Does ownership matter? : Differences in ownership of Swedish primary health care centres and its effects on patient satisfaction.

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Does ownership matter?

Differences in ownership of Swedish primary health care centres

and its effects on patient satisfaction

MASTER THESIS

THESIS WITHIN: Business Administration NUMBER OF CREDITS: 15 ECTS

PROGRAMME OF STUDY: International Marketing AUTHORS: Milica Cicic and Hannah Trenk

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Executive summary

Purpose: The purpose of this research is to describe the differences in ownership of Swedish primary healthcare centres and its effects on patient satisfaction.

Methods: For this thesis, a semi-inductive research approach was used to analyse secondary data by conducting several statistical analyses.

Findings: This study found that it is important to differentiate between the two private types of ownership within primary care. This finding is based upon the fact that all private independently owned PHCCs have higher patient satisfaction in all seven dimensions. These dimensions include participation and involvement, continuity and coordination, availability, emotional support, respect and kindness, information and knowledge and overall impression. Furthermore, the study found that publicly owned and private corporately owned centres have lower patient satisfaction. The two types of ownership had similar outcomes. This only highlights the importance of making a clear differentiation within the private ownership category.

Limitations: The study uses secondary data from 2017 that was collected for the Swedish Government. This brings with all the limitations of using secondary data. However, the source of this data is reliable and can thus be used for further analysis.

Keywords: Primary Health Care, Patient Satisfaction, SERVQUAL, Sweden, Privatisation, Types of Ownership

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Tables

Table 1: Overall Impression - Descriptive Statistics ... 27

Table 2: Emotional Support - Descriptive Statistics ... 28

Table 3: Participation and Involvement - Descriptive Statistics ... 28

Table 4: Respect and Kindness - Descriptive Statistics ... 29

Table 5: Continuity and Coordination - Descriptive Statistics ... 29

Table 6: Information and Knowledge - Descriptive Statistics ... 29

Table 7: Availability - Descriptive Statistics ... 30

Table 8: Overall Impression - Hypothesis Testing ... 31

Table 9: Emotional Support - Hypothesis Testing ... 32

Table 10: Participation and Involvement - Hypothesis Testing ... 32

Table 11: Respect and Kindness - Hypothesis testing ... 33

Table 12: Continuity and Coordination - Hypothesis Testing ... 33

Table 13: Information and Knowledge - Hypothesis Testing ... 34

Table 14: Availability - Hypothesis Testing ... 35

Table 15: Correlations between the dimensions ... 36

Table 16: Linear Regression and Multicollinearity ... 38

Table 17: Linear Regression with removed Information and Knowledge... 39

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Acknowledgements

Firstly, we want to thank our tutor Tomas Müllern for his support and for giving us the freedom to grow and make our own decisions.

Furthermore, we want to thank Toni Duras for his help with the statistical analysis.

Lastly, we want to thank all our friends and family that have supported us, encouraged, and distracted us.

Thank you, Stefan, Jakob, Mi and Mari, and of course our parents!

Sincerely,

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1. Introduction

This chapter will grant the reader first insights into the topic of the Swedish primary health care system, types of ownership and patient satisfaction. Furthermore, the purpose of the research will be revealed followed by a presentation of the key terms of this research.

1.1 The Swedish health care system

The Swedish health care system is considered as one of the best when compared to international competition (Wang & Aspalter, 2007). Sweden is ranked continuously among the best and most innovative systems (Proksch et al., 2019). It furthermore already found innovative solutions to problems the other systems will be facing in the future (Avby et al., 2019). The object of investigation in this study will be primary health care centres (PHCC) by analysing secondary data collected by an organisation employed by the Swedish government. These PHCCs have a unique function in the overall system. They consist of a multidisciplinary workforce. Typically, four to ten doctors work alongside a team consisting of social workers, psychologists, nurses, physical and occupational therapists as well as administrators. In front of an international background, these multidisciplinary centres are an unusual innovation. In most of the OECD region, private general practitioners are responsible for primary care. (Anell, 2015). But these centres are exposed to constant political reforms and changes (Effektiv Vård, 2016; Rosen, 2015). The latest major transformation the PHCC went through was the dissolution of the state-owned primary care monopoly. This incident resulted in two developments that effected patients directly (Anell, 2011).

Firstly, the system was partially privatised. This opened the market for private players to take ownership of existing practices or open new ones. In some cases, the existing staff converted their PHCCs into a company and in others, international health care firms, like the Capio group, took over the centres (Anell, 2015; Capio Group, 2020). In many cases, the type of ownership is only divided into two groups, private and public. However, this thesis is going to investigate three types of ownership by making a further distinction between private independently owned centres and private corporately owned ones. Secondly, the system was opened to patient’s choice meaning that the patients were allowed to choose the PHCC at

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will and not be assigned to one based on geographical factors and availability. Thus, the players in this market operate in a more competitive environment. Consequently, patient satisfaction becomes increasingly important as it can affect several factors that influence the economic dimensions of a PCHH (Prakash, 2010). The reason for the reform was the decision to focus and redirect patients to the outpatient system of primary care. Outpatient indicates that the patient does not spend the night at a health care facility but is send home on the same day that a procedure takes place. The outpatient system has increased as medical procedures became less invasive and reduce cost. Since inpatient care is more cost-intensive the Swedish government decided to use the PHCCs as a buffer to prevent increasing expenditures in hospitals and palliative care that are more inpatient focused (Anell et al., 2012). However, first and foremost patient satisfaction should be defined.

Patient satisfaction as a modern phenomenon has been investigated in a high number of studies. It is seen as one of the main criteria in evaluating the service quality in health care. The term patient satisfaction can be defined in many different ways. According to Prakash (2010) patient satisfaction is the most frequently used indicator for measuring the quality of health care systems and the success of hospitals (Prakash, 2010). Another definition given by author Linder-Pelz (1982) states that patient satisfaction is deﬁned as an evaluation of distinct health care dimensions (Linder-Pelz, 1982). This is especially important as in the process of this study the measurement dimensions will be introduced.

Since marketing and promoting actions of primary care and hospital care, in general, are not legally allowed, primary care facilities had to come up with other techniques concerning the promotion of their services (Evans, 2006). Promotional techniques require the use of services marketing principles. To initiate and maintain a positive reputation among patients, primary care facilities have to continually generate positive patient experiences that will lead to future patient satisfaction. According to the Technical Assistant Research Programs (TARPs), word of mouth leads to improved patient retention. In other words, if one of the patients is satisfied with the provided service and care, the positive information will spread among at least ten other patients (Goodman, 1986). Consequently, the importance of patient satisfaction has been investigated in various studies supporting the fact that higher patient satisfaction leads to various benefits in the health industry (Leebov & Scott, 1994).

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The benefits are the previously mentioned patient retention, higher patient (customer) loyalty, consistent profitability, positive clinical outcomes, increased professional and personal satisfaction, and reduced risk of malpractice suits (Prakash, 2010).

In general, patients are considered as buyers of health services, therefore many hospitals began to function as service providers in the service industry (Prakash, 2010). Consumer involvement in health care has grown rapidly. Previous studies have suggested a high number of explanations when it comes to the individual’s involvement in information seeking and choosing the right health care provider (Hoffstedt et al., 2018).

Patient involvement resulted in patients becoming active decision-makers and information seekers. With the help of available information, patients started demanding both functional and technical health care services, to achieve the right levels of satisfaction (Corbin et al., 2001). Subsequently, the crucial component of many health care systems is the patient’s ability to choose their health care providers based on available information and promotion. Being aware of the free patient choice, health care providers need to improve the quality and the range of their services, to reduce the risk of losing patients by not being chosen (Hoffstedt et al., 2018).

In conclusion, this study is especially important as Sweden is considered as one of the leaders in health care provision which makes it an exemplary case to study. Furthermore, the importance of patient satisfaction is rising. Many countries are thinking about implementing a pay for performance scheme where patient satisfaction is a key indicator (van Herck et al., 2010). Consequently, the implemented system of care must be evaluated regarding the equal treatments of its subjects. This should make sure that all Swedish residents have access to a similar level of care regardless of the type of ownership of a PHCC.

1.2 Purpose

The purpose of this thesis is to describe the differences between Sweden’s private and public primary health care centres (PHCC) in terms of patient satisfaction. Furthermore, the difference between private independent and private corporately owned centres and their

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effects on patient satisfaction is investigated. This adds particular value to the thesis as previous studies have not made this distinction and have seen private PHCCs s a homogeneous group. In contrast to that, this study allows for a more specific grouping and thus a more differentiated outcome. The factors participation and involvement, continuity and coordination, availability, emotional support, respect and kindness, information and knowledge and overall impression will be utilized to gain a deeper understanding of the patient satisfaction phenomenon. The outcome of this research will assist the private and public operators to review and re-evaluate the factor of patient satisfaction and its role in the primary health care sector. Furthermore, the operators can gain insights into their strengths and weaknesses and make informed decisions based on the results. Therefore, a semi-inductive research approach was chosen to allow for further investigation. Even though, the dimensions and factors were pre-determined the research still brings in an inductive component by analysing and searching for patterns in the existing data. Hence, this research can be a starting point for further investigation e.g. how each factor contributes to the overall impression of the performance of the facility. In contrast, it can also serve as the groundwork for a debate on patient satisfaction as a measuring factor for service quality in the health care sector.

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1.3 Key Terms

PHCC - Primary Health Care Center, The first point of access to the Swedish health care system. Usually, a centre consists of a multidisciplinary team of doctors and nurses of different specializations (Anell, 2015).

OECD Region - Organisation for Economic Co-operation and Development, Intergovernmental Organization of most of the world's developed nations that aims to stimulate worldwide trade (OECD Regional Statistics, 2017).

Capio Group - International Health Care Provider that entered the Swedish Primary health care sector upon the dissolution of the state-owned monopoly on primary care (Capio Group, 2020).

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2. Methods

This chapter will provide an overview of the methodological choices made by the researchers to allow for the best possible outcome of this research. The research paradigm will be discussed as well as the research approach and technique which includes several limitations that have to be taken into account. Lastly, the methods of analysis in SPSS are discussed and presented.

2.1. Research Paradigm

In this research, a positivist research perspective is used. It is defined by ontology, epistemology and axiology (Henderson, 2011; Saunders, 2011). The nature of being and the perception and nature of reality is described by the ontology. Positivists perceive reality as an absolute constant phenomenon that can be measured using the correct tools. This view fits the quantitative research approach that this body of work uses due to the numerical and statistical outcome of this research. The reality of patient satisfaction has been captured and recorded over several years as a means to understand the underlying reality of it and draw conclusions for society. (Yu, 2004)

The epistemology of a research paradigm regards the nature of knowing. The epistemology of a positivist research paradigm is fact-based and aims to describe that absolute reality using tests. It also works towards the prediction of behaviour as well as discovering laws and rules. In this research, several hypotheses are tested to establish a general rule of law regarding the differences between private and public PHCCs in the Swedish health care system. Hence, a universal trend of the quality of care using patient satisfaction as an important indicator is established. Thus, a positivistic epistemology is suitable for this type of research. (Henderson, 2011)

The axiology describes the values that a certain research paradigm relies on. A positivist axiology values trust, honesty and personal integrity above all else (Saunders, 2011). Through these values, a reliable and trustworthy environment is created. For the purpose of this body of work the personal integrity, objective and honest of the participants must be assumed to guarantee the reliability of the data. If these values were not the foundation of this research

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a trustworthy data pool could not be assumed. Thus, the research would not be valid. (Ryan, 2006)

2.2. Research Approach

This research uses a semi-inductive research approach. Typically, inductive research collects data that is subsequently scanned for patterns. Consequently, a theory is developed according to these patterns (Hayes et al., 2010). This research aims to assess the collected data in order to discover distinctive patterns related to patient satisfaction in private and public PHCCs in Sweden. Consequently, these research findings shall contribute to the development of a suitable theoretical framework. As this research is not based on a standardised theoretical framework and due to the high ambiguity of the data the outcome of the research is yet to be determined. Thus, a semi-inductive research approach has been chosen as it opens unlimited ways of conceiving the results. This frees the outcome from the restraints that a model or theoretical framework would impose on the data. Hence, the field of study can be understood in its full complexity. Nevertheless, the findings will be compared and critically evaluated by comparing it to existing data in this field.

To better understand the mentioned semi-inductive research approach that has been used in this study, it is important to highlight the distinction between the first two parts of the analysis, which will be presented in the fourth chapter of this thesis. As mentioned above, a semi-inductive approach was used to scan for patterns in the collected data. The first part of the analysis chapter contains descriptive statistics. In this part the mean scores and standard deviation will be presented, to gain a first overview of the existing data and gain insights into first trends. The second part of the analysis is considered as semi-deductive since it involves hypotheses testing, which is typically used for deductive approaches. Still, this part of the analysis is not accepted as a fully deductive approach, since this study is not based on a theoretical framework, thus the hypotheses were not built on the existing theory. Rather, they were developed based on the exciting survey and its dimensions as well as by working and experimenting with the data. Furthermore, a correlation analysis is utilized alongside a linear regression to determine further patterns or outcomes. This is an approach typically used in inductive research as it is meant to discover deeper insights and underlying patterns.

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Still, the approach is not fully inductive as the dimensions of the research were previously given by the survey. This is limiting the inductive portion of this research. Hence the research of this thesis concludes that a semi-inductive research approach must be used. This means that the thesis is more inductive than it is deductive. However, a purely inductive approach cannot be constituted as the thesis does borrow deductive elements such as hypothesis testing by using the Pearson correlation and predetermined dimensions.

Still, a descriptive approach is used in this study, as it aims to clarify and identify attributes of a certain phenomenon and the discovery of a link between two or more variables on an observational basis (Jebb et al., 2017). Even though a semi-inductive approach is used to discover patterns and develop general theories for this field of research, the purpose of this body of work is to describe and present them. As there is a large amount of data that has not been analysed in this way before, a descriptive approach has been chosen so the basis of further investigation is established (Williams, 2011). However, this descriptive purpose will be exceeded by additional statistical analysis to enrich and add value to the investigation. This will give the foundation for further research more direction and additional information to base informed choices upon. This also adds to the studies more inductive reasoning as statistical tools such as correlation analysis and linear regression were performed. However, the risk of performing these analyses is that multicollinearity or other issues can arise. This means that the dimensions are so similar to each other that they do not portrait a unique point of view. Thus, they do not add value or more insights into the data. This might limit the reliability and prevent the research’s from drawing a solid conclusion based on this outcome.

In this research, exploratory data analysis has been conducted. Exploratory type of analysis proposes and develops hypotheses, which can be strictly and precisely tested in the future with the help of confirmatory data analysis (Goeman & Solari, 2011). The research can be semi-inductive and exploratory as the outcome of the analysis is still undetermined and a large amount of data is investigated. A large amount of data prevents the formulation and investigation of clear correlations for each factor. However, the research can be the groundwork for a more specified and in-depth analysis in the form of a correlational or explanatory study of the data. First efforts in this direction were already conducted. These can be used as the basis for further work.

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In conclusion, a semi-inductive approach was used because the research is not fully inductive. This can be seen as hypotheses are developed and tested, as a fore mostly deductive method. Also, a large portion of the thesis is descriptive. However, by performing additional statistical analysis, like correlation analysis and linear regression, inductive methods influence this thesis greatly. Thus, a semi-inductive research approach must be used to fully grasp the versatility of this research.

2.3 Research technique

Secondary, quantitative data is used in this research. In general, quantitative data is based upon numbers or other forms of quantifiable data. Quantitative research allows investigating numerous factors, their relationship, and interactions. This type of data tries to capture information and evaluate them by constructing statistical models that can be analysed and used to falsify or verify the hypotheses (McCusker & Gunaydin, 2015). In current research methodology, the pairing of inductive research and quantitative approach is rare as it is usually matched with a qualitative approach (Chapman et al., 2015; Gioia et al., 2013). This misconception roots in the assumption that qualitative interviews are the most attainable way to gather detailed information. However, a quantitative research design can also fulfil that cause by using a data-driven approach to investigate potential concepts. This also leads to not using a fully inductive but rather a semi-inductive research approach. Furthermore, the strength of having a data-driven research approach establishes the outcome as statistically significant while also working inductively towards uncovering new patterns and connections. Still, this research combines the two by fulfilling both requirements. The research fulfils the inductive necessities by searching for patterns in the quantitative data without relying on a theoretical framework.

The data was collected using a longitudinal approach by the Institute for Quality Indicators on behalf of the Sveriges Landsting Och Regioner I Samverkan (Swedish Association of Local Authorities and Regions). These national patient surveys (NPS) are conducted every second year to provide information on the patient's perception of primary health care in Sweden. Patients are encouraged to participate by motivating them to assist in the improvement of health care services. The data is collected anonymously but identifiable by region. The data is

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published on the following website www.patientenkat.se and is accessible for everyone. However, the data has not been analysed and there are no official publications regarding the data. Data currently available include the years 2011, 2013, 2015, 2016, and 2017. The NPS is filled out by a random sample of patients from both private and public PHCC from each region. It consists of eight indicators of patient satisfaction.

However, the indictor sections were adjusted each year. Therefore, this research excludes data from 2011 until 2016. Hence, this study will focus exclusively on the data of 2017 because the comparability of the data sets cannot be guaranteed due to changing questionnaires. Furthermore, it is out of the scope of the research purpose as it would have increased the data analyses to an extent that is not manageable within the scope of a master thesis.

The indicators that have been used in the study are participation and involvement, continuity and coordination, availability, emotional support, respect and kindness, information and knowledge and overall impression. A detailed description and explanation for the factor choice can be found in Chapter 3 “Theory” under the sub-chapter “Measuring Patient Satisfaction”.

The following section will describe the questionnaire that was used in the survey. This questionnaire consists of 54 questions related to the seven different factors measuring patient satisfaction. Additionally, the respondents were inquired regarding their personal information like their occupation and highest educational level as well as habits like consumption of alcohol, tobacco and food.

The questionnaire did not sort the questions by section to avoid repetition and prevent biased answers. The questions were however structured in a way that a natural flow of respondents’ thought was enabled.

The section overall impression consists of five individual questions. Further, the section discussing emotional support consisted of three questions. The next section was participation and involvement, that consisted of five questions. Furthermore, respect and kindness consisted of four questions. Section continuity and coordination had ten questions. Information and knowledge as the next section consisted of eight questions. Lastly, the

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section availability consisted of six questions regarding general accessibility and six questions regarding availability in general.

Over 80.000 patients treated by 1149 PHCCs took part in the NPS that was conducted in 2017, which makes it one of the biggest surveys conducted in Sweden. All patients that visited a Swedish PHCC in October 2017 were sent a questionnaire. The time to reply to the survey was limited to 2017-11-27 - 2018-01-07. All answers that did not arrive within the proposed timeframe were excluded.

Individuals from the age of 15 were permitted to take part in the NPS. There is no maximum age for participation. The survey does not provide demographical insights into the sample. It could be argued that due to the multi-morbidity of the senior population the sample contains more senior participants because they are assumed to use the services of PHCCs more frequently (Salive, 2013). However, due to the large size of the sample, these effects can be disregarded as it represents the population of interest. Also, as they are the largest group of PHCC visitors their opinion and perception are especially relevant and rightfully influence the data to a more considerable extend.

However, other challenges of the data should be discussed. As stated above, 80.000 overall respondents were recorded. Yet, it is not possible to determine the exact number of responses per centre. This could result in an unequal valuation of the individual responses. In a centre with many patients and thus many answers the individual answer is valued less than the one in a small centre with a lower number of respondents. Still, the researchers that did the primary data collection assured the validity of the cumulated results by conducting statistical analysis. Hence, the collected data remains statistically significant. Furthermore, the individual’s answers were weighed in an adjusted manner. To form a total dimension value for each of the factors the responses for each question that describe the dimension are weighed differently. However, if an individual did not complete all questions describing a dimension the calculation of the weight was adjusted. This means that if an individual answered only two of three questions the weight was adjusted to be 0,5/0,5 equalling 1 in total. In contrast, if the individual answered all of the questions that describe a dimension the answers were weighted according to the underlying theory that was used in the patient

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satisfaction assessment. In this case, the weights of the answers were determined by the principal component analysis (PCA).

2.4 Methods of Analysis in SPSS

The first step of preparing the data for the analysis was the translation of the indicator sections and the questionnaire from Swedish to English. This translation was conducted by two native speakers. Both received a full set of questions and were asked to translate them. Thereafter the two translations were compared and harmonized to ensure accuracy and correctness.

Secondly, each PHCC was assigned to a category based on the ownership status. Before providing information on the different categories it must be pointed out that some of these PHCCs that were categorised show characteristics of more than one category. However, they were clustered to the researcher's best knowledge and on the foundation of Andresson et al. 2019 (Andersson et al., 2019). Other PHCCs had to be excluded from the analysis due to the lack of information provided on their status of ownership. These categories are (1) publicly-owned PHCCs, (2) independent privately publicly-owned PHCCs, and (3) corporate-publicly-owned PHCCs. Publicly owned PHCCs remained in government ownership even after the privatisation attempts. These PHCCs are mostly located in demographically weaker regions of Sweden (National Patient Survey, 2020). This must be considered when conducting the analysis. The second category includes PHCCs that are privatised but owned by independent entities. This type of PHCC developed because the employees decided to take over the ownership of these facilities. This research classifies private independent owners as the ones who own less than four centres, while the corporate (the third category) owners own more than four centres (Andersson et al., 2019). These form the third and last category which are the private corporately owned PHCC’s.

Subsequently, the data was transferred from Excel into SPSS and numerous tests regarding reliability and validity were performed. Validity as an indicator shows to which degree a concept is truthfully represented by the obtained scores (Babin & Zikmund, 2016). Furthermore, validity can be defined as the extent to which a concept is precisely measured in quantitative research (Heale & Twycross, 2015). For a measure to be valid, it needs to own

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face validity (Babin & Zikmund, 2016). When the applied scale truly reflects the concept that has been measured in scientific research, face validity is present. Since the scales that have been applied in the presented research were used in previous studies on similar topics, they are considered as valid and they possess face validity.

The analysis of the data will be performed in the following way. Firstly, descriptive statistics will be provided. This includes the calculations of mean scores and standard deviations, for all three types of PHCCs, within the seven dimensions of patient satisfaction. Secondly, hypothesis testing will be conducted with the help of correlation analysis. Lastly, to stay true to the inductive research approach, linear regression will be performed. This analysis aims to find relevant trends and patterns in the data and to gain more detailed insights.

2.5 Limitations

As this thesis did not collect a set of primary data only secondary data was used and analysed. The data were carefully checked and validated to serve the right purpose and have similar motives to ensure it could be used for this research and to answer the research question. However, the possibility of the original data being collected for a different reason and the resulting discrepancies cannot be underestimated and are thus a limitation to this thesis. The data might be vague and too general to match the research questions or hypotheses.

Other errors in data collecting are not known and hence present a risk that should be accounted for. Data could have been falsified or the respondents could have been biased and the researches of this thesis would not know. However, as the data was collected on behalf of the Swedish government a certain degree of integrity can be assumed. Still, the possibility of the manipulation of the data, for example for political reasons, persists.

Further limitations of working with secondary data include the age of the data. The data used in this thesis is three years old at the present day. The new results of 2019 were published while the work on this thesis had already started. Thus, the older data was used making the results not the newest possible. Furthermore, it could be possible that the observed trends have changed throughout the years.

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Even though the limitations of using secondary data are clear, the researchers of this study still deem the data fit for further investigation. The data was collected by a professional firm for the Swedish government. Thus, the source of this data is trustworthy and reliable. Hence it is justified to utilize the data for further analysis.

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3. Theory

In the following theory chapter, firstly the concept of quality will be discussed. This will be followed by the definition and description of patient satisfaction phenomena. Furthermore, the effectiveness of Word of Mouth and its ability to spread information will be discussed. This section will be followed by a discussion related to the measuring factors of patient satisfaction. Lastly, private, and public ownership and private independent and private corporate ownership among Swedish primary care centres will be explained.

3.1. The Concept of Quality

For every firm and organization, quality is considered as the crucial component in their production and service processes (Inman et al., 2003; Sachdev & Verma, 2004). Furthermore, quality became a strategic differentiating tool for maintaining a competitive advantage. The improvement of quality will lead to positive company image, higher productivity, higher profits and lower costs (Mosadeghrad, 2014).

Quality in health care is a complex and multidimensional phenomenon, that is difficult to define, due to its subjective and intangible characteristics (Naidu, 2009). Characteristics such as heterogeneity, simultaneity, and intangibility make it even harder to precisely define and adequately measure the quality in health care systems (Mosadeghrad, 2014; Weisman et al., 2000). For this reason, various definitions of quality in health care exist in the scientific literature.

One of the definitions states that quality is the provision of provided care that transcends the expectations of patients and accomplishes the highest possible medical outcomes with the use of available resources (Øvretveit, 2009).

According to Lohr (1990) quality is the extent to which services in health care for both population and individuals enlarge the likelihood of desired outcomes (Lohr, 1990). Furthermore, high quality in health care appears when the providers supply patients with appropriate health services incompetent ways, with high quality and cultural sensitivity (Schuster et al., 1998). Generally, service quality is often regarded as the antecedent of patient satisfaction (Senić & Marinković, 2013).

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In this study, the service quality of private independently and corporately owned and public primary care centres in Sweden has been investigated from a more in-depth patient satisfaction view. A deeper understanding of the quality concept was necessary for this study since it is considered as the main differentiating factor among both private and public primary care centres. To understand patient satisfaction which is the main topic of this research, the understanding of service quality needs to be accessed for every primary care centre in Sweden.

3.2 Patient Satisfaction

The topic of consumer satisfaction has been widely investigated in various fields such as health care management, marketing, psychology, sociology, and others (Forsythe, 2007; Malthouse et al., 2004). One of the main reasons why this subject was present in many scientific researches is because consumer satisfaction is considered as the core of modern marketing theory (Baalbaki et al., 2008). Secondly, consumer satisfaction is a requirement and necessity of many organizations, since their businesses are considered successful when they meet the needs of consumers (Newsome & Wright, 1999). Moreover, patient satisfaction improves the image of hospitals, which will, in turn, bring increased service use, higher market shares and increased number of satisfied customers with favourable behavioural intentions (Naidu, 2009).

Consequently, patient satisfaction is considered as the main quality assessment when it comes to designing and managing health care institutions and their activities (Naidu, 2009).

In the health care area, consumer satisfaction had gained extensive recognition as being the main measure of service quality. Moreover, patient satisfaction is the most frequently used factor for measuring the quality of health care systems (Prakash, 2010).

In general, quality is positively correlated with patient satisfaction, the higher the quality of services the higher the patient satisfaction is. The previously given quality statement underlines the importance of patient satisfaction for every health care centre in general (Leebov & Scott, 1994).

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As it was previously mentioned, patient satisfaction as an indicator of quality can be measured in many ways. The most prominent example is the SERVQUAL scale, which many researchers regard as an appropriate tool to measure the service quality in health care (Headley & Miller, 1993). According to Parasuraman et al. (1985), the global quality of a health care service can be measured through five underlying dimensions of SERVQUAL (Parasuraman et al., 1985).

The mentioned SERVQUAL dimensions are tangible elements, reliability, responsiveness, empathy, and assurance (Parasuraman et al., 1985). The first dimension is the tangible elements, which include health care facilities, equipment, and working personnel. Reliability as the second dimension stands for the ability of a health care centre to perform the promised service for a patient. The third dimension is responsiveness, which is the willingness of the personnel to help the patients and to provide prompt service. The next dimension is empathy, which stands for individualized attention towards the patients. Lastly, assurance is a combination of the health centre’s credibility, security, and competence (Parasuraman et al., 1985). The explanation of SERVQUAL dimensions makes it easier for the researchers of this study to compare the mentioned dimensions to the ones used in measuring patient satisfaction.

All in all, service quality is a measure of how well the provided service level of PHCC matched patients' expectations (Parasuraman et al., 1985).

3.3 Effectiveness of Word of Mouth in Health Care

Consumer satisfaction is a crucial component of every service-oriented sector (Bone, 1995). Since health care system belongs to service-based industry, patient satisfaction became an important aspect. To achieve high patient satisfaction, PHCCs have to constantly provide a high quality of services (J. Rama, K. Naik, Dr B. Anand, I. Bashir, 2013). Consequently, high patient satisfaction could lead to many benefits in health care. One of the benefits is the improved patient retention or in other words positive word of mouth (Prakash, 2010).

Word of mouth (WOM) has a powerful impact on patients’ behaviour and attitudes, therefore it will significantly affect both long-term and short-term opinions of patients (Bone 1995). The

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term word of mouth can be defined as the client’s willingness and readiness to recommend a certain product or service to others in the future (Dabholkar et al., 1996).

Consumers of services, in this case, patients, rely on the word of mouth to reduce the level of risk and uncertainties that concern their decisions about services (Murray, 1991). Word of mouth has been considered as the main tool of risk-reducing for different types of risks, such as functional, social, financial, organisational, etc. (Sweeney et al., 2008).

In general, for the majority of consumers, word of mouth is the only way to gain insights into both positive and negative aspects of services (Martin, 2017).

The importance of word of mouth for organisations has been studied before in various studies. Due to the new forms of communications among consumers and increasing competition in the health care sector, the importance of word of mouth is still growing (Martin, 2017). Furthermore, word of mouth is strongly influencing all health care providers and their behaviours (Hether et al., 2014). In a highly competitive market, all health care providers are seeking to achieve positive word of mouth since it is considered a competitive advantage. Moreover, word of mouth has the power to influence the attitudes and future behaviours of patients (Sweeney et al., 2008).

In recent years, patients demand being integrated both in treatments and the choice of health care providers grew. This patient movement is often described as patient emancipation (Williamson, 2008). The mentioned high demands result in patients actively seeking relevant information to help them make decisions related to the choice of health care providers, quality of the service, treatment options etc. The importance of word of mouth is highlighted in this context, since it is considered as one of the important information sources, together with public reports and patients’ personal experiences (Martin, 2017).

Word of mouth strongly influences perceptions about products and services, which will lead to a change of value ratings, judgements, and the likelihood of purchases (Sweeney et al., 2008). In the case of the health sector, it influences the patients' perceptions.

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3.4 Measuring Factors of Patient Satisfaction

In the present thesis, to measure and compare patient satisfaction among private independently and corporately owned and public PHCCs, seven different dimension are used and examined. These dimensions are taken from annual quality surveys in Swedish health care. The annual surveys are filled in by a sample of patients every second year, coming from all Swedish primary care centres.

The dimensions that are used to measure patient satisfaction are patient participation and involvement, availability, emotional support, respect and kindness, information and knowledge, continuity and coordination, and overall impression. In the following section, the previously listed dimensions are going to be described briefly.

“Participation and Involvement” has been studied in many previous types of research. It could be defined as an active role of patients in medical decision making and the patients' participation in different medical treatments (Arnetz et al., 2004). Subsequently, active patient involvement leads to improved health outcomes and higher patient satisfaction (Grosset & Grosset, 2005). The involvement dimension aims to investigate the patient’s level of involvement in the provided care and decision making about the care (National Patient Survey, 2020).

“Availability”, as the second dimension, presents the core of public demand in health care systems. In other words, it is the general demand for primary health care teams to be available 24 hours a day and responsible for patient care in every unit (Wensing et al., 2002). Availability is a crucial dimension that is used to discover how patients perceived the accessibility of care, as well as the availability of staff (National Patient Survey, 2020).

“Emotional Support” is a dimension used to evaluate to which extent is the patient satisfied with the responsiveness of medical staff regarding pain, fear, anxiety and other issues. Furthermore, this factor could be used for measuring the levels of support of medical staff towards the patients (National Patient Survey, 2020).

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“Respect and Kindness” is a dimension used for gaining information about how the patients’ experienced the ability of the medical staff in responding to their individual needs with commitment, respect, and compassion (Goodman, 1986).

“Information and Knowledge” as the fifth dimension aims to describe how patients feel about the received amount of information. Furthermore, it shows the ability of the particular Primary Care Centre to communicate and inform patients in ways that are adjusted to the patient’s conditions. The provided information includes relevant details about different treatments, medications, waiting times, side effects, delays, etc. (National Patient Survey, 2020).

The next dimension is “Continuity and Coordination”. This dimension aims to showcase the ability of patients for continuity and coordination in their medical journey. In other words, it shows how well the care for a patient is coordinated in both internal and external ways. Internal ways show the ability of personnel and medical staff to cooperate with the patients (National Patient Survey, 2020).

Finally, the “Overall Impression” as the last dimension could be defined as the patient’s overall experience of primary care, well as the perceived usefulness and efficiency of the received care, in terms of outcomes and safety (National Patient Survey, 2020).

3.5 Private and Public Ownership

The European health care systems have always had a close connection to the government as they are responsible for guaranteeing a healthy and cared for population (Spencer & Walshe, 2009). However, that also entails the increasing number of political decisions that affect these health care systems (Missinne et al., 2013; Rico et al., 2003). Some systems are run by the government itself e.g. in the UK the National Health Care Services (NHS) are a state-owned system (Grosios et al., 2010; Stevens, 2004). Some are fully privatised, like the US system. Other European systems are partially public owned and privatised like in Germany or Sweden (R. B. Saltman, 1994; Wendt, 2009). In comparison to other countries with partially privatized health care systems, Sweden’s privatization is relatively young and thus still to experience the full effects of the transformation (Alber, 1988). Still, already 40% of the primary care providers

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are privately owned and 60% remain in public hand (Mossialos et al., 2016). As stated, and discussed above, in this body of work, it is assumed that patient satisfaction is an important indicator in measuring service quality. In the health care sector quality is arguably one of the most important factors as a lack of quality can have serious effects on individuals’ lives (Zineldin, 2006). The difference between countries and ownership of the facilities can have a large effect on patient satisfaction and thus on perceived quality (Alber, 1988). In the following, previous research regarding primary health care, public and private ownership, and patent satisfaction in Sweden are analysed and the results will be presented. Due to the limited amount of research in this field for Sweden, the research was widened to include other European countries that fulfil the criteria of having both private and public primary health care providers.

The keywords used to structure the search include primary care, Sweden, patient satisfaction and private and public ownership. After an initial literature review and correspondence with researchers in the field, these terms were determined. The search engines are Google Scholar and the Jönköping University Library search engine. The results are filtered by their relevance to the investigated topic, their actuality, and the quality of the research magazine they were published in.

An observational study was conducted in Västra Götaland that investigated if the type of ownership influences the perceived quality. They, however, used different measurement criteria like the frequency of antibiotics that were prescribed and the use of benzodiazepines. In general, that study was conducted using a more demographic and medical approach. In contrast, this study focuses on patient satisfaction and its key indicators as opposed to the factors described above. Interestingly, the findings still indicate that privately-owned PHCCs are on average less populated and more often to be found in urban areas. This study also found that the overall perception of the quality of treatment is better in privately owned PHCCs supporting the hypothesis of this research (Maun et al., 2015). However, the researchers of this study were reluctant to formulate an unambiguous answer as to whether ownership influences the quality of service in Swedish primary care (Maun et al., 2015).

Another article focused more on the outcome of the health care reform in general including opening the market to private business entities as well as patient choice. According to this

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research, following the reform, visits to PHCC’s increased among individuals with lesser needs for health care which made it increasingly difficult for individuals with complex health care needs to get an appointment. It is also stated that the newly accredited primary health care centres are located in urban areas with a demographically more advantageous population. A survey among doctors and nurses produced the outcome that in their opinion patients with lesser health care needs are prioritized (Burström et al., 2017).

Further, researchers stress that publicly owned PHCCs may face more competition than initially intended by the lawmakers. It is also pointed out that a reason for the reform was to strengthen overall access and responsiveness as well as strengthening the primary care sector in total. This article still warns that fixed payment may lead to the under-provision of treatment to increase financial gains of the private owners (Anell, 2011).

Within this search string, many other sources were found. Still, only the three presented above effectively matched the search string and thus the purpose of this research. Hence, other results were disregarded, and the word “Swedish” was removed from the search string to grant a wider outcome.

Internationally, the difference between private and public health care providers regarding patient satisfaction depends on many factors. However, as a preambular, it has to be stated that all countries have complex health care systems with highly individual players and processes. Even though the comparability of the systems themselves is limited on the large scale of privatisation this research can still benefit from the experience of the international community. Firstly, the state of the country appears to play a role. In developing countries, privately-owned health care providers seem far superior to the publicly-owned ones. Furthermore, the location of the different health care providers can impact the outcome of the various quality assessments (Meng et al., 2000; Tangcharoensathien et al., 1999; Tuan et al., 2005). Evidence from Vietnam, rural China and Bangkok split the quality of service into rural and urban areas stating that public and private health care can be compared in urban areas but not in rural regions (Meng et al., 2000). In these rural regions, the publicly owned facilities seem to be far superior in comparison to the privately-owned ones. For a while, China decided on a prohibition of privately owned health care facilities due to safety risks (Meng et al., 2000). It still must be mentioned that the overall level of health care was

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recorded as very poor. Also, the private sector was not regulated or accredited (Tuan et al., 2005). Additionally, the category of the size of the facility and profit orientation seems to impact patient satisfaction and thus service quality (Tangcharoensathien et al., 1999).

More developed countries draw different conclusions from opening their system to private players. The Slovenian health care system was opened to private entities from 1992 to 2008. As of now, Slovenia records an increase in private health care expenditures. Other issues like equity, solidarity and fairness of the reformed system are open for debate. Still, patient satisfaction seems to remain constant (Albreht & Klazinga, 2009).

It should be considered that these research findings are not limited to primary care, but include other health care institutions. To curate more results, the keyword primary care had to be abandoned from the search string.

Other frameworks discuss the mixed-ownership on a more general level. The main issue that these frameworks stress is that ownership cannot be limited to just public and private entities. As mentioned above these frameworks argue towards including more factors into the analysis (Øvretveit, 1996; R. B. Saltman, 2003).

Systematic reviews of health care sector institutions mostly found that patient satisfaction is higher in private for-profit PHCCs across Europe (Basu et al., 2012; Eggleston et al., 2008; Herrera et al., 2014; Tiemann et al., 2012). There was no outcome regarding the difference between public and private not-for-profit PHCCs (Berendes et al., 2011; Comondore et al., 2009; Devereaux et al., 2002).

Among others, one outcome of this literature review is the three ownership categories that the research will focus on. This is an attempt to react and incorporate the information that the division between public and private ownership only begins to cover the topic of ownership. Hence, public ownership, private independent ownership and private corporate ownership were identified as suitable categories. The following study will investigate the existing differences in patient satisfaction between these three categories. More categories were rejected by the research team due to the non-representative nature of the categories that would have been created.

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In conclusion, for this research patient satisfaction is understood as a major contributing factor that defines service quality in primary care. Patient satisfaction is measured with the help of seven measuring factors. Furthermore, the study assumes that patient satisfaction positively affects word of mouth, which leads to positive marketing outcomes. Additionally, the differences between private and public ownership in primary health care are understood as a multifaceted construct. Hence, this study focuses only on two aspects namely public vs private ownership and corporate vs independent.

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3.6. Hypotheses

Based on the previously conducted literature review and the predetermined dimensions that the survey provides, the researchers with the following hypotheses were developed. Even though many studies discuss the differences in ownership, there are not many that discuss the differences within the private categories. However, some studies indicate that there are differences within the categories. The hypotheses are inspired by other studies that investigate the differences in for-profit and not-for-profit environments (Deber, 2002). Furthermore, the hypotheses were also derived using an indictive approach to the data by experimenting with the data. The descriptive statistics indicated a positive connection between the dimensions and private independent PHCCs. Thus, the hypotheses were developed and are presented below in a listed format instead of a text to grant the reader a swift and clear overview of the hypotheses. These hypotheses should assist in clarifying the influence of the ownership categories on the seven dimensions of the survey.

H1.1: PHCCs under independent private ownership are positively connected to higher overall patient satisfaction.

H1.0: PHCCs under independent private ownership are not positively connected to higher overall patient satisfaction.

H2.1: PHCCs under independent private ownership are positively connected to higher emotional support when it comes to patient satisfaction.

H2.0: PHCCs under independent private ownership are not positively connected to higher emotional support when it comes to patient satisfaction.

H3.1: PHCCs under independent private ownership are positively connected to higher participation and involvement when it comes to patient satisfaction.

H3.0: PHCCs under independent private ownership are not positively connected to higher participation and involvement when it comes to patient satisfaction.

H4.1: PHCCs under independent private ownership are positively connected to higher respect and kindness when it comes to patient satisfaction.

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H4.0: PHCCs under independent private ownership are not positively connected to higher respect and kindness when it comes to patient satisfaction.

H5.1: PHCCs under independent private ownership are positively connected to higher continuity and coordination when it comes to patient satisfaction.

H5.0: PHCCs under independent private ownership are not positively connected to higher continuity and coordination when it comes to patient satisfaction.

H6.1: PHCCs under independent private ownership are positively connected to higher information and knowledge when it comes to patient satisfaction.

H6.0: PHCCs under independent private ownership are not positively connected to higher information and knowledge when it comes to patient satisfaction.

H7.1: PHCCs under independent private ownership are positively connected to higher availability when it comes to patient satisfaction.

H7.0: PHCCs under independent private ownership are not positively connected to higher availability when it comes to patient satisfaction.

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4. Findings

In this research, the analysis of the data will be done in three steps. Firstly, the data will be described using the mean and the standard deviation. This will enable the research to get an overview of the data and give a preview of possible trends. Secondly, the hypothesis testing will be conducted so the hypothesis can be accepted or denied by using a form of

correlation analysis. Lastly, linear regression will be performed to stay true to the inductive approach and look for more elaborate patterns in the data and gain more detailed insights.

4.1 Descriptive Statistics

To describe the outcome of this research, the means and standard deviations were calculated for all types of ownership and all influence factors. These calculations were performed since they will allow insights into the first trends. Before explaining the performed calculations, a brief definition of both mean and standard deviation will be given. Standard deviation is the most frequently used measure of data dispersion (Livingston, 2004). In general, the standard deviation shows how spread out the data is from the mean. While mean, often referred as the average score, could be defined as the sum of collected data points that are divided by the total number of all data points (Livingston, 2004). Mean is usually understood as the most common measure of central tendency.

The first factor that was analysed was the “Overall Impression”.

Overall Impression Mean Standard Deviation

Public PHCC 77.86 8.15

Private independent PHCC 83.61 7.60

Private corporate PHCC 78.92 9.15

Table 1: Overall Impression - Descriptive Statistics

As seen in Table 1 the highest mean in this dimension was 83.61 for the private independent PHCC’s. This indicates that the private independent PHCCs left the best overall impression with patients. It also had the lowest standard deviation with a value of 7.60. This indicates that the sample is more concise than the others. However, one must be aware that the standard deviation for all the data is relatively high, indicating that the data is spread widely

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among the sample (Wan et al., 2014). More reasons and an attempted explanation for a high standard deviation can be found in the discussion section of this work under point 5.1.

Private corporate PHCCs overall impression had a mean of 78.92 with a standard deviation of 9.15. The mean for the public primary health care centres in the dimension overall impression had a value of 77.86, with a standard deviation of 8.15.

Next, the dimension “Emotional support” will be presented. In table 2., it could be seen that the private independent PHCC’s had on average the highest score among their peers, again. The mean had a value 79.46 with a standard deviation of 7.64.

Emotional Support Mean Standard Deviation

Public PHCC 73,45 8,30

Private independent PHCC 79,46 7,64

Private corporate PHCC 74,76 9,45

Table 2: Emotional Support - Descriptive Statistics

The private corporate PHCCs had a mean score of 74.76 together with a standard deviation of 9.45, while the public PHCCs had a mean of 73.45 with a standard deviation of 8.30.

The third dimension is the “Participation and Involvement”.

Participation and Involvement Mean Standard Deviation

Table 3: Participation and Involvement - Descriptive Statistics

Like in the previously observed two dimensions, the highest mean was found within the category of private independent PHCCs. The private independent Primary Health Care Centres had an 82.13 mean score, together with a 6.59 standard deviation. The second-largest mean score was 78.40 and it was found within the category of the private corporate PHCCs. In this group, the standard deviation had a value of 7.84.

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The next dimension is “Respect and Kindness”.

Respect and Kindness Mean Standard Deviation

Table 4: Respect and Kindness - Descriptive Statistics

The outcome can be seen in Table 4 depicted above. Here the mean scores and standard deviation for all three ownership categories were similar. The similar scores indicate that the respondents had a similar opinion regarding the respect and kindness dimension in every type of PHCC. Still, it was found that the highest mean value was 86.63 within the group of private independent PHCC.

The following dimension is “Continuity and Coordination”.

Continuity and Coordination Mean Standard Deviation

Table 5: Continuity and Coordination - Descriptive Statistics

As seen in Table 5. the highest mean value was found in the private independent group of PHCCs and it had a value of 78.23. Here, the standard deviation was the lowest at 8.88. The following centres were the private corporate ones, with a 71.73 mean score and a standard deviation of 10.56. Lastly, the public PHCCs had the lowest mean score of 67.57 together with a 9.90 standard deviation.

The next dimension that is going to be presented is “Information and Knowledge”.

Information and Knowledge Mean Standard Deviation

Table 6: Information and Knowledge - Descriptive Statistics

Table 6. shows that the private independent group of PHCCs had the highest mean score, with 78.46 and a 6.87 standard deviation. Private corporate PHCCs had the second-largest mean

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score, 74.31, while the public centres had the lowest mean, 72.40. Furthermore, private corporate Primary Health Care Centres had a 7.51 standard deviation, while the public PHCCs had a 7.06 standard deviation.

The last dimension that was analysed is the “Availability”.

Availability Mean Standard Deviation

Table 7: Availability - Descriptive Statistics

Table 7 shows that for the “Availability” dimension, the three types of Primary Health Care Centres had similar mean scores and similar standard deviations. Still, the private independent PHCCs had the highest mean score of 84.96 and a 5.65 standard deviation. The comparable means indicate that there were no substantial differences when it comes to the patients' opinions regarding the availability of all ownership categories. Furthermore, the findings indicate that the observed three types of PHCCs performed similarly in the matter of availability.

In conclusion, all private independently owned PHCCs stand out by having the highest mean and in almost all cases the lowest standard deviation. Only for the dimension “Respect and Kindness” public ones have a lower standard deviation. Thereafter, private corporate and public PHCCs alter from between the second and third highest mean and standard deviation. This already hints that there might be a positive connection between private independent PHCCS and higher scores in the dimensions of patient satisfaction. This also indicates that it is crucial to differentiate between the types of private owners.

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4.2 Hypothesis Testing

In this section, the hypothesis will be tested. In this case, the hypotheses are that there is a direct positive effect of private independent ownership on all dimensions of patient satisfaction. As seen above, the descriptive statistics already indicate that private independently owned PHCCs have a higher mean and thus the chances for having a positive correlation are increased. To prove these hypotheses, a Pearson correlation was used (Benesty et al., 2009). First, the overall correlation of private compared to public ownership was tested and consequently, the private independent ownerships correlation to the dimensions was tested. The first step in the hypothesis testing was to ensure that all data sets were used for the analysis. The final number of sets of data from PHCCs in Sweden (N) is 1110. All other data sets were either incomplete or the facility had been closed. Thus, only complete data sets of operating primary health care centres remain. It is anticipated that this will be the underlying case number for all examined correlations. Subsequently, it was crucial to investigate the strength and direction of the correlative relationship. The following general rules apply:

If the Pearson Correlation between two variables, e.g. ownership and dimension of patient satisfaction, is greater (lesser) than 0 the correlation is positive (negative). The closer the Person Correlation is to +1 (-1) the stronger the correlation (Pallant, 2007). Cohen (1988) specifies that a correlation of 0.10 – 0.29 or their negatives is considered a weak correlation, between 0.30 – 0.49 or their negatives a medium correlation and over 0.5 or -0.5 a strong correlation (Cohen, 1988).

The correlation of private ownership in total was tested. The second test checked only the independent private ownerships correlation with the dimensions. The first dimension that was examined was the “Overall Impression”.

Overall Impression Private Independent

Pearson Correlation 0,001 ,224

p-Value 0,975 0,000

N 1110 1110

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When testing for the correlation between overall impression and all private primary health care centres a significant level was not reached. However, when testing for a correlation between the same dimension and only private independent centres a weak positive direct correlation with statistical significance can be found. Therefore, the Hypothesis H1.1 PHCCs under independent private ownership are positively connected to higher overall patient satisfaction is accepted.

Emotional Support Private Independent

p-Value 0,725 0,000

N 1110 1110

Table 9: Emotional Support - Hypothesis Testing

As above, the correlation for all private ownership was tested first, but the results didn’t reach a significant level. Hence, the Pearson correlation will not be taken into account. For the private independent ownership category, a significance level was reached. Here, a weak direct positive correlation was found that does confirm the Hypothesis H2.1 PHCCs under independent private ownership are positively connected to higher emotional support when it comes to patient satisfaction. Hence, the H2.0 Hypothesis PHCCs under independent private ownership are not positively connected to higher emotional support when it comes to patient satisfaction can be rejected.

The next dimension tested was “Participation and Involvement”. Firstly, the correlation for all privately owned PHCCs was tested. However, the results were not statistically significant. Hence, they were excluded from this analysis. In contrast, the private independently owned results were significant.

The data indicates that there was a weak direct positive correlation detected with a Pearson Correlation of 0.229. This hints on centres with this type of ownership having a higher score in this dimension. Additionally, that lead to the confirmation of Hypothesis H3.1 PHCCs under

Participation and Involvement

Private Independent

p-Value 0,239 0,000

N 1110 1110

Does ownership matter? : Differences in ownership of Swedish primary health care centres and its effects on patient satisfaction.