Irish Journal of Medical Science (1971 -)

https://doi.org/10.1007/s11845-019-02062-z

ORIGINAL ARTICLE

Patient satisfaction reporting—a cohort study comparing reporting

of patient satisfaction pre- and post-discharge from hospital
Muhammad Fahad Ullah 1 & Christina A. Fleming 1 & Kenneth Mealy 1

Received: 11 April 2019 / Accepted: 12 July 2019

# Royal Academy of Medicine in Ireland 2019

Abstract
Background Patients’ satisfaction reporting is important for assessing the quality of care in surgical practice. Post-discharge
questionnaire reporting is considered best practice; however, the logistics of this method remains problematic.
Aims To examine patient satisfaction response rates prior to and following discharge from the hospital in a general surgery
department.
Methods Two patient groups were examined: group 1—questionnaires were completed by patients prior to discharge; and group
2—questionnaires were posted to patients following discharge and were advised to return the questionnaire in a given time frame.
The questionnaire design was based on the WHO strategy on measuring responsiveness guidelines tailored to a population of
surgical patients.
Results Four hundred and fifty patients were examined [group 1 (N = 150); group 2 (N = 300)]). Results from pre- and post-
discharge questionnaires were similar in almost all parameters. The response rate dropped significantly in group 2, and the cost
was also significantly higher.
Conclusions There were no significant differences in reporting between pre- and post-discharge questionnaire responses. As pre-
discharge reporting is more efficient, less costly and has a higher response rate, this should be considered the preferred practice in
patient satisfaction assessments.

Keywords General surgery . Patient safety . Patient satisfaction

Introduction
In Donabedian’s healthcare quality model, patient satisfaction
is defined as patient-reported outcome measures where the
structures and processes of care can be measured by patient-
reported experiences [1, 2]. Optimising patient satisfaction
within health services has many benefits. It has been shown
that satisfied patients have better compliance rates to medica-
tion and treatments and thus have overall improved health
outcomes [3, 4]. High levels of patient satisfaction also corre-
late with improved efficiency of the healthcare team and has
been associated with reduced hospital length of stay (LOS),
* Muhammad Fahad Ullah
fahad.dowite@gmail.com
1
Department of General Surgery, Wexford General Hospital,
Wexford, Ireland
less frequent hospital visits and reduced hospital waiting list
times [5–8]. All of these factors combine facilitate improved
patient flow in both elective and emergency settings which
can have further monetary benefits [9]. Therefore, efforts to
improve patient satisfaction may contribute to increased effi-
ciency in hospital care. To maintain high levels of patient
satisfaction, regular assessment of patient satisfaction is re-
quired to identify problem areas that can be targeted for im-
provement [10]. The World Health Organisation (WHO) has
devised a framework for measuring health systems perfor-
mance through measurement of responsiveness in healthcare
[11]. Responsiveness may be considered as to how well the
health system meets the legitimate expectations of the popu-
lation for the non-health enhancing aspects of the health
system [12]. It includes the following elements: dignity, pri-
vacy and confidentiality, autonomy, prompt attention, com-
munication, social support, basic amenities and choice of pro-
vider. Accurate assessment of patient satisfaction can be per-
formed by interrogating these domains.

Until 2013, minimal evidence of patient satisfaction
reporting in an Irish setting was available. A study at
University Hospital Kerry reported on patient satisfaction
within the acute medical unit (AMU) in 2013
[13]. Following this, in April 2017, the Health Service
Executive (HSE) launched the National Patient Experience
Survey [14]. This was a joint initiative between the Health
Information and Quality Authority (HIQA), the HSE and
Department of Health with the aim to utilise data collected
to shape future healthcare policy, and improve health out-
comes for patients. Patients received a survey pack 2 weeks
following discharge from hospital. Response rate was 51% in
2017 [15] and 50% 2018 [16].
Post-discharge postal questionnaire reporting is consid-
ered a better practice for the assessment of patient satis-
faction; however, the logistics of data collection in this
setting remains problematic. Response rates tend to be
low and postal costs are incurred [17, 18]. In our study,
we aimed to analyse patient satisfaction among patients
attending a general surgery department. We further aimed
to compare response rates and outcomes relating to patient
satisfaction reporting pre- and post-discharge from hospi-
tal. The costs of both methods were also compared.
Methods
This study was performed in two phases (Table 1). Phase
1 involved distribution of patient satisfaction question-
naires pre-discharge from the hospital (February–
March 2015), whereby patients completed their paper-
based questionnaire in the discharge lounge and dropped
them into a box prior to discharge from the hospital.
Phase 2 involved distribution of patient satisfaction ques-
tionnaires post-discharge from the hospital (June–August
2015), whereby questionnaires were posted to patients
with a returning envelope following the discharge.
Patients were advised to return the envelope in a given
time frame. Patients undergoing both elective and emer-
gency treatment/surgery were included. In the 2nd phase.
The response rate was slow, and return envelopes were
coming back at a very slow speed; to overcome this, more
questionnaires were sent to more people, and the project
was finished once 100 questionnaires were received in a
given period of time. Patients who were less than 18 years
of age and those who came only for endoscopic proce-
dures were not included in this study. No patient identi-
fying information was recorded.
Questionnaire design
Our questionnaire was designed based on the WHO strat-
egy guideline for measuring responsiveness in healthcare.
Ir J Med Sci
In this strategy, the main domains are outlined, including
patient dignity, autonomy, confidentiality, prompt atten-
tion, social support, basic amenities and choice of provid-
er. This comprehensive questionnaire examined patient
satisfaction with access to services and waiting times,
communication and information, staff responsibilities,
empathy and respect by nursing team, empathy and re-
spect by medical team, patient-provider relationship,
safety/infection control, bed management, pain relief, hos-
pital facilities, complaints process, post-discharge advice
and care. Satisfaction was reported on a 5-point Likert
scale as follows: strongly agree, agree, disagree, strongly
disagree and does not apply to me. An overall satisfaction
rating was sought at the end of the questionnaire on a
scale of one to ten with one equating to least satisfied
and ten equating to most satisfied. A pilot study of 20
patients was performed to assess the initial questionnaire
for relevance and readability and appropriate changes
made.
On basic cost analysis, the 150 questionnaires that were
distributed in the 1st phase (in hospital prior to discharge) cost
a total of 20 euros (10 cents per questionnaire, and price of
stationery, etc.). Comparatively, the post-discharge postal
questionnaires (n = 300) cost a total of 600 euros (including
postal charges, labour charges, etc.). That is 0.13 € compared
to 2.00 € per questionnaire.
In the 1st phase, there was no expense of posting the ques-
tionnaires, questionnaires were printed privately from the hos-
pital library that cost 15 € for 150 questionnaires. Discarded
boxes were utilised to make collection boxes. Tapes and other
accessories cost 5 €, so in total, 20 € was the total amount
spent on phase 1.
Data analysis
Data were analysed using IBM SPSS, version 20.0.0.
Responses from the two groups were reported as absolute
values and percentages of the overall group size.
Comparison of satisfaction rates between pre- and post-
discharge phases was performed using the Wilcoxon-Mann-
Whitney rank test for assessment of non-parametric variables.
Statistical significance was observed at p < 0.05.
Results
Demographics and response rate
In total, 450 patients were included in the study. The most
common age group was 31–50 years in the 1st phase (28%)
and 51 to 70 yrs in 2nd phase. Old respondents were most
common in the 2nd phase (34%). The total number of female
respondents was 37% in the 2nd phase, as compared to 57.4%
Ir J Med Sci

Table 1 Study characteristics and

patient demographics Table Patient demographics P values*

Questions 1st Phase 2nd Phase

Time period Feb-march 2015 June-Sep 2015

Number of patients responded 150/150 100/300 <0.05
No: of females 57.4% n = 86 37% n = 37 0.06
Most common age group 31–50 (28%) 51–70 (34%) 0.46
Emergency vs elective admission ratio 3:1 3:1

*Where applicable

in phase 1. Elective vs emergency ratio was 3:1 in both sur-
veys (Table 1). Response rates were 100% in the 1st phase
while only 33.3% in the second (postal) phase. In the 2nd
phase, respondents were advised to return the questionnaire
within 4 weeks time. The 1st questionnaire was received
13 days post-discharge. The return envelopes were continued
to be accepted over a period of 2 months post-discharge. As
the response rate was low and return envelopes were coming
back at a very slow speed, more questionnaires were sent to
more people, and the project was finished once 100 question-
naires were received in two months time.
Comparison of outcomes between pre-
and post-discharge surveys
There were no significant differences in satisfaction rates
across different domains between the inpatient or day case,
outpatient, and accident and emergency users. After both sur-
veys, the majority of people graded our hospital above 7 out of
10 on an overall satisfaction level. Areas of highest
satisfaction were similar in both surveys, Fig. 1 shows the
areas with the highest satisfaction, where satisfaction is the
sum of agreed and strongly agreed. The only recognisable
differences were in the organisation of admissions where sat-
isfaction dropped from 100 to 86% (p < 0.05) and information
received at the time of admission (100 to 87%, p < 0.05).
Areas with least satisfaction included awareness about
consultant-in-charge of care, identity check prior to medica-
tion administration and getting help after pressing alarm bell.
However, all of these domains had slightly higher satisfaction
levels when measured in the 2nd phase. Areas with least sat-
isfaction are shown in Fig. 2.
Table 2 shows a comparison of satisfied respondents
across different domains in both phases. Again no signif-
icant differences are identified. The number of questions
‘not answered’ and number of responses with ‘do not
know’ were higher in phase 2 as shown in Table 3. This
table shows the response comparisons across the different
domains and p values after using the Wilcoxon-Mann-
Whitney test. The results obtained as a result of this were
not statistically significant.

Areas with highest satisfaction

105

100
satisfaction

95

90

85

80

75
The
if I needed
information I I was always hospital staff
help,it was members of I was satisfied
my admission recieved treated with were neat in
always given nursing team with the level
was well regarding my dignity and appearnace
in a timely were of privacy I
organised admission respect by and dressed
manner by courteous received
was nursing team appropriately
hospital staff
satisfactory
2nd phase % satisfied 86 87 90 95 97 95 97
1st phase % satisfied 100 100 96.6 97.3 97.4 97.3 96.7

Fig. 1 Areas with highest satisfaction

 Ir J Med Sci

Fig. 2 Areas with lowest

satisfaction Areas with least Satisfaction
90
80
70

satisfaction%
60
50
40
30
20
10
0
A member of health care
Did u know name of the team confirmed my After you pressed the call
consultant incharge of identity prior to button did you get the
your care administering my appropriate help
medication?
phase 2 85.6 83.5 70
phase 1 64 62.7 57.4

The results of the 2 phases were discussed at Perioperative The suggestions included:
governance meeting. The meeting included representatives
from different medical and allied surgical groups, e.g., nurs- & Regular satisfaction surveys
ing, health care assistants, etc. After discussion, summaries & Proper introduction of medical staff to patients
and conclusions and suggested changes were displayed on & Mentioning of names of consultant on patients beds
the noticeboard. The representatives from different groups & Provision of information leaflets
were advised to implement the suggestions. & A better explanation of procedures to patients

Table 2 Overall satisfaction rates with comparison between both study phases. ‘Satisfied’ is defined as ‘sum of agreed and strongly agreed responses’

Satisfied respondents in 2nd Satisfied respondent in 1st

phase phase

Questions Number Percentage Number Percentage p value

My admission was well organised 86 86 150 100.0 0.419

The information I received regarding my admission was 81 81 150 100.0 0.264
The purpose of test/procedures/operations/new medication was explained to me 89 89 116 100.0 0.46
Did the doctor explain procedure/operation before hand 56 56 129 77.3 0.036
If I needed help it was always given in a timely manner by hospital staff 90 90 145 86.0 0.77
It was possible to have a private conversation with member of my healthcare team 83 83 126 96.7 0.95
Members of nursing team were courteous 95 95 146 84.0 0.89
I was always treated with dignity and respect by nursing team 97 97 146 97.3 0.98
Members of nursing team protected my confidentiality 93 93 137 97.3 0.922
I was satisfied with the level of privacy I received 95 95 146 91.3 0.89
Did the nurses explain things in way you could understand 98 98 143 97.3 0.88
After you pressed the call button did you get the 70 70 86 95.3 0.33
Members of my medical team were courteous 97 97 97 142 57.3
I was treated with dignity and respect by my medical team 98 98 142 94.7 0.85
Members of my medical team protected my confidentiality 92 92 136 94.7 0.93
I was satisfied with the level of privacy I received 95 95 138 90.7 0.86
Did my medical team explained you things in a way you could understand 91 91 129 92.0 0.76
Hospital staff were neat in appearance and dressed 97 97 145 86.0 0.98
Everything possible was done to relieve my pain 92 92 133 96.7 0.84
Did member of your health care team wash their hands before attending to you 77 77 126 88.7 0.65
Ir J Med Sci

Table 3 P value with Wilcoxon-Mann-Whitney test

Questions Phase Strongly agree Agree Disagree Strongly agree Not applicable Not answered p value

My admission was well Phase 1 61 39 0 0 0 8.7 0.52

organised Phase 2 60.5 25.6 2.3 2.3 9.3 0
The information I received Phase 1 60.9 39.1 0 0 0 0 1
regarding my admission Phase 2 58.1 23.3 0 0 16.3 2.3
was satisfactory
The purpose of Phase 1 38 39.3 4.7 0.7 2.7 14.7 1
test/procedures/- Phase 2 50.5 38.1 4.1 0.0 4.1 3.1
operations/new
medication was
explained to me
Did the doctor explain Phase 1 46 40 1.3 0 12.7 0 0.916
procedure/operation be- Phase 2 33.0 23.0 2.5 0.0 26.5 21.0
fore hand
If I needed help, it was Phase 1 41.3 55.3 0 0 3.3 0 0.83
always given in a timely Phase 2 54.6 35.1 6.2 1.0 1.0 1.0
manner by hospital staff
It was possible to have a Phase 1 28 56 5.3 0 3.3 0 0.753
private conversation Phase 2 40.2 42.3 8.2 0.0 6.2 3.1
with member of my
healthcare team
Members of nursing team Phase 1 57.3 40 0 0 0.7 2 0.39
were courteous Phase 2 72.2 22.7 1.0 1.0 1.0 2.1
I was always treated with Phase 1 64.7 32.7 0 0 0 2.7 0.58
dignity and respect by Phase 2 71.1 25.8 0.0 1 1.0 1.0
nursing team
Members of nursing team Phase 1 54.7 36.7 0 0 1.3 7.3 1
protected my Phase 2 60.8 32.0 0.0 0.0 6.2 1
confidentiality
I was satisfied with the Phase 1 48 49.3 0 0 0 2.7 0.588
level of privacy I Phase 2 53.6 41.2 2.1 0.0 2.1 1.0
received
Did the nurses explain Phase 1 55.3 40 2 0 0 2.7 1
things in way you could Phase 2 60.8 37.1 1.0 0.0 0.0 1.0
understand
After you pressed the call Phase 1 36.7 20.7 3.3 0 36.7 2.7 1
button, did you get the Phase 2 39.2 30.9 2.1 1.0 22.7 2.1
appropriate help
Members of my medical Phase 1 55.3 39.3 0 0 0 5.3 0.59
team were courteous Phase 2 62.9 34 2.1 0.0 1 0.0
I was always treated with Phase 1 52 42.7 0 0 0 5.3 0.823
dignity and respect by Phase 2 62.9 35.1 1.0 0.0 0.0 1.0
my medical team
Members of my medical Phase 1 46 44.7 0 0 0 9.3 0.59
team protected my Phase 2 53.6 38.1 1.0 0.0 3.1 4.1
confidentiality
I was satisfied with the Phase 1 45.3 46.7 0 0 0 8 0.59
level of privacy I Phase 2 51.5 43.3 2.1 0.0 1.0 2.1
received
Did my medical team Phase 1 41.3 44.7 2 0 0 12 0.671
explained you things in a Phase 2 54.6 36.1 2.1 0.0 2.1 5.2
way you could
understand
Hospital staff were neat in Phase 1 62 34.7 0 0 0 3.3 1
appearance and dressed Phase 2 58.8 38.1 0.0 0.0 0.0 3.1
appropriately
Everything possible was Phase 1 69.3 19.3 1.3 0 2.7 7.3 1
done to relieve my pain Phase 2 60.8 30.9 2.1 0.0 2.1 4.1
Did member of your health Phase 1 79 5.3 0 0 10 5.3 0.829
care team wash their Phase 2 63.9 13.4 0.0 0.0 16.5 6.2
hands before attending
to you

The above-mentioned initiatives showed an improvement
in results in phase two, especially in awareness about the name
of consultant in charge and better explanation of the procedure
to patients (Fig. 2).
Discussion
In this study, we identified that reporting of patient satisfaction
using two different survey methods (pre-discharge, in-hospital
versus post-discharge, postal) did not find significantly differ-
ent levels of patient-reported satisfaction with our hospital
service. This is relevant because mailed surveys are consid-
ered to offer less bias, as there is less hospital staff influence
on patients when they are at home, but the cost difference
between the two different types of surveys (mailed vs inpa-
tient) is significant. Postal surveys also present logistic issues,
as there is a need to send reminder letters and the response
rates are low [17, 18]. In our study, a total of 150 question-
naires were distributed in the 1st phase that cost 20 euros in
total, while post-discharge 300 questionnaire cost 600 euro
making postal questionnaires 15 times more expensive. The
response rate was also lower in the postal phase (33%) as
compared to inpatient phase where the response rate was
100%. This postal response rate is in line with international
data [17, 18]. In addition, the postal phase took approximately
2 months following the dispatch of the questionnaires for
completion.
Our study showed that most common age group of respon-
dents in 1st phase was (31–50), which changed to (51–70) in
2nd phase. The reason is not clear and needs further studies,
but one possible reason is younger people get busy in their
daily life activities and are unable to find time to post ques-
tionnaires back to the hospital. Number of female respondents
also dropped in 2nd phase in our study that needs further
studies. Studies have suggested that younger age, male sex,
more pain, working status, marital status and smoking were
associated with not responding to follow-up in post surveys.
People working full time and patients with families and chil-
dren have shown lower response rates in many studies
[19–23]. One possible explanation for this would be lack of
interest or time for such activities, among people with children
or full-time job. Younger patients usually are not compliant
even with medication, so it becomes even harder for them to
do this extra duty. Further studies are needed to examine the
demographics of the non-responders in the Irish population.
This is relevant at national level, and the survey results
from national patient satisfaction survey also show a low re-
sponse [15, 16].
The number of answers with "do not know " or ques-
tions left unanswered was significantly higher in phase 2
that reflects a decreased engagement or interest towards the
filling of the questionnaires following hospital discharge.
Ir J Med Sci
Patient’s satisfaction can be defined as the degree to
which the patients’ desired expectations, goals and/or
preferences are met by the healthcare provider and service
[24–26]. Patient satisfaction is a generally broad term that
can cover the technical quality of care, finance, continuity
of care, convenience physical environment, the outcome
of care and accessibility [24–26]. Patient satisfaction is
considered an indirect measure of the efficacy of a
healthcare team [27]. Results from patient satisfaction sur-
veys can be used to improve the quality of the health care
processes and also to modify quality improvement initia-
tives [28–30]. Patient satisfaction surveys are compulsory
in certain countries, e.g., France [31] where surveys and
patient feedback analyses are mandatory to maintain li-
cencing. To date, very little work had been done in
Ireland on patient satisfaction surveys. However, in
2017, the launch of the National Patient Experience
Survey sought to fill this gap.
In the National Patient Experience Survey, information on
patient experience is collected through a structured survey
questionnaire. Eligible participants receive the survey in the
post about 2 weeks after they are discharged from the hospital.
The survey can either be filled out or returned in the freepost
envelope provided, or completed online. The response rate for
the national patient experience survey was 51% in 2017 [15]
and 50% in 2018 [16]. This paper provides a cost-effective
suggestion for analysing patient satisfaction with a higher re-
sponse rate.
Our questionnaire was based on eight domains of
health responsiveness as defined by the WHO, i.e., digni-
ty, autonomy, confidentiality, prompt attention, access to
social support during care, quality of basic amenities,
choice of care provider and the responsiveness of health
system [32]. Responsiveness refers to the ability of a
health system to respond to the legitimate expectations
of the population. This is associated with the non-
medical aspect of the health system and environment in
which the people are treated [33]. Our questionnaire cov-
ered questions on all these domains and analysed the
whole patient journey from arrival or appointment ar-
rangement to post-discharge care.
In conclusion, this study found little difference between
the results of pre- and post-discharge patient satisfaction
survey results. In addition the logistical ease and low cost
support use of a pre-discharge survey. As there is no
recognised ‘gold standard’ measure of patient satisfaction
[34], we believe pre-discharge method of patient satisfac-
tion reporting should be more widely used.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
interest.
Ir J Med Sci
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