Evaluation of Quality of Healthcare: To What Extent  Can We Rely on Patient Expectations and Preferences


Ismail Alrashdi

  DOI 10.5001/omj.2012.107  

Department of Quality Management, Royal Hospital, Sultanate of Oman.

Received: 03 Aug 2012
Accepted: 06 Oct 2012

*Address correspondence and reprints request to: Ismail Alrashdi, Department of Quality Management, Royal Hospital, Sultanate of Oman.
E-mail: alrashdi.7@gmail.com

How to cite this article

Alrashdi I. Evaluation of Quality of Healthcare: To What Extent  Can We Rely on Patient Expectations and Preferences. Oman Med J 2012 Nov; 27(6):448-449.

How to cite this URL

Alrashdi I. Evaluation of Quality of Healthcare: To What Extent  Can We Rely on Patient Expectations and Preferences. Oman Med J 2012 Nov; 27(6):448-449. Available from http://www.omjournal.org/fultext_PDF.aspx?DetailsID=301&type=fultext


Consumers today are more aware of the offered alternatives and rising standards of services, thus their expectations have increased markedly.1 With the pressure of competition and the increasing necessity to deliver to the satisfaction of patients, the elements of looking at the quality issues in healthcare and provider understanding of patients’ preferences and satisfaction attributes have become an absolute necessity. Like any service provider, it is crucial for healthcare providers to constantly determine the factors associated with the satisfaction of patients with the quality of healthcare provided to understand what is valued by the patient, how the quality of care is constructed by the patient and to determine how service improvement can be made and prioritized in a health service with limited resources.

Understanding the perception and narrowing the gap between the customer’s expectation and what can actually be provided should be what any organization works to accomplish. Thus, it is logic that the quality of health services be evaluated on the basis of the patients, who are after all the final recipient of the process outcome of the services, since the health service’s product primarily concerns the patients themselves and their families.

Researchers such as Charles et al. (1999) and Hausman (2004) found that patients desire a shift from the usual classic approach in which the doctor has a dominant role and makes the decision on his own, to patient oriented approach, a more informative, shared and negotiated approach in which the patient can exchange information with staff and has a more active role in the decision making.2,3

Patient’s point of view helps the provider to be more sensitive and responsive to the specific needs of the individual patient to offer patient oriented approach and it helps patients to obtain the more personalized and holistic medical attention that they seek.4 Looking at the whole picture, when patients get response to their specific needs and receive good quality communication for example, not only do they tend to be more satisfied with the care received, but they exercise greater adherence to agreed treatment plans and courses of action and seem to make more rapid recoveries with fewer complications, and thus may reduce the cost of delivering the service.

The differences between healthcare service and other services and the trust relationship that must be established between health professionals and patients require a deeper understanding of the preferences of patients in the medical encounter.

Any plausible program to bring about improvement in health service without sufficient and comprehensive understanding of the expectations and preferences of patients is likely to face serious difficulties.5 Therefore, with the increasing cost of health services and limited resources, patient preferences and priorities should help to determine and prioritize quality improvement agenda. Some authors went far with this concept. Peterson (1988) for example suggests that: “It really does not matter if the patient is right or wrong. What counts is how the patient felt even though the caregiver’s perception of reality may be quite different”.6

Considering the differing needs of the recipients of healthcare services, we assume that we can also find differing evaluations of the degree of importance attached to the service aspects among the patients and this raises the question as to what extent we can really take patients’ expectations and preferences into consideration when we evaluate the service. The wide diversity of health services constitutes a factor that poses measurement and monitoring difficulties. That is in addition to the fact that the provision of hospital services, in contrast to other high-contact services is based on collective actions. The high specialization and complexity of healthcare requires the interaction and coordination of different encounters, playing diverse roles, and all contributing with their specialized expertise to the management of a single patient. The high degree of heterogeneity and complexity associated with healthcare process may make a customer’s evaluation of the system invalid.7

While customers may lack the knowledge and expertise to assess some aspects of the system, not only their input regarding their perception but also understanding their concerns and priorities are still invaluable tools for providers. Health organizations may assume the preference areas of their patients only to later establish information asymmetry between the priority issue of patients and what the organization assume they value.8,9 

While a lot of studies on the evaluation of patient satisfaction have been published, some issues of methodology concerning the appropriateness and validity in particular of such research on recipient of the service have been raised.10,11 The paradoxical results of some studies, such as Papanikolaou and Ntani (2008) raise such concern.12 The argument is that the aspects measured in some research are irrelevant to patient satisfaction or that patients are irrational. The bad news is that a literal interpretation of high-satisfaction ratings may be naïve.13  When a patient receives medical treatment, their perceptions of service quality is influenced by the functional quality (rather than technical quality) produced by the service provider. It might also be related to the patient’s comparison of their perception of the medical service encounter experience with their pre-encounter expectations.

Any new encounter experience adds up on the patient's previous experience and thus modifies their expectations, but what if the patient is seeking medical help for the first time with no prior experience (at least in some aspects of the service)? It should be put in consideration that healthcare is a service that is usually required by people and most of the time is not desired. It is only sought when people fall sick and potentially become stressed to the extent that their priorities (rather than expectations) in life change.

Patient satisfaction studies using the perceptual gap (of expectations and perceptions) assume that patients are rational beings that have specific expectations from healthcare. If “expectations” are defined as the wants of the consumers that they feel a service provider should offer,1 maybe then we should question whether patients really have expectations that are sufficient to be used for such assessment. In fact, they are not likely to have enough information about service standards from which they know what to expect from it. Thus, it might be logical to fully understand what patients expect or prefer, we must first explore how much they know and what rights and obligations they feel they have. In other words what they perceive their role to be.

This might be particularly true when it comes to situations where “bad quality healthcare outcome” could be life threatening or where the social context shapes the trust and expectations a patient can put on the provider. Patients construct their identities and preferences differently where risk is high and the outcome may be life threatening. This might be true not only for functional aspects of quality but also for the technical aspects. For example, satisfaction with the clinical outcome of a particular treatment may more accurately reflect the confidence on the ability of the health professionals involved rather than the assessment of the adequacy of the technical quality itself.

Similarly, patients may not consider a particular task as a duty of the service, or if it is missed they do not consider the service culpable for missing it. Again, even if the quality of a service is high, expectations and satisfaction of a particular patient are both highly influenced by, for example their awareness of what is the best servicethe provider could offer. On the other hand, even if the quality of a service is poor, satisfaction with the service remains high as long as it is thought to be the best the provider could offer or service was not below expectations.14

In conclusion, using consumers’ perspective in assessing quality seems to be very helpful for service providers by being more sensitive and responsive to their requirements to bring about quality improvement and customer satisfaction. However, its reliability and feasibility as a measurement tool for healthcare quality and its contribution to reflect patient satisfaction have to be well studied considering several factors related to the nature of health service such as the heterogeneity and complexity of the process of healthcare delivery.


1.   Lim PC, Tang NK. A study of patients’ expectations and satisfaction in Singapore hospitals. Int J Health Care Qual Assur Inc Leadersh Health Serv 2000;13(6-7):290-299.

2.   Charles C, Gafni A, Whelan T. Decision-making in the physician-patient encounter: revisiting the shared treatment decision-making model. Soc Sci Med 1999 Sep;49(5):651-661.

3.   Hausman A. Modeling the patient-physician encounter: improving patient outcomes. Academy of Marketing Science Journal 2004;32(4):403-417 .

4.   Berry LL, Bendapudi N. Health care: a fertile field for service research. J Serv Res 2007;10(2):111-122 .

5.   Sewell N. Continuous quality improvement in acute health care: creating a holistic and integrated approach. Int J Health Care Qual Assur Inc Leadersh Health Serv 1997;10(1):20-26.

6.   Petersen MB. Measuring patient satisfaction: collecting useful data. J Nurs Qual Assur 1988 May;2(3):25-35.

7.   Wong J. Service quality measurement in a medical imaging department. Int J Health Care Qual Assur 2002;15(2):206-212 .

8.   Donnelly M, Wisniewski M. Measuring service quality in the public sector: the potential for SERVQUAL. Total Qual Manage 1996;7(4):357-365 .

9.   Lam SS. SERVQUAL: a tool for measuring patients’ opinions of hospital service quality in Hong Kong. Total Qual Manage 1997;8(4):145-152 .

10. Williams B. Patient satisfaction: a valid concept? Soc Sci Med 1994 Feb;38(4):509-516.

11.  Lin B, Kelly E. Methodological issues in patient satisfaction surveys. Int J Health Care Qual Assur 1995;8(6):32-37.

12.  Papanikolaou V, Ntani S. Addressing the paradoxes of satisfaction with hospital care. Int J Health Care Qual Assur 2008;21(6):548-561.

13.  Sitzia J, Wood N. Patient satisfaction: a review of issues and concepts. Soc Sci Med 1997 Dec;45(12):1829-1843.

14.  Williams B, Coyle J, Healy D. The meaning of patient satisfaction: an explanation of high reported levels. Soc Sci Med 1998 Nov;47(9):1351-1359.