a summary attribute phenomenon coexisting

with other consumption emotions.


(Yi, 1990) It is a collective outcome of perception,

evaluation and psychological reactions to the

consumption experience with a product/service.

Cognitive

and

affective

Consumption

(Tse &

Wilton,

1988)

The consumers response to the evaluation of the

perceived discrepancy between prior expectations

(or some norm of performance) and the actual

performance of the product as perceived after

its consumption

Cognitive Consumption

(Cadotte,

Woodruff,

An evaluative response to the perceived outcome

of a particular consumption experience.


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& Jenkins,

1987)

(R. A.

Westbrook,

1987)

Global evaluative judgment about product

usage/consumption


(R. L.

Day, 1984)

The evaluative response to the current

consumption event...the consumers response in a

particular consumption experience to the

evaluation of the perceived discrepancy between

prior expectations (or some other norm of

performance) and the actual performance of the

product perceived after its acquisition.

Cognitive Acquisition

and

consumption

(R.

Westbrook

& Reilly,

1983)

An emotional response to the experiences

provided by and associated with particular

products or services purchased, retail outlets,

or even molar patterns of behaviour such as

shopping and buyer behaviour, as well as the

overall marketplace.

Affective Consumption(

specifically

at the post

purchase

stage)

(G.A

Churchill

&

Surprenant

, 1982)

An outcome of purchase and use resulting from

the buyers comparison of the rewards and costs

of the purchase relative to anticipated

consequences. Operationally, similar to attitude

in that it can be assessed as a summation of

satisfactions with various attributes.


and

consumption

(Engel &

Blackwell,

1982)

An evaluation that the chosen alternative is

consistent with prior beliefs with respect to

that alternative.

Cognitive Purchase

(R.L.

Oliver,

1981)

An evaluation of the surprise inherent in a

product acquisition and/or consumption

experience. In essence, the summary

psychological state resulting when the emotion

surrounding disconfirmed expectations is coupled

with the consumers prior feelings about the

consumption experience.


and

consumption

(J. Swan &

Trawick,

1980)

A conscious evaluation or cognitive judgment

that the product has performed relatively well

or poorly or that the product was suitable or

unsuitable for its use/purpose. Another

dimension of satisfaction involves affect of


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feelings towards the product

(R.

Oliver,

1980)

It is the result of an evaluative process that

contrasts prepurchase expectations with

perceptions of performance during and after the

consumption experience.


(LaTour &

Peat,

1979)

A general evaluative response to a product,

perhaps not discernibly different than the well-

studied concept of attitude.

Not

defined

Acquisition

and

consumption

(J. I.

Westbrook,

Newman, &

Taylor,

1978)

Satisfaction is an emotional or feeling

reaction. It is the result of a complex process

that requires understanding the psychology of

customers.

Affective Post

purchase

(H. K.

Hunt,

1977)

An evaluation rendered that the experience was

at least as good as it was supposed to be.

Cognitive

and

affective

Consumption

(R. L.

Day, 1977)

Customer satisfaction is a reaction to recognize

and evaluate the differences before and after

consumption.


(J. A.

Miller,

1977)

It is the interactive process of customers

level of expectation and real cognition.


(R. E.

Anderson,

1973)

The disparity between expectation & the

perceived product performance.


(J. A.

Howard &

Sheth,

1969)

The buyer's cognitive state of being adequately

or inadequately rewarded for the sacrifices he

has undergone.

Cognitive Not defined

(Cardozo,

1965)

The customers perception of product

performance.


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1.1.3 Shared Perspectives in the Satisfaction Literature

The analysis of definitions presented in Table 1 as well as the analysis of complementary papers

on satisfaction reveals that researchers generally agree on three common components:

1.1.3.1 The Relative Character of Satisfaction

Most researchers have suggested that Consumer Satisfaction / Dissatisfaction is influenced by a

pre-experience comparison standard and disconfirmation, that is, the extent to which this pre-

experience comparison standard is disconfirmed (e.g., (R. E. Anderson, 1973; Cadotte, et al.,

1987; Cardozo, 1965; R. L. Day, 1977; J. A. Howard & Sheth, 1969; LaTour & Peat, 1979; J. A.

Miller, 1977; R. Oliver, 1980; J. Swan & Trawick, 1980; Tse & Wilton, 1988)).

1.1.3.2 The Time and Temporal Focus of Satisfaction

Satisfaction is an end state resulting from a consumption experience (E. W. Anderson, Fornell, &

Lehmann, 1994; R. L. Day, 1984; J. A. Howard & Sheth, 1969; H. K. Hunt, 1977; R.L. Oliver,

1981; Richard L. Oliver, 1997) and notably from a post purchase consumption experience (G.A

Churchill & Surprenant, 1982; C. Fornell, 1992; R. L. Oliver, 1997; Tse & Wilton, 1988; R. A.

Westbrook, 1987). However, few exceptions exist in this perspective. For instance, the purchase

decision may be evaluated after choice, but prior to the actual purchase of the product or it may

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comparison standard is disconfirmed, they have not converged on the exact conceptualization of

the comparison standard (consequently, on which comparison standard best predicts product

satisfaction) and disconfirmation constructs. For example, the comparison standard has been

conceptualized as expected (e.g., (R. Oliver, 1980)), ideal (e.g., (J. A. Miller, 1977)), or

normative performance (e.g., (Tse & Wilton, 1988)). Similarly, disconfirmation has been

modeled as the result of subtractive functions (e.g., (LaTour & Peat, 1979)) between product

performance and some comparison standards or as the subjective evaluation (e.g., (R. Oliver,

1980)) of this discrepancy.

1.1.4.2 The Disposition of Satisfaction

A fundamental inconsistency is evident by the argument of whether satisfaction is a process or

an outcome (Parker & Mathews, 2001). More precisely, satisfaction definitions have either

emphasized an evaluation process (e.g., (Fornell, 1992; H. K. Hunt, 1977; R.L. Oliver, 1981)) or

a response to an evaluation process (e.g., (Halstead, et al., 1994; J. A. Howard & Sheth, 1969;

R.L. Oliver, 1981; R. L. Oliver, 1997; Tse & Wilton, 1988; R. Westbrook & Reilly, 1983)).

Satisfaction as an evaluation process:

Historically, the earliest attempts to capture the phenomenon of satisfaction were directed at a

conceptual model which postulated a direct causal link between the performances of products

attributes and overall state of satisfaction (Tan, 2004). By looking at satisfaction as a process (R.

L. Day, 1984; J. F. Engel & Blackwell, 1982; H. K. Hunt, 1977), these definitions concentrate on

the antecedents to satisfaction rather than satisfaction itself. Consequently, much research effort

has been directed at understanding the cognitive processes involved in satisfaction evaluations.

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Satisfaction was described as an evaluation process that occurs during the service delivery

process and that takes the form of a comparison between the actual performance of a product and

the customer's prior expectations (e.g., (R.L. Oliver, 1981; Tse & Wilton, 1988)). This strand of

theory appears to have origins in discrepancy theory (L. W. Porter, 1961), and a number of

authors have, over the years, used some form of comparison to model satisfaction (e.g. (Olson &

Dover, 1979)).

Satisfaction as an outcome to an evaluation process

In the literature, there is a dominant view of satisfaction as an end state or a summary response to

an evaluation process (i.e., a fulfillment response (R. L. Oliver, 1997); affective response

(Halstead, et al., 1994); overall evaluation (C. Fornell, 1992); non observable psychological

state (Aurier & Evrard, 1998; J. A. Howard & Sheth, 1969); global evaluative judgment (R. A.

Westbrook, 1987); summary attribute phenomenon (Richard L. Oliver, 1992); or evaluative

response (R. L. Day, 1984)). While this view focus on the nature (not cause) of satisfaction, it

acknowledges the input of comparative cognitive processes but goes further by stating that these

may be just one of the determinants of the affective state satisfaction (Parker & Mathews,

2001).

The status of satisfaction in the context of this study

For the purpose of this study, a choice must be made between these two approaches to

satisfaction. Evidences from the literature show that patient satisfaction is a multi-dimensional

concept, which derive from an evaluation of varied features of the care experience (Crowe, et al.,

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2002). Patients evaluate their healthcare experience to give a single global summary outcome or

response (C. Lin, 1996).

Accordingly, in the current study satisfaction will be considered as an outcome to an evaluation

process.

1.1.4.3 The Nature of the Satisfaction Outcome

While most researchers have sustained the idea of satisfaction as an outcome to an evaluation

process, they disagree on the nature of this response. In fact, they portray satisfaction as either a

cognitive response (e.g., (R. N. Bolton & J. H. Drew, 1991; J. A. Howard & Sheth, 1969; Tse &

Wilton, 1988)) or an affective response (e.g., (Cadotte, Woodruff, & Jenkins, 1987; Halstead, et

al., 1994; R. Westbrook & Reilly, 1983)) or both cognitive and affective response to an

evaluation process (R. L. Oliver, 1997).

Satisfaction as exclusively cognitive response to an evaluation process

Historically, satisfaction was conceptualized as a cognitive construct (Robert A. Westbrook,

1989). In this case, satisfaction results from a comparison between the customers perception of

product performance and their expectation level. For example, Engel and Blackwell refer to An

evaluation that the chosen alternative is consistent with prior beliefs with respect to that

alternative (Engel & Blackwell, 1982).

The most well-known descendent of this cognitive approach is the expectation-disconfirmation

paradigm (Fournier & Mick, 1999; Halstead, et al., 1994) which is analyzed hereafter.

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Having roots in social psychology (Weaver & Brickman, 1974) and organizational behavior

(Ilgen, 1971), expectancy disconfirmation is actually two processes consisting of the formation

of expectations and the disconfirmation of those expectations. Assuming that the customer is

capable of evaluating the product performance, the result is compared to expectations prior to

purchase or consumption. Any discrepancy leads to disconfirmation; i.e. positive disconfirmation

increases or maintains satisfaction and negative disconfirmation creates dissatisfaction (review

Figure 2) (R. Oliver, 1980). Even though positive disconfirmation and negative disconfirmation

are both clearly related to a subsequent level of satisfaction, the outcome is more confusing for

zero disconfirmation. Many authors consider that zero disconfirmation refers to a "zone of

indifference" (R. Woodruff, Cadotte, & Jenkins, 1983). This zone of indifference surrounds a

performance range that is acceptable to the consumer. Notwithstanding the fact that the concept

is intuitively appealing; Oliver noted that "unfortunately, little research exists to guide

researchers on identifying the existence and limits of indifference zone" (R. L. Oliver, 1997).

Thus, such a concept will not be considered in this study.

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Figure 2: Expectancy Disconfirmation Paradigm.

Source: adapted from Oliver (R. Oliver, 1980)

Satisfaction as exclusively affective response to an evaluation process

In the mid 1990s, research had started to not only criticize the overwhelming dominance of the

expectation-disconfirmation paradigm (H. Keith. Hunt, 1993) but also increasingly investigated

affective antecedents of satisfaction (e.g. (Brockman, 1998; Dube-Rioux, 1990; Yves. Evrard &

Aurier, 1994; Mano & Oliver, 1993; R.L. Oliver, 1989; Richard L. Oliver, 1992, 1994; Robert A.

Westbrook, 1989; R. A. Westbrook & Oliver, 1991; Wirtz, Mattila, & Tan, 2000)).

Fournier and Mick declared that: "Research within customer satisfaction paradigm has probably

underrepresented the emotional aspects of satisfaction and that the further study of affective

satisfaction modes could play a promising corrective role" (Fournier & Mick, 1999).

Cadotte et al. referred to a feeling developed from an evaluation of the use experience

(Cadotte, et al., 1987).

Westbrook examined customer affective responses to consumption experience and established

that good and bad feelings represent two dimensions of affective response to products in use (R.

A. Westbrook, 1987) . The author also demonstrated that these two dimensions relate directly,

and in the expected direction, to product satisfaction judgments.

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Giese and Cote proposed a general definitional framework for satisfaction and also asserted that

satisfaction is an affective construct (Giese & Cote, 2000). Their definition is a result of thirteen

group interviews and twenty-three personal interviews with consumers. Giese and Cote observed

during these interviews that 77,3% of group interview responses and 64% of individual

interviews responses specifically used affective terms to describe satisfaction(Giese & Cote,

2000). Thus, Giese and Cote proposed to define satisfaction as "a summary affective response of

varying intensity"(Giese & Cote, 2000).

Satisfaction as both cognitive and affective response to an evaluation process

There has been an increasing recognition among satisfaction researchers that a purely cognitive

or a purely affective approach may be inadequate in modeling satisfaction evaluations (e.g.,

(Garbarino & Johnson, 1999; Martnez Caro & Martnez Garca, 2007). It is now generally

accepted that customers' evaluative judgments are based partly on cognition and partly on

affective responses to a product stimulus (Oliver, 1997). Fournier observed that: Our cases

reveal satisfaction as technical and artful, cognitive and affective, purposeful and spontaneous,

and interlaced with meanings of many kinds" (Fournier & Mick, 1999).

It is noteworthy that if satisfaction results from both cognitive and affective processes, no clear

consensus exists on the relationships between both dimensions. For instance, Oliver observed

that the "hybrid cognition-emotion" is not well described in the literature (R. L. Oliver, 1997).


In the context of this study, the question of whether the satisfaction response relies on cognitive,

affective or cognitive-affective processes should be discussed. The marketing approach to

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conceptualizing of satisfaction draws heavily on the work of Fishbein and Ajzen (Fishbein &

Ajzen, 1975b) into beliefs and attitudes (Newsome & Wright, 1999). Central to this approach is

the notion that satisfaction arises out of an interplay between cognitive and affective processes.

According to Fishbein and Ajzen perceptions, including beliefs, are cognitive in nature (referring

to the process of knowing or thinking) and represent the information an individual has about the

object in question while attitudes, on the other hand, are affective in nature (referring to the

process of emotion) and are characterized by a general evaluation or feeling of favorableness or

un-favorableness toward the object (Fishbein & Ajzen, 1975b). As far as satisfaction is

concerned, the expectation formation process, the comparison of performance to expectations or

desires, and judgments based on equity and attributions are mostly conscious, overt activities and

therefore primarily cognitive in nature. The role that affective responses, not under conscious

control, play in the satisfaction process is less well developed. However, it is now accepted that a

variety of emotional responses, including such affects as joy, excitement, pride, anger, sadness

and guilt do play a significant, complimentary, role in determining satisfaction (R.L. Oliver,

1993a).

Thus, in the current study satisfaction will be considered as a cognitive - affective response.

1.1.4.4 The Scope of the Evaluative Judgment

Two perspectives are considered in the literature: transaction-specific satisfaction and cumulative

satisfaction:

Transaction- specific satisfaction

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From a transaction-specific perspective, satisfaction is viewed as a post-choice evaluative

judgment of a particular purchase/consumption occasion (R.L. Oliver, 1993a).

Behavioral researchers in marketing have developed a rich body of literature investigating the

antecedents and consequences of this type of satisfaction at the individual level (E. W. Anderson,

et al., 1994). Distinctive reasons justify the advantages of the analysis of transaction-specific

satisfaction. First, the analysis of a specific transaction is necessary to understand the satisfaction

formation process (Johnson, 1995). Then, satisfaction is a function that comes from the

discrepancy between the consumer's prior expectations and his/her perceived consumption

experience. As expectations can evolve over time, the analysis should take place over a short

period (Iacobucci & Grayson, 1994). For these different reasons, the transactional vision of

satisfaction has been largely adopted, even in longitudinal studies (e.g., (R. N. Bolton & J. H.

Drew, 1991; LaBarbera & Mazursky, 1983; Mittal, et al., 1999; Richins & Bloch, 1991)).

Cumulative satisfaction

By comparison, cumulative satisfaction is an overall evaluation based on the total

purchase/consumption experiences with a good or service over time (Bitner & Hubbert, 1994).

Since overall satisfaction is based on information from all previous experiences with the service

provider, overall satisfaction can be viewed as a function of all previous transaction-specific

satisfactions (Parasuraman & Zeithaml, 1994; Teas, 1993). Overall satisfaction may be based on

many transactions or just a few, depending on the number of times the customer has used a

particular provider. In essence, overall customer satisfaction is an aggregation of all previous

transaction-specific evaluations and is updated after each specific transaction much like

expectations of overall service quality are updated after each transaction (Boulding, Kalra,

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Staelin, & Zeithaml, 1993). It should be noted that although overall satisfaction at time t-1 will

have an impact on the expectations which produce transaction-specific satisfaction at time t, this

transaction-specific satisfaction will only be influenced indirectly by overall satisfaction (through

expectations) and not completely reflect or subsume the overall satisfaction construct. Overall

customer satisfaction at time t will then be based on overall satisfaction at time t-1 (which

reflects all previous transaction-specific satisfactions), as well as the transaction-specific

customer satisfaction that resulted from the information collected from the most recent service

transaction produced at time t(Boulding, et al., 1993).

In general, transaction-specific satisfaction may not be perfectly correlated with overall

satisfaction since service quality is likely to vary from experience to experience, causing varying

levels of transaction-specific satisfaction. Overall satisfaction, on the other hand, can be viewed

as a moving average that is relatively stable and more similar to an overall attitude (Parasuraman

& Zeithaml, 1994). For example, a customer may have a dissatisfying experience because of lost

baggage on a single airline flight (i.e. low transaction-specific satisfaction) yet still be satisfied

with the airline (i.e. overall satisfaction) due to multiple previous satisfactory encounters.


As this study refers to the analysis of potential antecedents of outpatient satisfaction and their

impacts on the satisfaction formation process, the focus is clearly on transaction specific

satisfaction.

1.1.4.5 Distinction between the Operationalization of Satisfaction and Other Closed Concepts

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Satisfaction being a problematical and multi-dimensional construct, Yi observed that: another

issue that needs further attention is whether or not customer satisfaction is conceptually distinct

from other concepts (Yi, 1990). Actually, the risks of confusing satisfaction and three related

constructs - attitude, perceived quality and perceived value - are demonstrated in the literature.

Henceforward, satisfaction and each of the abovementioned concepts are accordingly contrasted.

Satisfaction and Attitude

The concept of attitude has been called the most distinctive and indispensable concept in

contemporary American social psychology. In fact several writers define social psychology as

the scientific study of attitudes (Allport, 1967). Nonetheless, attitudes have been defined in

many, often conflicting ways. There is general agreement on the meaning of attitudes with

respect to one characteristic, namely, persistent affect: "Attitudes refer to persistent and

affectively charged psychological states that enable individuals to relate to their surroundings

and to 'objects' (people and/or things) that comprise their surroundings in ways that make for

behavioral consistency" (Allport, 1967).

In reviewing the satisfaction literature, we can notice that few researchers have spread suspicions

on the discriminant validity of the satisfaction construct:

"Given that attitude and satisfaction are both evaluative responses to products, it is not clear

whether there are any substantive differences between the two. In fact, it may be more

parsimonious to consider satisfaction measures as post-consumption attitude measures" (LaTour

& Peat, 1979).

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"Consumer satisfaction is an attitude in the sense that it is an evaluative orientation which can

be measured. It is a special kind of attitude because by definition it cannot exist prior to the

purchase or consumption of the attitude object" (Czepiel & Rosenberg, 1977). Another sources

of perplexity arises from the nature (involve both a cognitive and an emotional component) and

relative character (being an evaluation) of satisfaction has sometimes led some researchers to

assimilate this concept to a form of attitude (R. L. Day, 1984; Evrard, 1993).

Although the logic of the two concepts seems relatively close, three differences have been

highlighted in the literature:

Firstly, satisfaction is related to a (or to several) consumption experience(s), which is not

necessarily the case for attitude (Evrard, 1993).

The second difference is related to the formation process. Satisfaction relies on comparison

between a consumer's prior expectation and the actual performance of a product (Oliver, 1980).

Oppositely, attitude is not related to comparative judgments.

Finally, Oliver suggested another conceptual difference by defining satisfaction as an

evaluation of the surprise inherent in a product acquisition and/or consumption experience, the

surprise or excitement is of finite duration, so that satisfaction soon decays into attitude toward

purchase (R. Oliver & Linda, 1981). This is the reason why an immediate measure of

satisfaction after consumption/purchase is the one that offers the highest discriminant validity

(Vanhamme, 2002).

Satisfaction and Service Quality

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Although there seems to be a consensus in the literature that satisfaction and service quality are

two different constructs, distinctions in their definitions have not always been made clear

(Tomiuk, 2000). An important source of confounding between these two constructs has been the

use of the expectancy disconfirmation model in defining both concepts conceptually and

operationally (Gronroos, 1982; R.L. Oliver, 1993b; R. L. Oliver, 1997; Parasuraman, Zeithaml,

& Berry, 1985). In an attempt to provide clarity to the distinction between these two constructs,

two different types of standards have been proposedone reflecting a desired state and the other

an ideal state. Boulding proposed that the ideal expectation (or should) be used as the referent

in the expectancy disconfirmation involving service quality and the desirable expectation (or

will) as a referent in the case of satisfaction (Boulding, et al., 1993).

Oliver treated this issue noticeably in his book and presented some key variations which one

finds between the two concepts (R. L. Oliver, 1997). He suggests that quality is a judgment or

evaluation that concerns performance pattern, which involves several service dimensions specific

to the service delivered. Quality is believed to be determined more by external cues. Satisfaction,

however, is perceived as a global consumer response in which consumers reflect on their

pleasure level. Satisfaction is based on service delivery predictions/norms that depend on past

experiences, driven by conceptual cues (e.g., equity, regret). Although service quality may be

updated at each specific transaction or service experience, it tends to last longer than satisfaction,

which is understood as being transitory and merely reflecting a specific service experience.

These variations are presented in Table 2.

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Table 2: Differences between service quality & satisfaction

Comparison dimension

Quality2Satisfaction

Experience dependency Perception of quality may come from

external mediation rather than experience

of service/product (e.g., interpersonal

communication).

Experiencing the product/service is

required (we have to eat at the

restaurant to define if we are

dis/satisfied toward it).

Dimensions Results only from specific quality

characteristics of products/services

(e.g., the freshness of a fish)

Potentially it results from all

attributes of the product or service

(some are related to quality while

others are not).

Expectation / standard Is judged according to an ideal standard

of quality

Can be judged according to others

standards then the ideal one, such

as predictions, product category

norms, needs (related or not to

quality).

2 Even if not clearly mentioned in this table, the term quality refers, according to the author, to perceived quality(Oliver, 1997: 165).

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Cognitive / affective Primarily cognitive Cognitive & Affective

Conceptual antecedents Service quality is influenced by a very

few variables (e.g., external cues like

price, reputation, and various

communication sources).

Satisfaction is influenced by

numerous cognitive and affective

causes (e.g., equity, attribution, and

emotion).

Temporal focus Primarily long term Primarily short term

Source: adapted from (R. L. Oliver, 1997)

Satisfaction and Perceived Value

While reviewing the literature, we can notice that the existent definitions of perceived value may

lead to potential confusions with satisfaction. For instance, customer perceived value has been

defined as the "consumers' overall assessment of the utility of a product based on perceptions of

what is received and what is given" (Valarie A. Zeithaml, 1988). Oliver defined the same

concept as "a judgment comparing what was received (e. g. performance) to the acquisition

costs (e. g. financial, psychological, effort)" (R. L. Oliver, 1997).

Although the two concepts seem relatively close, four discrepancies have been highlighted in the

literature.

First, value is the result of a cognitive comparison process. The concept has been described as a

cognitive based construct which captures any benefits sacrifice discrepancy in much the same

way disconfirmation does for variations between expectations and perceived performance

(Patterson & Spreng, 1997). In contrast to the purely cognitive value construct, satisfaction may

encompass an affective evaluative response (R. L. Oliver, 1997).

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Second, while satisfaction is considered as a post purchase construct, customer perceived value,

in turn, is independent of the timing of the use of a market offering (R. B. Woodruff & Gardial,

1996) and can be considered as a pre- or post purchase construct. Consequently, it is not related

to any purchase/consumption experience (Vanhamme, 2002).

Third, although the two constructs rely on comparisons, the standards are different. Many

authors summarized customer perceived value as a trade-off between perceived benefits and

costs (P. Kotler, 2002).

Finally, although the two constructs have directions, they have different aims. In fact, while

customer satisfaction measures how well a supplier is doing with his/her present market offering,

as perceived by existing customers. Such a tactical orientation provides guidelines of action for

improving current products. The customer value construct, in turn, points at future directions. Its

strategic orientation aims at assessing how value can be created for customers and by which

means a suppliers market offering can best meet customers requirements. Table 3 provides an

overview of major conceptual differences between customer satisfaction and customer perceived

value.

Table 3: Differences between perceived value & satisfaction

Satisfaction Customer Perceived Value

Affective and/ or cognitive Purely cognitive construct

Post purchase perspective Pre / post purchase perspective

Tactical orientation Strategic orientation

Present customers Present and potential customersSuppliers offerings Suppliers offerings and competitors offerings

Comparison between expectations and

perceived performance

Comparison between perceived benefits and perceived

costs

Source: adapted from (Eggert, 2002).

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To conclude, satisfaction has been clearly distinguished from attitude, perceived quality and

perceived value. These distinctions justify the discriminant validity of the satisfaction construct.

The following sections will review the way in which the concept of satisfaction is conceptualized

and measured in the healthcare environment where patient satisfaction counterpart customer

satisfaction (Otani, Herrmann, & Kurz, 2010).

1.2 Conceptualization of Patient Satisfaction

1.2.1 Introduction to Healthcare and Patient Satisfaction

Between about 1850 and 1950 there was a fundamental shift in the role of clinicians (R. Porter,

1997). Their role changed from being one of helping patients through their sickness (where the

determinants of the outcomes were largely a function of the natural course of the condition) to

one where the clinician was expected to either cure the patient or alleviate the symptoms of a

chronic condition (where the determinants of the outcomes were perceived to be largely a

function of the efficacy of the medical intervention, or the clinicians expertise).

Consequent upon this change in perceived role was accountability, first defined around 1900 as

assessing the value of the care provided (Ezekiel, 1996 ). Two broad areas of value assessment

were developed. First was the search to find ever better clinical outcomes through improved

interventions (Campanella, Campanella, & Grayson, 2000). This in turn gave rise, from the

1960s onwards, to the patient rights movement (B. Williams, 1994) a movement that led

directly to management concerns with service quality, and the assessment of that quality by those

using the services; hence patient or consumer satisfaction. By the late 1960s, then, the debate

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over the relationship between patient satisfaction as an assessment of the value of the technical

care versus the process of care was well established (Donabedian, 1966, 1979, 1980).

1.2.2 A Patient or a Consumer

Usually, words as patient, user and consumer are indistinctly used as synonyms, even though

they differ for the nature of relationships between health professionals and citizens. While the

patient is a person who has an illness and comes to doctors and nurses asking for advice and

treatment, the user may identify people who used, use or could use health care services. Instead,

the consumer reminds us of a person who purchases goods and services for his needs or a person

who consumes something (Herxheimer & Goodare, 1999). According to McIver in the 1980s a

general shift towards consumerism, evident in UK National Health System, increased the

promotion of a customer service-oriented culture (McIver, 1991). Thus, even though the use of

consumer concept in health care mainly received a wide opposition from the medical

establishment (Wassersug, 1986) because of its strong commercial connotation (Blaxter, 1995;

Leavy, Wilkin, & Metcalfe, 1989; Normand, 1991), the consumerism movement introduced in

health systems the issue of the protection of the consumers interests. Patient becomes a

consumer when he looks for health services after having collected all information helpful to

make the best choice (Shackley & Ryan, 1994). In this regard, researchers questioned: Can

patient fulfill the role of consumer? and more, Does patient wish to fulfill it? (Owens &

Batchelor, 1996). In 2002 a study conducted in eight European countries (Germany, Italy,

Poland, Slovenia, Spain, Sweden, Switzerland and UK) highlighted that patients ask for a more

autonomous role in the health care decision-making process and, then, for more information,

equitable access, freedom of choice, prompt attention, respect and quality of amenities (Coulter

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& Jenkinson, 2005). Nonetheless, consumers of health care still are often not well and

sufficiently informed. This information asymmetry causes an imbalance in the relationship

between who asks for health services and who provides them. Even though much effort has been

put into these issues, the healthcare systems still have to work in order to move away from the

idea of patient as a passive and dependent stakeholder.

In the context of this study, which occurs at a primary care setting, both the words patient and

outpatient refers to a consumer of healthcare services due to the fact that ambulatory settings

usually treat cold cases that correspond to patients who possess the characteristics associated

with consumers in the private sector; i.e., enough time, ability and freedom to search, inquire

about and as a result choose the service provider that best fulfill their needs and expectations

(Carr-Hill, 1992).

1.2.3 Defining Patient Satisfaction

Despite its large use, the patient satisfaction was initially considered as a difficult concept to be

measured and interpreted (Fitzpatrick & Hopkins, 1983; B. Williams, 1994). A common

consensus on the definition of satisfaction with healthcare is not already fully achieved (review

Table 4) due to the multidimensional and subjective nature of this concept, which is affected by

individuals expectations, needs or desires (Avis, Bond, & Arthur, 1995; R. Baker, 1997; Gill &

White, 2009). For example, when users have limited knowledge of opportunities and low

expectations of service quality, high satisfaction scores may be recorded even though poor

standards of care have been ensured.

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Factors influencing dissatisfaction could be somewhat different from factors generating

satisfaction. While on one side an adequate or acceptable standard of quality might be considered

as necessary, on the other, a feeling of satisfaction might result from a high quality service.

Moreover, when something negative happens consumers might be satisfied or not; for instance,

this depends on whether the negative event is caused by the health professionals or it is not due

to their behavior (B. Williams, Coyle, & Healy, 1998). Thus, it is possible that what makes one

person satisfied might make another one dis-satisfied (Avis, et al., 1995; Greeneich, 1993).

- Working definition of patient satisfaction

The current study will define patient satisfaction as:

The patients global judgment, that derives from a subjective evaluation of a received healthcare

service, and where the evaluation contains both cognitive and affective reactions.

The present definition derived from the definition of consumer satisfaction discussed in the

preceding part of this chapter not only clearly states the disposition (global judgment that derives

from an evaluation), the nature (cognitive and affective), and the scope (a received healthcare

service) of patient satisfaction; but, it also explicitly argues that it is the patients subjective

perspective that is central to patient satisfaction.

Consequently, this new definition is detached from the vagueness or drawbacks of previous

definitions.

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WHAT ATTRIBUTES OF HEALTHCARE ARE THE MOST IMPORTANT TO IMPROVE PATIENT SATISFACTION IN LEBANESE PRIMARY CARE SETTINGS: THE CASE OF MOUNT LEBANON CLINIC