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PLoS One. 2015 Jul 7;10(7):e0131805. doi: 10.1371/journal.pone.0131805. eCollection 2015.

Patient Experience Shows Little Relationship with Hospital Quality Management Strategies.

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Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom; Red de investigación en servicios de salud en enfermedades crónicas REDISSEC, Barcelona, Spain.
Department of Epidemiology, The Fielding School of Public Health, University of California, Los Angeles (UCLA), Los Angeles, California, United States of America.
Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.
Netherlands Institute for Health Services Research, Utrecht, the Netherlands; Department of Public and Occupational Health, VU University Medical Center, Amsterdam, the Netherlands.
Danish Clinical Registries, Aarhus, Denmark, and Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
Unité Méthodes Evaluation en Santé, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France.
School of Social and Political Science, University of Edinburgh, Edinburgh, United Kingdom.
Palo Alto Medical Foundation Research Institute (PAMFRI), Palo Alto, California, United States of America.
Institute of Medical Sociology, Health Services Research and Rehabilitation Science, University of Cologne, Cologne, Germany.
Avedis Donabedian Research Institute (FAD), Universitat Autonoma de Barcelona, Barcelona, Spain; Red de investigación en servicios de salud en enfermedades crónicas REDISSEC, Barcelona, Spain.



Patient-reported experience measures are increasingly being used to routinely monitor the quality of care. With the increasing attention on such measures, hospital managers seek ways to systematically improve patient experience across hospital departments, in particular where outcomes are used for public reporting or reimbursement. However, it is currently unclear whether hospitals with more mature quality management systems or stronger focus on patient involvement and patient-centered care strategies perform better on patient-reported experience. We assessed the effect of such strategies on a range of patient-reported experience measures.


We employed a cross-sectional, multi-level study design randomly recruiting hospitals from the Czech Republic, France, Germany, Poland, Portugal, Spain, and Turkey between May 2011 and January 2012. Each hospital contributed patient level data for four conditions/pathways: acute myocardial infarction, stroke, hip fracture and deliveries. The outcome variables in this study were a set of patient-reported experience measures including a generic 6-item measure of patient experience (NORPEQ), a 3-item measure of patient-perceived discharge preparation (Health Care Transition Measure) and two single item measures of perceived involvement in care and hospital recommendation. Predictor variables included three hospital management strategies: maturity of the hospital quality management system, patient involvement in quality management functions and patient-centered care strategies. We used directed acyclic graphs to detail and guide the modeling of the complex relationships between predictor variables and outcome variables, and fitted multivariable linear mixed models with random intercept by hospital, and adjusted for fixed effects at the country level, hospital level and patient level.


Overall, 74 hospitals and 276 hospital departments contributed data on 6,536 patients to this study (acute myocardial infarction n = 1,379, hip fracture n = 1,503, deliveries n = 2,088, stroke n = 1,566). Patients admitted for hip fracture and stroke had the lowest scores across the four patient-reported experience measures throughout. Patients admitted after acute myocardial infarction reported highest scores on patient experience and hospital recommendation; women after delivery reported highest scores for patient involvement and health care transition. We found no substantial associations between hospital-wide quality management strategies, patient involvement in quality management, or patient-centered care strategies with any of the patient-reported experience measures.


This is the largest study so far to assess the complex relationship between quality management strategies and patient experience with care. Our findings suggest absence of and wide variations in the institutionalization of strategies to engage patients in quality management, or implement strategies to improve patient-centeredness of care. Seemingly counterintuitive inverse associations could be capturing a scenario where hospitals with poorer quality management were beginning to improve their patient experience. The former suggests that patient-centered care is not yet sufficiently integrated in quality management, while the latter warrants a nuanced assessment of the motivation and impact of involving patients in the design and assessment of services.

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