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. 2019 Dec 24;17(1):152.
doi: 10.3390/ijerph17010152.

Combining Direct and Indirect Measurements to Assess Patients' Satisfaction With the Quality of Public Health Services in Romania: Uncovering Structural Mechanisms and Their Implications

Free PMC article

Combining Direct and Indirect Measurements to Assess Patients' Satisfaction With the Quality of Public Health Services in Romania: Uncovering Structural Mechanisms and Their Implications

Elena Druică et al. Int J Environ Res Public Health. .
Free PMC article


Introduction: Patients' satisfaction was extensively researched over the last decades, given its role in building loyalty, compliance to treatment, prevention, and eventually higher levels of wellbeing and improved health status. Patients' feedback on the perceived quality of health services can be incorporated into practice; therefore, understanding factors and mechanisms responsible for patients' satisfaction allows providers to tailor targeted interventions. Method: A questionnaire assessing patients' perception of the quality of health services was administered to a country-representative sample of 1500 Romanian patients. Using a partial least squares-path modeling approach (PLS-PM), with cross-sectional data, we developed a variance-based structural model, emphasizing the mediating role of trust and satisfaction with various categories of health services. Results: We confirmed the mediating role of trust in shaping the relationship between the procedural accuracy of health professionals, along with the perceived intensity of their interaction with patients, and patients' experienced quality of the health services. We confirmed the mediating role of satisfaction by the categories of services in the relationship between waiting time on the premises, attention received, and the perceived reliability of the information received, as predictors, and the experienced quality of the health services. In addition, indirect assessment of patients' satisfaction is a good predictor for direct assessment, thereby affirming the idea that the results of the two types of evaluations converge. Discussions: One of the most efficient solutions to increase both patients' satisfaction and their compliance is to empower the communication dimension between patients and health practitioners. Given the non-linear relationships among variables, we advocate that, unless the nature of the relationships between satisfaction and its predictors is understood, practical interventions could fail. The most relevant variable for intervention is the degree of attention patients perceive they received. We suggest three methods to turn waiting time into attention given to patients.

Keywords: PLS–PM modeling; health services quality; mediation analysis; patients’ satisfaction.

Conflict of interest statement

The authors declare no conflict of interest. The founding sponsors had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, and in the decision to publish the results.


Figure 1
Figure 1
Conceptual research model and hypotheses.
Figure 2
Figure 2
The non-linear relationship between procedural accuracy—doctors (PAD) and patients’ perception of the experienced quality of health services (EQ).
Figure 3
Figure 3
The non-linear relationship between the perception of overall quality and waiting time.

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