Patient satisfaction sets the foundation for a positive health care visit with a provider. Physicians provide a service, and this care is judged not only by the accuracy of their diagnoses but also by the manner in which it is provided. Patient satisfaction surveys are being increasingly used to understand what impacts patients' responses so as to improve the quality of care and overall outcomes of treatment.1 The Centers for Medicare & Medicaid Services has initiated value-based purchasing programs concerning patient satisfaction with incentive payments to hospitals regarding their performance on “quality” measures.2,3 Additionally, these programs are used as promotional advancement metrics for physicians and reimbursement.4,5
Measuring patient satisfaction is multidimensional. The Press Ganey Survey is widely used across different health care specialties and settings and attempts to capture or measure the various dimensions or domains of patient satisfaction.6,7 It is generated from 6 domains: access, moving through the visit, nurse/assistant, care provider, personal issues, and special services/valet parking. These domains are unique in their ability to impact a patient's overall experience, investigating everything from the courtesy of the staff and the provider to the efficiency of the visit. Each domain's individual influence on patient satisfaction is commonly overlooked, and the overall visit is typically interpreted in the overall patient satisfaction score. Each patient brings his or her own innate characteristics to the visit and perceives the importance of the visit differently.8 The Press Ganey Survey is a valid instrument for measuring satisfaction,6 but it is not known which domains are most impactful on patient satisfaction. Clinics attempt different strategies to increase overall patient satisfaction, and satisfaction scores are often used to merit promotion and physician monetary bonuses.9 A paucity of research exists concerning which of the 6 domains of the Press Ganey Survey are most impactful on patient satisfaction and therefore potential areas on which to focus resources.
Given the diverse nature of the 6 domains that make up the Press Ganey Survey, their individual impact on a patient's overall satisfaction with a visit must be investigated. Therefore, the purpose of this study was to evaluate patient satisfaction with an academic orthopedic clinical encounter as a function of the 6 domains of the Press Ganey Survey. In particular, the authors examined which of the 6 domains had a greater magnitude of relative importance in the expected relationship with patient satisfaction. The authors hypothesized that overall satisfaction would be influenced not only by the physician interaction but also by other factors out of the control of the physician.
Materials and Methods
This study received institutional review board approval. The authors retroactively reviewed patient satisfaction scores from 4737 clinical encounters (3900 patients) in the adult reconstructive surgery (n=899), sports medicine (n=1726), hand (n=961), foot and ankle (n=717), trauma (n=11), and general orthopedics (n=423) clinics within the orthopedic department of a single academic medical center between November 2010 and May 2017. All clinical encounters with patients 18 years and older who completed a survey following a clinic appointment were included in this study. After obtaining patient responses to the Press Ganey Survey, the following characteristic information was extracted from the patients' medical records for this cross-sectional study: age, sex, race, religion, marital status, comorbidities, type of health insurance provider, body mass index, zip code, provider, type of orthopedic clinic visited, and whether first or repeat visit to the clinic. A Charlson Comorbidity Index score10 was calculated for each patient. Patient zip code was used to approximate how far the patient traveled to the clinic. Provider age, sex, and race were obtained and included for descriptive purposes.
Measures of Patient Satisfaction
The Press Ganey Survey consisted of 24 questions/items that were divided into 6 domains: access (5 questions), moving through the visit (2 questions), nurse/assistant (2 questions), care provider (10 questions), personal issues (4 questions), and special services/valet parking (1 question). To focus on total patient satisfaction with the clinical encounter, the primary outcome of patient satisfaction was determined using all 24 items (or all 6 domains) of the Press Ganey Survey. The items were measured on a 5-point Likert-type scale and were summed to produce a total score that ranged from 0 to 100: very poor (0), poor (25), fair (50), good (75), and very good (100). Higher total scores indicated greater patient satisfaction with the clinical encounter.
Multiple Imputation for Missing Values
Missing values for the Press Ganey Survey items and characteristic variables, which occurred in no more than approximately 10% of the sample, were imputed. Missing values (with an assumed arbitrary missing pattern) for the classification variables and for the continuous variables were imputed via 500 burn-in iterations (samples) using fully conditional specification along with the discriminant method (for classification variables) and the predictive mean matching method (for continuous variables) of the PROC MI procedures in SAS version 9.4 software (SAS Institute, Inc, Cary, North Carolina).11
Demographic and clinical characteristics of the sample of 4737 orthopedic patient clinical encounters were described using sample mean and standard deviation for continuous variables and frequency and percentage for categorical variables. Multiple linear regression, with least squares estimation, was implemented to evaluate total patient satisfaction as a function of the 6 domains of the Press Ganey Survey. The standardized parameter estimates (ß) along with the squared semi-partial correlation coefficients (using type I sums of squares) were interpreted to identify (in rank order) which of the 6 domains had a greater magnitude of relative importance as well as the incremental R2, respectively, in the expected relationship with total patient satisfaction. A larger standardized parameter estimate indicated greater relative importance. To ascertain the presence of any multicollinearity in the linear regression model, the authors examined the variance inflation factor for each of the 6 domains. Finally, as a sensitivity analysis, a principal components analysis, with promax rotation, was used to define the dimensionality of the Press Ganey Survey total patient satisfaction scale (based on all 24 items) and to interpret (via the eigenvalues) the proportion of explained variance per factor (domain). Statistical analyses were performed using SAS version 9.4 software (SAS Institute, Inc).
Of the 4737 orthopedic encounters, 37.51% were with male patients and 72.83% were with non-Hispanic, white patients. Mean age of the patients was 59.03±15.51 years. Mean body mass index was 29.01±6.94 kg/m2, with 63.27% of the patients having a body mass index less than 30 kg/m2. Approximately 36% of the patients had Medicare insurance, approximately 36% traveled a mean of 35.81±111.17 miles to the clinic, and approximately 45% were new patients to the clinic. The mean Press Ganey Survey total satisfaction score was 90.08±12.35. Demographic and clinical characteristics of the overall sample of orthopedic patient clinical encounters are listed in Table 1.
Demographic and Clinical Characteristics of the Overall Sample
Patient Satisfaction With the Clinical Encounter
As shown in Table 2 and Figures 1–2, from the multiple linear regression model, the standardized parameter estimates revealed that, of the 6 domains of the Press Ganey Survey, care provider can be interpreted as having a greater magnitude of relative importance in the expected relationship with total patient satisfaction (standardized ß=0.53972). Almost 80% of the variance in total patient satisfaction was accounted for, or explained by, the care provider. Conversely, of the 6 domains, valet parking services had the least magnitude of relative importance in the expected relationship with total patient satisfaction (standardized ß=0.06302). Less than 1% (0.358%) of the variance in total patient satisfaction was accounted for, or explained by, valet parking services. Access, personal issues, moving through the visit, and nurse/assistant ranked second, third, fourth, and fifth, respectively, in relative importance in the expected relationship with total patient satisfaction (Table 2 and Figures 1–2). The estimated variance inflation factor for each of the 6 domains was close to 1 and less than 3 (Table 2), suggesting that multicollinearity was not present or problematic for any of the domains in the authors' linear regression model.
Multiple Linear Regression Results for Press Ganey Total Satisfaction as a Function of the 6 Domains
Plot of the standardized estimates against the Press Ganey satisfaction score for each of the 6 domains. The standardized parameter estimates indicated which of the 6 domains had a greater magnitude of relative importance in the expected relationship with Press Ganey total satisfaction; a larger standardized estimate indicated greater relative importance (N=4737 clinical encounters).
Plot of the standardized estimates against the incremental R2 of Press Ganey total satisfaction score for each of the 6 domains. The standardized parameter estimates indicated which of the 6 domains had a greater magnitude of relative importance in the expected relationship with Press Ganey total satisfaction; a larger standardized estimate indicated greater relative importance. Incremental R2 indicated the proportion of variance in total patient satisfaction that was accounted for, or explained by, each of the 6 domains (N=4737 clinical encounters).
Finally, as a sensitivity analysis, the principal components analysis suggested a 6-factor (domain) solution to operationalize the dimensionality of the Press Ganey total satisfaction scale (based on all 24 items), with the care provider being the most dominant factor (eigenvalue=11.8659) and valet parking services being the least dominant factor (eigenvalue=0.8398) of the 6 domains. Examination of the factor pattern loadings also suggested that access (eigenvalue=2.7282), personal issues (eigenvalue=1.0996), nurse/assistant (eigenvalue=1.0353), and moving through the visit (eigenvalue=0.8604) ranked second, third, fourth, and fifth, respectively, in the relative factor structure in defining the Press Ganey total patient satisfaction (Table 3).
Factor Loadings for the 24-Item Press Ganey Total Satisfaction Scale
As hypothesized, the 6 domains impacted patient satisfaction to differing degrees. The care provider was the most impactful element of the overall patient satisfaction during the clinic visit. This evaluation was developed from the patient's interpretation of the provider's friendliness, ability to explain the care, empathy, providing clear instructions, and amount of meaningful time spent. This finding is consistent with those of previous studies that focused on physician empathy in a hand surgery clinic, providers' time spent with patients in a spine clinic, and the level of explanation patients received concerning their condition when examining qualities patients most value in their providers.12–14 The overwhelming majority of total patient satisfaction was accounted for by the care provider. Patients' experience in the orthopedic surgery clinic strongly reflects the short, but intimate, interaction with their provider, although more time is spent navigating and handling the logistics of the visit. The remaining 5 domains, in descending order of importance to patient satisfaction, were access, personal issues, moving through the visit, nurse/assistant, and special services/valet parking. These 5 domains combined explained approximately 20% of a patient's overall satisfaction.
Americans are becoming more conscientious regarding their care, and there are well-documented growing trends toward consumerism in relation to health care services.15 Although health care providers are increasing their efforts to enhance the patient experience, they continue to struggle in this regard because the identification of areas in need of quality improvement is multidimensional. Health care delivery is remodeling to a structure in which patient satisfaction is almost equivalent to diagnostic and treatment outcomes. In the pediatric orthopedic outpatient setting, considered unique because the care dynamics involve multiple individuals, one study found that the likelihood of a practice being recommended by patients was most influenced by the patient–physician relationship, the cheerfulness of staff, and how well staff collaborated during the visit.16 These qualitative measures focus on how care is provided rather than the specific care that is provided.
These findings are important in the current health care climate, with the reimbursement model focusing more on measures of the quality of health care, such as patient satisfaction, than volume.1–3 The scores produced by patient satisfaction surveys hold value in the promotion and monetary bonuses at most academic medical centers. Many hospitals, providers, and administrators spend a significant amount of time and resources teasing out where to focus their energy for the highest return in increasing patient satisfaction.17 This is a prominent area of interest, and these findings are evidence that concentrating resources to improve physicians' approachability, increase the time they allocate during visits, and ensure that they answer all patient questions and provide clear instructions at each patient's level of understanding could have the greatest impact on patient satisfaction. Treating each patient as an individual and focusing on aspects of the visit such as the care provider or access could yield higher returns, as these domains have the greatest influence on patient satisfaction.
A potential limitation of this study was the self-reporting of patient satisfaction in an academic setting of a single health care specialty (orthopedic surgery). The results could have been different for patients in the private sector or for patients of other health care specialties with more autonomy regarding the care they receive.18 Although the large sample provided power to the study, the intrinsic limitations of a retrospective chart review remained. Further research is needed to determine whether these findings can be generalized to other health care settings and specialties. Additionally, after actions have been taken to improve the most influential factors of a patient's visit, a follow-up study would be beneficial to determine whether satisfaction scores have indeed improved significantly. This would offer a focus for providers when devoting resources to increase patient satisfaction and be more cost-effective.
Patients' experience with their care provider during their outpatient orthopedic surgery visit had the greatest impact on their overall satisfaction with the clinical encounter. Access, personal issues, moving through the visit, nurse/assistant, and special services/valet parking combined explained only approximately 20% of patients' total overall satisfaction. This knowledge can be useful in the evolving health care climate, where patient consumerism is becoming the driver of care. Additionally, health care providers can focus their resources on improving the physician–patient relationship, which in turn should have a greater impact on patient satisfaction.
- Batbaatar E, Dorjdagva J, Luvsannyam A, Savino MM, Amneta P. Determinants of patient satisfaction: a systematic review. Perspect Public Health. 2017;137(2):89–101. doi:10.1177/1757913916634136 [CrossRef]
- Zusman EE. HCAHPS Replaces Press Ganey survey as quality measure for patient hospital experience. Neurosurgery. 2012;71(2):N21–N24. doi:10.1227/01.neu.0000417536.07871.ed [CrossRef]
- Centers for Medicare & Medicaid Services. Hospital value-based purchasing. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLN-Products/downloads/Hospital_VBPurchasing_Fact_Sheet_ICN907664.pdf. Accessed December 19, 2018.
- Atasoylu AA, Wright SM, Beasley BW, et al. Promotion criteria for clinician-educators. J Gen Intern Med. 2003;18(9):711–716. doi:10.1046/j.1525-1497.2003.10425.x [CrossRef]
- The Physicians Foundation 2016 physician survey. https://physiciansfoundation.org/research-insights/physician-survey. Accessed January 9, 2019.
- Presson AP, Zhang C, Abtahi AM, Kean J, Hung M, Tyser AR. Psychometric properties of the Press Ganey outpatient medical practice survey. Health Qual Life Outcomes. 2017;15(1):32. doi:10.1186/s12955-017-0610-3 [CrossRef]
- Graham B, Green A, James M, Katz J, Swiontkowski M. Measuring patient satisfaction in orthopaedic surgery. J Bone Joint Surg Am. 2015;97(1):80–84. doi:10.2106/JBJS.N.00811 [CrossRef]
- Sofaer S, Firminger K. Patient perceptions of the quality of health services. Annu Rev Public Health. 2005;26:513–559. doi:10.1146/annurev.publhealth.25.050503.153958 [CrossRef]
- Lee VS, Miller T, Daniels C, Paine M, Gresh B, Betz AL. Creating the exceptional patient experience in one academic health system. Acad Med. 2016;91(3):338–344. doi:10.1097/ACM.0000000000001007 [CrossRef]
- Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373–383. doi:10.1016/0021-9681(87)90171-8 [CrossRef]
- van Buuren S. Multiple imputation of discrete and continuous data by fully conditional specification. Stat Methods Med Res. 2007;16(3):219–242. doi:10.1177/0962280206074463 [CrossRef]
- Menendez ME, Chen NC, Mudgal CS, Jupiter JB, Ring D. Physician empathy as a driver of hand surgery patient satisfaction. J Hand Surg Am. 2015;40(9):1860–1865. doi:10.1016/j.jhsa.2015.06.105 [CrossRef]
- Etier BE Jr, Orr SP, Antonetti J, Thomas SB, Theiss SM. Factors impacting Press Ganey patient satisfaction scores in orthopedic surgery spine clinic. Spine J. 2016;16(11):1285–1289. doi:10.1016/j.spinee.2016.04.007 [CrossRef]
- Williams G, Pattison G, Mariathas C, Lazar J, Rashied M. Improving parental satisfaction in pediatric orthopaedics. J Pediatr Orthop. 2011;31(5):610–615. doi:10.1097/BPO.0b013e3182203955 [CrossRef]
- Kolstad JT, Chernew ME. Quality and consumer decision making in the market for health insurance and health care services. Med Care Res Rev. 2009;66(1)(suppl):28S–52S. doi:10.1177/1077558708325887 [CrossRef]
- Peng FB, Burrows JF, Shirley ED, Rosen P. Unlocking the doors to patient satisfaction in pediatric orthopaedics. J Pediatr Orthop. 2018;38(8):398–402. doi:10.1097/BPO.0000000000000837 [CrossRef]
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Demographic and Clinical Characteristics of the Overall Sample
| Age, mean (SD), y||59.03 (15.51)|
| Male (No.)||37.51% (1777)|
| White, non-Hispanic (No.)||72.83% (3450)|
| Married (No.)||57.53% (2725)|
|Care provider demographics|
| Age, mean (SD), y||49.83 (10.81)|
| Male (No.)||89.57% (4243)|
| White, non-Hispanic (No.)||75.36% (3570)|
| Body mass index, mean (SD), kg/m2||29.01 (6.94)|
| Body mass index <30 kg/m2 (No.)||63.27% (2997)|
| Body mass index ≥30 kg/m2 (No.)||36.73% (1740)|
| First visit to clinic (No.)||44.71% (2118)|
| Medicare health insurance status (No.)||36.54% (1731)|
| Private health insurance status (No.)||63.46% (3006)|
| Distance to clinic, mean (SD), miles||35.81 (111.17)|
| Charlson Comorbidity Index score, mean (SD)||2.37 (1.96)|
|Press Ganey patient satisfaction scores (0 to 100)|
| Total composite score|
| Press Ganey total satisfaction score, mean (SD)||90.08 (12.35)|
| Domain items, mean (SD)|
| Care provider||91.62 (16.01)|
| Access||88.67 (13.92)|
| Personal issues||92.39 (12.45)|
| Moving through the visit||80.84 (24.90)|
| Nurse/assistant||91.50 (14.84)|
| Special services/valet parking||88.21 (18.68)|
|Care provider subspecialty (No.)|
| Sports medicine||36.44% (1726)|
| Hand||20.29% (961)|
| Adult reconstruction and hip||18.98% (899)|
| Foot and ankle||15.14% (717)|
| General orthopedic||8.93% (423)|
| Trauma||0.23% (11)|
Multiple Linear Regression Results for Press Ganey Total Satisfaction as a Function of the 6 Domains
|Standardized Estimatea||Incremental R2b||Cumulative R2||Variance Inflation Factor|
|Moving through the visit||0.16795||0.02322||0.99052||1.51969|
|Special services/valet parking||0.06302||0.00358||1.00000||1.10971|
Factor Loadings for the 24-Item Press Ganey Total Satisfaction Scale
|Press Ganey Total Satisfaction||Factor Loadingsa|
|Factor 1||Factor 2||Factor 3||Factor 4||Factor 5||Factor 6|
|Access question 1||0.33517||0.82038||0.39627||0.39698||0.33335||0.20600|
|Access question 2||0.39765||0.81989||0.48637||0.42547||0.37763||0.23478|
|Access question 3||0.36270||0.83627||0.45881||0.39158||0.41202||0.17389|
|Access question 4||0.35481||0.63773||0.50425||0.58117||0.43114||0.24947|
|Access question 5||0.33906||0.75770||0.40847||0.38814||0.40799||0.20552|
|Moving through visit question 1||0.33393||0.44594||0.40732||0.41156||0.92509||0.17640|
|Moving through visit question 2||0.35964||0.46181||0.44791||0.44928||0.91622||0.15632|
|Nurse/assistant question 1||0.45177||0.47489||0.53210||0.94680||0.41607||0.22000|
|Nurse/assistant question 2||0.50863||0.50068||0.54935||0.92801||0.45698||0.22974|
|Care provider question 1||0.87792||0.38478||0.51873||0.45718||0.30421||0.16182|
|Care provider question 2||0.92398||0.38775||0.51067||0.44858||0.31487||0.16249|
|Care provider question 3||0.93038||0.37468||0.51272||0.44043||0.31318||0.15640|
|Care provider question 4||0.91078||0.39451||0.51446||0.42527||0.30236||0.17769|
|Care provider question 5||0.74847||0.36589||0.47802||0.32859||0.31406||0.17044|
|Care provider question 6||0.85423||0.42024||0.52962||0.43305||0.33585||0.16677|
|Care provider question 7||0.84405||0.38833||0.53283||0.44254||0.29704||0.17326|
|Care provider question 8||0.86396||0.41680||0.52119||0.45051||0.38540||0.20235|
|Care provider question 9||0.92052||0.34839||0.50451||0.41954||0.30693||0.16525|
|Care provider question 10||0.90558||0.35117||0.48920||0.41347||0.32872||0.14668|
|Personal issues question 1||0.48904||0.44533||0.86567||0.46550||0.39817||0.24122|
|Personal issues question 2||0.73006||0.49579||0.78060||0.53859||0.43273||0.21639|
|Personal issues question 3||0.56292||0.50450||0.89325||0.53613||0.40252||0.24891|
|Personal issues question 4||0.55227||0.51132||0.86337||0.49196||0.38876||0.24246|
|Valet parking services question 1||0.19351||0.26047||0.27834||0.23988||0.17637||0.99859|
|Eigenvalue for each factor||11.86598||2.72829||1.09964||1.03538||0.86046||0.83988|