Myth: High Patient Satisfaction Means High Quality Care

by admin admin | Nov 01, 2012
While quality of care is often evaluated through patient satisfaction surveys, results can be influenced by factors independent of care delivery and have proven to be, at times, unreliable and invalid. To truly evaluate and improve quality, healthcare providers must capture the patient experience through meaningful engagement strategies.
Myth busted October 2012

Following your last hospital visit, you may have been asked to fill out a survey about your satisfaction. Patient satisfaction surveys have become a familiar fixture in healthcare delivery, providing an avenue for patients to shape the delivery of healthcare.1 They tend to be low-cost and easy to implement— likely a reason for their widespread use2 —and the rationale behind them is sound and simple: providers can adjust how they deliver care based on the post hoc feedback they receive.

Patient satisfaction surveys can serve other purposes as well. For example, satisfaction scores have been incorporated into pay-for-performance agreements.3 They have also been used for benchmarking and quality improvement.4 The patient satisfaction metric has been revered as a gold standard for quality improvement and accountability5, and providers rely on it heavily as a way to see care “through the eyes of the patient”. Upon closer examination, patient satisfaction data have some important limitations, and collecting and analyzing them should be viewed as one aspect of a broader strategy for involving patients in the design and improvement of healthcare. 


Since they have many applications, it makes good sense to ensure patient satisfaction data are valid. A standard definition, however, remains elusive.6 Do we truly understand what it means when a patient expresses a high (or low) degree of satisfaction with care? What if satisfaction with care was determined by variables outside of providers’ control? Indeed, research on conventional satisfaction surveys shows that aspects of care delivery—for example, a patient’s length of stay—play a role in satisfaction, but parameters independent of care delivery—for example, a patient’s age—may play an even greater role.7, 8 Even in organizations that provided less than ideal care, a lack of information and a reluctance to be negative led to patients’ expressing artificially high levels of satisfaction.9

These findings make measurement of satisfaction particularly challenging, which explains the growing attention toward this area of research. Recent studies show that expectations for care are a significant predictor of satisfaction. 10, 11 If patients perceive their providers as being under pressure or constrained, aspects of care which they would otherwise expect may be overlooked without penalty. 12 If we extend this logic to the Canadian context, perhaps high levels of satisfaction can be explained in part by the widespread belief that its healthcare system is in a state of crisis.13


So if satisfaction data suffer from these limitations, are they still worth collecting? The answer is a qualified yes. As mentioned, work has been done to develop better, validated satisfaction surveys. And surveys are beginning to capture more information about patient experience, not just satisfaction. Indeed, healthcare providers are beginning to recognize that understanding patient experiences is vital to designing and delivering high quality health services.14 NRC Picker Canada highlights the advantages of moving from conventional satisfaction survey questions (e.g. ‘how satisfied were you with the information provided at discharge?’) to experience-based questions (e.g. ‘did hospital staff tell you when you could resume usual activities after treatment?’). Patient responses to experience-based questions can help organizations understand their performance on controllable behaviours that drive patient experience, and are vital for developing plans to improve the patient experience.

That said, meaningful patient engagement goes beyond asking discrete questions and tabulating the YESes and NOs. The collection of satisfaction and experience data is but one component of a broader patient engagement strategy. To overcome some of the limitations of these surveys, providers may begin asking more open-ended questions or holding focus groups with patients.12 Providers may also decide to form patient/family advisory councils, participatory models that are reflective of genuine patient involvement.15 Patients can also be intimately involved in efforts to (re)design care.16, 17 Bate and Robert (2007) suggest a continuum of patient involvement (see figure), from ‘complaining’ and ‘information giving’, to ‘experience-based co-design’.18  


Source: Bate and Robert (2007)


Knowing whether patients are satisfied with the care they receive can be useful for improving the quality of health services. Even more important is measuring patient satisfaction in ways that are validated and reliable.19, 12 That said, even a score of high satisfaction on a validated survey does not necessarily imply high quality care has been provided. To be successful in improving health services to meet patients’ needs and preferences, providers must have comprehensive patient engagement strategies that include the patient and/or their family members as full partners in the enterprise.20

In order to uncover lessons about how engagement can lead to improved care, CFHI has provided support to 17 organizations who are engaging patients and/or families in the design, delivery and evaluation of their services. For more information about this work, please visit Patient Engagement.


1. Tam, J. L. M. (2007). Linking quality improvement with patient satisfaction: a study of a health service centre. Marketing Intelligence & Planning, 25(7), 732-745. (LIN07)
2. Sitzia, J., & Wood, N. (1997). Patient satisfaction: A review of issues and concepts. Social Science & Medicine, 45(12), 1829-1843. 
3. Press, I., & Fullam, F. (2011). Patient Satisfaction in Pay for Performance Programs. Quality Management in Health Care, 20(2), 110-115
4. Health Quality Ontario (2011). 2011 Quality Improvement Plans: An Analysis for learning. Toronto, Canada: HQO
5. Veillard, J., Champagne, F., Klazinga, N., Kazandjian, V., Arah, O. A., & Guisset, A. L. (2005). A performance assessment framework for hospitals: the WHO regional office for Europe PATH project. International Journal for Quality in Health Care, 17, 487–496.
6. Williams, B. (1994). Patient satisfaction: A valid concept? Social Science & Medicine, 38(4), 509-516. 
7. Hekkert, K. D., Cihangir, S., Kleefstra, S. M., van den Berg, B., & Kool, R. B. (2009). Patient satisfaction revisited: A multilevel approach. Social Science & Medicine, 69(1), 68-75. 
8. Thi, P. L. N., Briançon, S., Empereur,F., & Guillemin, F. (2002). Factors determining inpatient satisfaction with care. Social Science & Medicine, 54(4), 493-504. 
9. Atkinson, S., & Medeiros, R. L. (2009). Explanatory models of influences on the construction and expression of user satisfaction. Social Science & Medicine, 68(11), 2089-2096.
10. Heidegger, T., Saal, D., & Nuebling, M. (2006). Patient satisfaction with anaesthesia care: What is patient satisfaction, how should it be measured, and what is the evidence for assuring high patient satisfaction? Best Practice & Research Clinical Anaesthesiology, 20(2), 331-346. 
11. Oliver, R. L. (2010). Satisfaction: A Behavioral Perspective on the Consumer (2nd ed.). New York: M.E. Sharpe.
12. Williams, B., Coyle, J., & Healy, D. (1998). The meaning of patient satisfaction: an explanation of high reported levels. Social Science & Medicine, 47, 1351–1359.
13. Canadian Health Services Research Foundation (2011). Public Perceptions and Media coverage of the Canadian healthcare system: a synthesis. 
14. Florin, D., & Dixon, J. (2004). Public involvement in health care, British Medical Journal , 328, 159-161.
15. Kreindler, S. A. (2009). Patient involvement and the politics of methodology, Canadian Public Administration, 51(1), 113–124.
16. Crawford, M. J., Rutter, D., Manley, C., Weaver, T., Bhui, K., & Fulop, N. (2002). Systematic review of involving patients in the planning and development of health care. British Medical Journal, 325, 1263–1265. 
17. Bate, S. P., & Robert, G. (2006). Experience-based design: From redesigning the system around the patient to co-designing services with the patient. Quality and Safety in Health Care, 15, 307-310.
18. Bate, P., Robert, G., & Maher, L. (2007). Bringing user experience to healthcare improvement: the concepts, methods and practices of experience-based design. Abingdon, UK: Radcliffe.
19. Sitzia, J. (1999). How valid and reliable are patient satisfaction data? An analysis of 195 studies. International Journal for Quality in Health Care, 11, 319-328.
20. Coulter, A. (2005). What do patients and the public want from primary care? British Medical Journal, 331, 1199–1201.

Production of this Mythbuster has been made possible through a financial contribution from Health Canada, through the Canadian Partnership Against Cancer. Mythbusters articles are published by the Canadian Foundation for Healthcare Improvement (CFHI) only after review by experts on the topic. CFHI is dedicated to accelerating healthcare improvement and transformation for Canadians and is funded through an agreement with the Government of Canada. Interests and views expressed by those who distribute this document may not reflect those of CFHI or the Government of Canada. © 2012.