Understanding the factors that influence patient satisfaction with ambulance services This is the ...

27 Pages·2016·0.49 MB·English

by  Kylie Aston

Understanding the factors that influence patient satisfaction with ambulance services
This is the peer reviewed author accepted manuscript (post print) version of a published work that
appeared in final form in:
Bogomolova, Svetlana, Tan, PJ, Dunn, SP & Bizjak-Mikic, M 2016 'Understanding the factors that
influence patient satisfaction with ambulance services' Health Marketing Quarterly, vol.33, no. 2,
pp. 163-180
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This is an Author's Accepted Manuscript of an article published in Health Marketing
Quarterly, vol. 32 no, 2 pp. 163-180, copyright 2016 Taylor & Francis, available online
at: http://www.tandfonline.com/doi/full/10.1080/07359683.2016.1166864
FACTORS INFLUENCING AMBULANCE PATIENT SATISFACTION
1
UNDERSTANDING THE FACTORS THAT INFLUENCE PATIENT
SATISFACTION WITH AMBULANCE SERVICES
Forthcoming in Health Marketing Quarterly

Bogomolova S.*, Tan P.J.*, Dunn S.P.*, and Bizjak-Mikic M.#
*Ehrenberg-Bass Institute for Marketing Science, University of South Australia, GPO Box
2471, Adelaide 5001,
[email protected]
#The Council of Ambulance Authorities, PO Box 7108, St Kilda Road, Victoria 8004,
[email protected]

The authors acknowledge the generous assistance of the Council of Ambulance Authorities
Inc. in the provision of patient satisfaction data.

Correspondence concerning this article should be addressed to Dr. Svetlana Bogomolova,
Senior Researcher, Ehrenberg-Bass Institute for Marketing Science, University of South
Australia. E-mail: [email protected]
FACTORS INFLUENCING AMBULANCE PATIENT SATISFACTION
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UNDERSTANDING THE FACTORS THAT INFLUENCE PATIENT
SATISFACTION WITH AMBULANCE SERVICES

Abstract
The quality of ambulance services has an immense impact on patients’ future wellbeing and
quality of life. Patient satisfaction is one of the key metrics for evaluating the quality of this
service. Yet, the patient satisfaction measurement may be limited in its ability to accurately
reflect this service quality, and even reflect factors beyond the patient experiences. The
authors analyze 10 years of survey data to reveal a number of factors that systematically bias
ambulance satisfaction ratings. Taking into account these biases provides more robust
comparison of ambulance performance over time or across different jurisdictions.

Keywords: ambulance services, patient satisfaction, overall satisfaction
FACTORS INFLUENCING AMBULANCE PATIENT SATISFACTION
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Introduction
Ambulance services and medical emergency transportation play pivotal roles in the
delivery of health-care, through pre-hospital emergency care and patient transport. The
quality of the service can directly impact immediate patient wellbeing, as well as their long-
term quality of life. The very first medical service that patients encounter, which is often
ambulance services, play a crucial role in patients’ recovery (Talib, Rahman, & Azam, 2011).
Given the importance of this service to the community, it is vital to have a robust metric to
evaluate service quality. Patient satisfaction is the key performance indicator for the
ambulance service.
The measurement of patient satisfaction is a common practice across the health-
services industry. Where quality of health-care provision has traditionally been assessed from
a clinical perspective, patient satisfaction provides insight into patients’ subjective
experiences (Gill & White, 2009). The proliferation of the measure has been in response to an
increasingly consumer-oriented focus in health-care (Avis, Bond, & Arthur, 1995), and is
now a central factor when evaluating and reforming health-care systems (Bleich, Özaltin, &
Murray, 2009; Rahmqvist & Bara, 2010). Additionally, patient satisfaction has been linked to
improved patient outcomes and reduced costs (Aharony & Strasser, 1993; Bleich et al., 2009;
Gill & White, 2009).
However, numerous studies of patient satisfaction have identified a range of issues
related to measurement and accuracy of reported results (Avis et al., 1995; Gill & White,
2009; Sitzia & Wood, 1997; Williams, 1994). These studies bring into question the
understanding of what patient satisfaction scores represent and their ability to accurately
identify changes in quality. A growing body of literature has identified various predictors of
satisfaction that are not even related to service quality, with differences in satisfaction scores
FACTORS INFLUENCING AMBULANCE PATIENT SATISFACTION
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found to be at least partly attributable to patient characteristics (Cohen, 1996; Jackson,
Chamberlin, & Kroenke, 2001; Rahmqvist & Bara, 2010). A comprehensive understanding of
the nature of patient satisfaction is needed for it to be useful evaluative metric and avoid
misinterpretations.
While progress has been made towards developing an understanding of patient
satisfaction measurement across a wide array of health-care areas, few studies have
specifically analyzed ambulance satisfaction (e.g. Anisah, Chew, Mohd Shaharuddin Shah, &
Nik Hisamuddin, 2008; Stewart, 2002). The nature of ambulance services is functionally
quite different compared to in-hospital services. For instance, it involves unique services
dimensions, such as the emergency phone calls and ambulance rides. From the patient
perspective, the expectations may also differ, perhaps a greater preference for speed of
service over bedside manner. As such, it is unclear whether prior findings, developed in the
context of in-hospital care, will generalize to the ambulance service and whether there are
additional influencing factors unique to the ambulance service.
This research aims to extend the understanding of patient satisfaction to the context of
the ambulance services industry. The research pursuits three objectives. The first is to
establish satisfaction score norms across different ambulance service dimensions (e.g.
paramedic care, ride quality, call taker assistance). Expected norms provide enhanced
interpretation of satisfaction surveys through identifying deviations, which can indicate areas
of service deficiencies and excellence. The second objective is to uncover dimensions of
ambulance experience that have the strongest relationship with the overall satisfaction. This
provides health care practitioners and stakeholders with insights into what the overall patient
satisfaction construct is actually measuring and highlights the areas most important to
patients, which may accordingly need a greater focus. The final objective is to explore
FACTORS INFLUENCING AMBULANCE PATIENT SATISFACTION
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person-based factors beyond the actual experience that influence overall ambulance patient
satisfaction scores. The ability to control for such factors can provide a more accurate
evaluation of the service, allowing for more robust comparison of the performance over time
or across the different ambulance jurisdictions. Increased accuracy will allow service
providers to better identify areas in need of attention to further improve their service to the
community. These objectives are addressed through the analysis of ten years of ambulance
patient satisfaction surveys collected for 11 state-based ambulance authorities across
Australia and New Zealand.
Hypothesis Development
Ambulance Satisfaction Ratings Norms
Ceiling effect
High patient satisfaction scores have been consistently reported across different health
services (e.g. hospital care, emergency departments, nursing, medical air transportation),
countries, sample sizes, and measurement scales (e.g., Fultz, Coyle, & Reynolds, 1998;
Kuisma, Määttä, Hakala, Sivula, & Nousila‐Wiik, 2003; Stevens, Reininga, Boss, & van
Horn, 2006; Sun et al., 2000). Of particular relevance is that similar response pattern has also
been found in a few studies that looked into the context of ambulance satisfaction (Anisah et
al., 2008; Stewart, 2002). Proposed explanations include a natural sample bias of surviving
patients (Hall & Dornan, 1988a), feelings of gratitude (Anisah et al., 2008), and desires not to
appear unappreciative (Sitzia & Wood, 1997; Williams, 1994).
The prevalence of very high satisfaction scores causes limitations for the analysis due
to a ceiling effect, which occurs when a variable’s score approaches its maximum for the
majority of respondents (Cramer & Howitt, 2004). Difficulty arises in identifying areas
FACTORS INFLUENCING AMBULANCE PATIENT SATISFACTION
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underperforming and/or areas that have improved as a result of substantial efforts (as the
score cannot move much higher hitting “the ceiling effect”). Our first hypothesis tests the
presence of this known pattern reported in previous in-hospital studies in the ambulance
service satisfaction scores:
H1: Ambulance patient satisfaction scores will display ceiling effects.
Dimensions of service experience
Patient surveys will generally involve satisfaction evaluations across various service
dimensions. Even though high satisfaction may persist across ambulance satisfaction scores,
disparities in evaluations could still develop between these service dimensions. Prior
literature indicates that the human aspects of the emergency health services will obtain higher
satisfaction scores compared to the tangible elements of the service, such as equipment
(Boudreaux & O'Hea, 2004; Hall & Dornan, 1988b; Stephenson, Wilson, & Gladman, 1995).
This is due to the care, empathy, and comfort that staff members can offer, which cannot be
acquired from the equipment. Therefore, patients would normally give a higher satisfaction
score towards the human aspects of the service. In a similar vein, Stewart (2002) showed that
the quality of the ambulance ride was the one aspect that obtained the lowest satisfaction
score amongst the other dimensions. Evaluation of the quality of the ride (transportation
experience), arguably, is the most tangible element of ambulance service, as it depends on the
quality of the vehicle, the facilities inside, the condition of the road. The second hypothesis
reflects the expected discrepancy in the scores for different dimensions of ambulance service:
H2: Dimensions of ambulance service satisfaction associated with human components
will receive higher scores than dimensions associated with non-human components.

Factors Associated with Overall Patient Satisfaction
FACTORS INFLUENCING AMBULANCE PATIENT SATISFACTION
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While satisfaction is collected across all service dimensions, overall satisfaction is
often the focal point of the research and managerial attention. For example, in Australia, the
overall patient satisfaction with the ambulance services is reported to the Health Minister and
is publically announced annually. Yet, the overall satisfactions, perhaps, one of the most
ambiguous metrics collected, due to its over-encompassing nature. Without a comprehensive
understanding of what this measure really reflects, its managerial usefulness is limited. The
remaining hypotheses relate to identifying factors contributing to the overall satisfaction.
This includes (1) the contribution of the service dimensions (e.g. the call response, paramedic
care, treatment, ride quality) and (2) the influence of demographic and other
patient/respondent characteristics.
Service dimensions associated with overall satisfaction
Service dimensions have previously been found to vary in their contribution towards
overall patient satisfaction. Research of the US emergency departments revealed the largest
contributor to the overall satisfaction to be interpersonal interactions with staff (Boudreaux &
O'Hea, 2004; Muntlin, Gunningberg, & Carlsson, 2006). In particular, staff communication
skills (e.g. the ability to listen, to show empathy and care, to explain the diagnosis) were the
primary driver of the overall satisfaction. Sitzia and Wood (1997) also recognized
interpersonal manner, such as the provider’s respect, concern, friendliness, and courtesy, was
one of the components of patient satisfaction. Understanding the dimensions reflected in
overall satisfaction will improve the interpretation and implications from the measure. In this
study, we examine whether these findings generalize to the ambulance service satisfaction:
H3: The dimensions of the service associated with human interaction will be the
strongest contributor towards the overall patient satisfaction with the ambulance
service.
FACTORS INFLUENCING AMBULANCE PATIENT SATISFACTION
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Patient characteristics associated with the overall satisfaction
Respondent characteristics have also been identified as determinants of overall patient
satisfaction scores. This means that scores reflect factors other than just the service quality.
Such biases need to be known and accounted for when interpreting satisfaction results. Age is
a patient characteristic consistently found to affect satisfaction scores, with older patients
providing higher scores (Barg et al., 2007; Cohen, 1996; Findik, Unsar, & Sut, 2010; Jackson
et al., 2001; Kuisma et al., 2003; Stewart, 2002). Another factor is prior experience, whereby
patients who had used the service previously reported being more satisfied (O'Meara, 2012;
Stewart, 2002). The satisfaction surveys often also have the option for relatives or carers to
complete the questions. Yet, relatives and carers perspectives on the service - as people who
are physically fit but are in emotional distress for their loved ones - could be distinctly
different from the perspective of the patient who might not even be conscious during the
experience. Studies taking this into account have identified higher satisfaction among patient
respondents (McCartan-Quinn, McAleer, & Naqvi, 1996; Walker & Restuccia, 1984).
Hypotheses 4, 5 and 6 test these three findings in the ambulance service context:
H4: Age will be positively related to satisfaction scores.
H5: Patients with prior ambulance experience will provide higher satisfaction scores.
H6: The satisfaction scores will be higher for patients than for relatives/carers.
The relationship between patient satisfaction and gender has been mixed between
studies (see Table 1). There are examples of higher satisfaction among males (Findik et al.,
2010; Nguyen Thi, Briancon, Empereur, & Guillemin, 2002), females (Davis & Duffy, 1999;
Lieberman, Sledge, & Matthews, 1989), and even no difference between genders (Kuisma et
al., 2003; Stephenson et al., 1995; Stewart, 2002). Importantly, Stewart’s (2002) analysis of
ambulance satisfaction was among the studies finding no gender bias.