Original Research

The Impact of Service Quality on Patient

Satisfaction and Revisiting Intentions: The
Case of Public Emergency Departments
Vasiliki Amarantou, PhD (C); Dimitrios Chatzoudes, PhD; Vasiliki Kechagia, PhD (C);
Prodromos D. Chatzoglou, PhD

Background and Objectives: This study attempts to (a) identify the main quality indicators that affect “service
quality” and (b) examine the effect of “patient satisfaction” on patient “revisiting intentions.” Methods: The sample
includes patients of 2 hospitals, 1 urban and 1 provincial. The comparative analysis of 2 emergency departments
(EDs) with different characteristics aims at understanding their diverse problems and their specific needs from a
patient point of view. Empirical data were collected in the fall of 2015. Three hundred questionnaires were distributed
in person. A total of 169 valid questionnaires, 80 from hospital A and 89 from hospital B, were returned, with a
response rate of 56.3%. Results: The Structural Equation Modeling technique revealed that overall satisfaction is
strongly influenced by “perceived service quality” (β = .79), while it positively affects patient “behavioral intentions”
(β = .39). Also, “perceived waiting time” proved to have a more intense impact on “perceived service quality” (β
= −.59), rather than on “perceived technical and functional quality” (β = .18). Moreover, it was determined that
patients visiting the urban ED pay more attention in waiting times, while patients visiting the provincial ED care
about receiving both quality and timely health care services. Overall, the study provides insight about the main
factors affecting “perceived service quality” and “overall satisfaction.” These factors fall into 2 distinct categories:
“perceived technical and functional quality” and “perceived waiting time.” Conclusions: The study concludes that
“overall satisfaction” acts as a mediator between “perceived service quality” and patient “behavioral intentions,”
while “perceived waiting time” is the most significant indicator of service quality and the most crucial predictor of
ED patient satisfaction. Moreover, it offers empirical evidence concerning the differences in the way patients rate the
services offered by a hospital, based on the hospital size and the region it is located (urban or provincial).
Key words: emergency department (ED), health care service quality, patient satisfaction, SEM analysis, waiting
time

P atient satisfaction is a crucial end point and a

central goal of medical care.1-3 The concept of
patient satisfaction has attracted the attention of the
research community4 ; however, it suffers from inad-
equate conceptualization.5 The lack of standardization
among different surveys and the incoherent measure-
ment of the concept have raised concern among var-
ious researchers.6,7 For many years, the positive cor-
relation between quality and satisfaction was widely
accepted.8-10 However, both the direction of the rela-
tionship and its predictive power remain quite vague.11
Its examination prerequisites the understanding of ex-
ogenous variation in the quality of provided care, since
satisfaction is sensitive to personal expectations, while
both quality and satisfaction occur simultaneously.
Author Affiliation: Department of Production and Management
Engineering, Democritus University of Thrace, Xanthi, Greece.
Correspondence: Vasiliki Amarantou, PhD (C), Department of Production
and Management Engineering, Democritus University of Thrace, 12
Vasilissis Sofias St, 67100 Xanthi, Greece (vasamara@pme.duth.gr).
The authors declare no conflicts of interest.
Q Manage Health Care
Vol. 28, No. 4, pp. 200–208
Copyright 
C 2019 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/QMH.0000000000000232
Behavioral intentions are defined as “patients’ po-
tential behaviors likely to be triggered by service quality
and satisfaction.”12 Previous studies have tried to mea-
sure revisiting (behavioral) intentions but faced various
difficulties. For instance, some researchers13 argued
that choice rarely applies in emergency departments
(EDs) (eg, because of acuity of the patient and/or geo-
graphical constraints); therefore, revisiting intentions in
EDs cannot be measured. However, other authors14-16
argued that (a) willingness to recommend a hospital,
(b) intention to revisit a hospital for other services in
the future, and (c) positive word of mouth can be mea-
sured and are also significant indicators for the health
care system, since they reduce information asymmetry
and present a tool for health care providers, in order to
understand what patients actually value.
Under that context, various researchers have at-
tempted to identify the influence of patient satisfaction
on revisiting intentions but generated contradictory em-
pirical results. On the one hand, much evidence argues
that satisfaction not only influences revisiting intention
and word of mouth15-18 but also acts as a mediator be-
tween service quality and revisiting intentions.19-21 On
the other hand, other studies concluded that a weak
correlation exists between satisfaction and return to
provider.22 Finally, many other studies have failed to ex-
amine the mediating role of patient satisfaction.16,23

200 October–December 2019 r Volume 28 r Number 4 www.qmhcjournal.com

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October–December 2019 r Volume 28 r Number 4
“Service quality” reflects the perceptions of the
patients about the quality of the provided services
during their visit in an ED.24 Although many studies
supported the strong influence of perceived service
quality (PQ) on patient satisfaction,16,25,26 there is lim-
ited research examining the simultaneous effect of ser-
vice quality on both patient satisfaction and behav-
ioral intentions.27 Service quality is recognized as a
multidimensional construct28,29 and researchers have
listed a variety of service quality determinants.30,31 Al-
though most previous studies have investigated health
care service quality based on the SERVQUAL instru-
ment, which includes 5 dimensions (tangibles, reliabil-
ity, responsiveness, empathy, and assurance),32 there
seems to be no commonly approved model of quality
constructs.33,34 Gholami et al,1 among numerous stud-
ies, have reported significant gaps between patient
expectations and their actual perceptions. Overall, it
can be concluded that, based on actual customer per-
ceptions, there is not a specific quality dimension that
stands out as the most significant.
Prolonged waiting times in EDs seem to be seri-
ously taken into consideration by the patients, as they
are associated with poorer clinical outcomes, or even
death.35,36 Although many researchers failed to iden-
tify long waiting times as a significant quality indicator
in EDs,37-39 others40,41 not only managed to prove that
waiting time is the most important determinant of pa-
tient perception concerning service quality but also es-
tablished that it is a primary driver of satisfaction.42-45
Despite that, “waiting time” has never been previously
measured as a single coherent factor (construct).
This study incorporates the 5 SERVQUAL quality
dimensions (tangibles, assurance, empathy, respon-
siveness, and reliability) into 1 comprehensive fac-
tor, titled “perceived technical and functional quality
[PTFQ].” Some studies5,46 determined that perceived
technical/functional quality may not have the strength
to directly affect patient satisfaction. However, Kitapci
et al16 found that all SERVQUAL dimensions are impor-
tant antecedents of satisfaction, meaning that all of the
5 service-related factors have a significant positive in-
fluence on patient satisfaction. In other words, it can be
assumed that high levels of medical care, interpersonal
communication, technical and personnel resources,
and so forth lead to high levels of patient satisfaction.47
The main contribution of this study lies in its at-
tempt to fill the gaps in the relevant literature. This
study attempts to examine the link between PQ, over-
all patient satisfaction, and willingness to return to the
same hospital for other health services in the future
and/or recommend the same hospital to others. Also,
it tries to identify the characteristics of service provi-
sion (quality dimensions) that are valued by patients of
2 different-sized EDs and highlight their relative impor-
tance. As such, it provides a comparative analysis of
2 EDs with different characteristics, offering the oppor-
tunity to understand their diverse problems and their
specific needs, from a patient point of view. Finally,
it develops a new instrument of quality indicators, in-
corporating factors that have been previously used in
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www.qmhcjournal.com 201
the literature, while also introducing waiting time as an
individual quality indicator.
Although many empirical studies have evaluated the
quality of health services in both developed and de-
veloping countries, limited empirical research in this
area has been carried out in countries facing economic
crisis. The present empirical research is conducted in
Greece during a period of financial crisis. Examining
“waiting times” under such context is expected to
be interesting for the following reasons: (a) the Greek
public health care system, as in many other countries,
needs immediate change; (b) there is an exponential in-
terest to increase patient satisfaction in environments
of financial depression; and (c) little research has been
conducted in countries that are facing similar financial
difficulties. This research aspires to assist Greek pol-
icy makers and managers who are keen to provide and
maintain high-standard health care to the residents of
the country.
To develop the proposed research model of this study
(see Figure 1), an extensive literature review analysis,
using the “Scopus database,” was initially conducted.
Its development was mostly based on the previous
work5,44,48 that provided empirical evidence supporting
the causal links among service quality, patient satis-
faction, and behavioral intentions. Some of the rela-
tionships among these factors have been explored by
previous studies published in highly esteemed journals
(see Table 1), while others have not been investigated
extensively.
METHODS
Sample
The survey was designed with the intent to be con-
ducted in 2 public hospitals, 1 urban, located in the
capital of Greece (Athens), and 1 provincial. The urban
hospital was selected because it has the largest num-
ber of daily patient admissions in the whole country.
Three provincial hospitals that have similar character-
istics with the urban hospital were also contacted to
participate in the survey. The hospital that was the first
to accept the invitation was included in this survey.
Although the participating hospitals may have differ-
ences regarding their size, resource allocation, and spa-
tial planning, they do not differentiate in the way they
operate; in any other case they would be incomparable.
The empirical study was conducted on a random
sample of patients visiting the EDs of these 2 hospi-
tals. When a patient was already admitted in a hospital
clinic or when he was not physically able to answer the
questionnaire, his escort was responsible for providing
the answers. A total of 300 questionnaires were dis-
tributed between August 2015 and October 2015, and
169 valid questionnaires were finally collected, with
a response rate of 56.3%. The sample is comprised
of 80 patients from hospital A and 89 patients from
hospital B. The response rate is considered to be
very satisfactory and is attributed to the professional
and empathetic approach that was adopted by the
members of the research team.
202 October–December 2019 r Volume 28 r Number 4 www.qmhcjournal.com

Figure 1. Research model.

Despite the fact that this study was conducted
in health care organizations (ie, hospital EDs), the
respondents (ie, patients) were not interviewed about
their medical records, nor did they provide identifiable
private information. The survey was strictly anonymous
(confidential) and collected only empirical (primary)
data about perceptions, beliefs, and intentions. Also,
during the data collection process, every possible
measure was taken to ensure that the completion
of each questionnaire was not conducted when the
patient was under any distress. The researchers were
very understanding about the health conditions of
each participant, ensuring that their presence was not
a factor that caused any anxiety or discomfort.
Measures
Perceived service quality
Generally, “perceived service quality” is the con-
sumer’s judgment about a product’s overall excellence
or superiority, based on subjective perceptions of what
is received and what is given.28 This study attempts
to calculate patient perceptions based on individual re-
sponses in various items/questions (eg, help in pain
management, provision of information regarding the
health situation, understanding the provided informa-
tion, reducing the concerns of the patient, personnel
discretion, personnel kindness, responsiveness to var-
ious complaints and questions, etc). The 5-point Lik-
ert scale was used to rate all items (1 = “Very poor”
or “Very dissatisfied,” 5 = “Very good” or “Highly
satisfied”).
Overall satisfaction
“Overall satisfaction (OS)” can be measured indirectly
by asking “users” to rate the quality of services they
have received or report their experiences. The level
of patient satisfaction is not an immediate result of
whether one person got better during his or her stay
at the ED; all patients can feel satisfied or dissatis-
fied, regardless the level of their health improvement.
Moreover, satisfied patients are more likely to com-
ply with treatments and less likely to file complaints or
lawsuits.43,55 The survey instrument asked respondents
to rate 10 items corresponding to 10 service quality in-
dicators, such as the provided services of the ED, the
waiting time, the speed of the diagnosis, the duration

Table 1. Construct Measurement

Number of
Factors Supporting Literature Questions
Overall satisfaction Baalbaki et al44 (2008); Boudreaux and O’Hea48 (2004); Gill and White5 10
(2009); Hall and Dornan49 (1988); and Soleimanpour et al50 (2011)
Perceived service quality Gok and Sezen25 (2013); and Kitapci et al16 (2014) 8
Behavioral intentions Kessler and Mylod17 (2011) and Kitapci et al16 (2014) 3
Perceived waiting times Baalbaki et al44 (2008); Welch51 (2010); Soremekun et al52 (2011); and 5
Boudreaux and O’Hea48 (2004)
Perceived technical and functional quality Kitapci et al16 (2014); Alrubaiee and Alkaa’ida30 (2011); Badri et al53 5
(2008); and Parasuraman et al54 (1988)

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October–December 2019 r Volume 28 r Number 4
of the examination, the overall attention to their health
problem, the overall perceived quality of service, and
so forth. Items were rated on a 5-point Likert scale
(1 = “Very poor” or “Very dissatisfied,” 5 = “Very
good” or “Highly satisfied”).
Behavioral intentions
“Behavioral intention” was operationalized as whether
a given patient is eager or not to return to the same
hospital in the future. The survey questionnaire utilized
3 items regarding the willingness to revisit the specific
hospital even if (1) there was another hospital available
in the area, (2) the patient could afford to visit a private
institution, and (3) a personal doctor was available. In
this case, a 5-point Likert scale was used to rate these
3 items (1: “Not likely,” 5: “Very likely”).
Perceived waiting times
According to Boudreaux and O’Hea,48 the patient’s sub-
jective experience concerning the waiting time is much
more important than the actual waiting time or the
length of stay. Satisfaction seems to depend not on
how long the patient actually waits but whether this
length is consistent with expectations. If waiting times
are longer than what the patient expects or deems ap-
propriate, then dissatisfaction is likely to arise, regard-
less of the actual time waited.56
In this study, respondents were asked to evaluate,
based on a 5-point Likert scale (1 = “Very short,” 5 =
“Very long”), the waiting times in 5 different stages
of their ED visit (waiting for admission, waiting for ex-
amination, waiting for laboratory examinations, waiting
for radiographic examination, waiting for laboratory re-
sults, and/or radiographic results). Moreover, the pa-
tients were asked to identify whether 6 dimensions
(items), namely, bureaucracy, personnel, shortcomings
in staff, shortcomings in technical equipment, and ED
management, are responsible for long waiting times,
delays, and so forth. Items were rated using a 5-point
Likert scale (1 = “Strongly disagree,” 5 = “Strongly
agree”).
Perceived technical and functional quality
This study incorporates the 5 service quality dimen-
sions of the SERVQUAL measurement scale into 1
comprehensive and coherent factor, titled “perceived
technical and functional quality.” “Technical quality”
refers to the outcome of the medical treatment, in-
cluding both physical and emotional recovery.28 “Func-
tional quality” includes features such as the physical
surroundings and other similar tangible attributes of
the health care organization.57
This study evaluates the technical and functional char-
acteristics of ED care by asking patients to evaluate
their visit at the ED on the 5 following SERVQUAL
dimensions (using the 5-point Likert scale): (a) phys-
ical facilities and equipment (tangibles), (b) interper-
sonal interactions (assurance), (c) individualized atten-
tion provided by the ED personnel (empathy), (d) ability
to perform the health care services accurately (relia-
bility), and (e) proper information and service delivery
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www.qmhcjournal.com 203
(responsiveness).58 In addition, patients were asked
whether each of the 5 dimensions (items) (bureaucracy,
personnel, shortcomings in staff, shortcomings in tech-
nical equipment, ED management) is responsible for
the technical and functional problems of the ED. Items
were rated using a 5-point Likert scale (1 = “Strongly
disagree,” 5 = “Strongly agree”).
Reliability analysis
The questionnaire that was used in this study was
tested for both its content and construct validity. Con-
tent validity was tested prior to the beginning of the
survey. It included (a) consultation with academics of
the field, (b) consultation with experienced practition-
ers, and (c) pilot testing. Results demonstrated strong
content validity.
Construct validity was assessed by performing a prin-
ciple component factor analysis. For determining the
appropriateness of the factor analysis, the following
measures were estimated: (a) the “Bartlett’s test of
Sphericity” (it should be statistically significant at the
.05 level) and (b) the statistical test of “Kaiser-Mayer-
Olkin” (values >0.6 are acceptable). Construct reliabil-
ity was assessed using Cronbach’s α value. Nunnally
and Bernstein59 argue that Cronbach’s α values should
be greater than 0.7 for items to be used together as
a coherent construct. The results of this analysis (see
Table 2 for more details) reveal that the proposed fac-
tors of this study are both valid and reliable.
RESULTS
Patient data
As mentioned earlier, 169 ED patients participated in
the study. The demographic characteristics of the par-
ticipants are fully presented in Tables 3 and 4.
In both EDs, the sample consists mainly of fe-
males and middle-aged individuals with Greek citizen-
ship and health insurance. Concerning the department
that the medical treatment was received from, pathol-
ogy seems to be the one most visited (22.5% and
49.4% in ED1 and ED2, respectively). Moreover, in
both hospitals, overcrowding was observed during the
morning hours, 8:00 AM to 2:00 PM (76.3% for ED1 and
86.3% for ED 2).
It is alarming, though, that a large percentage of the
patients who attended both EDs assessed that their
condition was not very urgent or not extremely ur-
gent (73.8% for ED1 and 64.1% for ED 2, with mean
scores 3.04 and 3.22, respectively). Regarding the wait-
ing times, the findings reveal that patients waited a long
time before they could enter the examination rooms
(the average waiting time was 54 minutes for ED1 but
only 12 minutes in ED2). The highly related problems of
overcrowding and long waiting times sometimes cause
another serious issue: the medical staff is not able to
devote the required attention to each patient. For exam-
ple, the medical personnel of ED2 devote more time
to the examination of each patient (average duration
of each examination = 50 minutes). Moreover, ED2
performs more laboratory examinations in comparison
204 October–December 2019 r Volume 28 r Number 4
Table 2. Factor Analysis and Reliability Analysis
KMOa
Factor ED1 ED2
Overall satisfaction 0.847 0.911
Perceived service quality 0.885 0.904
Behavioral intentions 0.690 0.641
Perceived waiting times 0.738 0.629
Perceived technical and functional quality 0.583 0.639
Abbreviations: ED, emergency department; KMO, Kaiser-Mayer-Olkin; TVE, total variance explained.
a
The significance of the Bartlett’s test of sphericity for all factors and both EDs is at the .000 level.
with ED1: of the 89 patients admitted in ED2, 61 un-
derwent a total of 112 laboratory tests.
Patients were also asked to highlight the reason of
any occuring problems (regarding waiting times and
technical/functional quality) in the EDs (see Table 4).
Regarding prolonged waiting times, the items with
the higher mean score (meaning that patients perceive
that these dimensions are more responsible for the
problems occurred in the ED) are (ED1): shortcomings
in staff (M = 3.59, SD = 1.46) and shortcomings in tech-
nical equipment (M = 3.32, SD = 1.58). For ED2, the
same dimensions are shortcomings in staff (M = 3.37,
SD = 1.36) and shortcomings in technical equipment
(M = 3.19, SD = 1.41).
Regarding the problems associated with the tech-
nical and functional aspects of the provided services,
the items with the higher mean score for ED1 are in-
adequate technical equipment (M = 3.31, SD = 1.45),
ED management (M = 3.29, SD = 1.18208), and short-
comings in staff (M = 3.20, SD = 1.44). For ED2, the
same items (or dimensions) are shortcomings in techni-
cal equipment (M = 3.30, SD = 1.32) and shortcomings
in staff (M = 3.22, SD = 1.31).
Causal relationships
The causal relationships of the research model were
examined via the “Structural Equation Modeling” tech-
nique (see Figure 2 for a visual presentation of the
results). All appropriate indices of model fit (eg, Com-
parative Fit Index (CFI), Goodness-of-Fit Index (GFI),
Normed Fit Index (NFI), Root Mean Square Resid-
ual (RMR), Root Mean Square Error of Approximation
(RMSEA) χ 2 /df = 2.323, CFI = 0.985, GFI = 0.964,
NFI = 0.964, RMR = 0.020, and RMSEA = 0.069) were
within their appropriate levels.
Empirical results revealed a strong positive influ-
ence of PQ on patient satisfaction (β = .79, P < .05).
As Figure 2 indicates, PQ explains 62% of the vari-
ance in overall patient satisfaction. According to Richter
et al,60 access to medical care, quality of care, and in-
terpersonal interaction with staff accounts for the ma-
jority of the variance in overall patient satisfaction. This
study also reveals a statistically significant direct impact
of patient (overall) satisfaction on behavioral intentions
(β = .39, P < .05). These findings indicate that patient
satisfaction acts as a significant mediator in the rela-
tionship between PQ and behavioral intentions.
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TVE Factor Loadings Cronbach’s α
ED1 ED2 ED1 ED2 ED1 ED2
55.201 71.424 0.575-0.843 0.766-0.929 0.892 0.947
63.207 72.696 0.702-0.869 0.661-0.905 0.915 0.946
66.409 72.521 0.805-0.825 0.791-0.915 0.739 0.808
54.887 51.699 0.656-0.782 0.664-0.788 0.794 0.763
69.153 67.254 0.703-0.921 0.712-0.875 0.772 0.753
In terms of perceived waiting times (PWT), the em-
pirical findings from both EDs show that the duration
of the waiting time directly and negatively influences
PQ (β = −.59, P < .05) and behavioral intentions (β =
−.27, P < .05). Despite that, the same effect was not
found regarding OS (the impact of waiting time on sat-
isfaction was not empirically established, P > .05). Re-
garding the factor “PTFQ,” the results from both EDs
indicated that it has a statistically significant positive im-
pact on PQ (β = .18, P < .05). Nevertheless, it was not
found to have an impact on behavioral intentions (P >
.05) and OS (P > .05).
Since this study was conducted in 2 EDs with dif-
ferent characteristics (1 provincial and 1 urban), we at-
tempted to make comparisons between the 2 different
Structural Equation Modeling models. Overall, the pre-
dictive power of the model that incorporates both hos-
pitals (EDs) is quite satisfactory. More specifically, it ex-
plains 30% of the variance in the main dependent factor
of the study, namely, “behavioral intentions” (Figure 2).
Nevertheless, the same results were obtained for each
ED separately (2 alternative Structural Equation Mod-
eling models were also estimated). The findings re-
vealed that although the predictive power of the model
for each ED is similar (R2 = 0.35 and R2 = 0.34), the
way the 2 main independent factors (PTFQ and PWT)
affect the 3 dependent factors (behavioral intentions,
PQ, and OS) differs significantly from model to model.
More specifically, in ED1 things are quite simple: wait-
ing times affect service quality (r = −0.45), service qual-
ity affects satisfaction (r = 0.76), and satisfaction affects
behavioral intentions (r = 0.59). In ED2, things become
quite complex: waiting times affect both service qual-
ity (r = −0.67) and behavioral intentions (r = −0.22),
while technical and functional quality also affects both
service quality (r = 0.30) and behavioral intentions (r =
0.23). In summary, the empirical results of the 2 alterna-
tive models suggest that each hospital is a completely
different case and, therefore, should be examined sep-
arately; in other words, conclusions cannot be gener-
alized. This finding is consistent with various previous
studies, which also argued that the empirical observa-
tions in public hospitals cannot be easily generalized to
other health care environments because of their signif-
icant complexity and unique characteristics.14,61-63
From the aforementioned findings, it seems that the
citizens of the urban ED consider “waiting time” as the
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Table 3. Respondents’ Demographic Table 3. Respondents’ Demographic

Characteristics Characteristics (Continued)
Emergency Emergency Emergency Emergency
Department 1 Department 2 Department 1 Department 2
Options Frequency % Frequency % Options Frequency % Frequency %
Age, y 61-120 min 13 16.3 9 10.1
18-35 19 23.8 24 27.0 121-180 min 7 8.7
36-50 16 20.0 10 11.2 Mean: 53.94 min Mean: 11.51 min
51-65 26 32.5 36 40.4 Duration of examination
65+ 19 23.8 19 21.3 0-10 min 45 56.3 29 32.6
Status 11-20 min 27 33.7 27 30.0
Patient 45 56.3 36 40.4 21-60 min 5 6.3 18 20.2
Escort 35 43.8 53 59.6 60-420 min 3 3.7 15 16.9
Gender Mean: 19.38 min Mean: 50.30 min
Male 26 32.5 27 30.3
Female 54 67.5 62 69.7
only and most important quality indicator, while citizens
Citizenship of the provincial ED perceive that it is only 1 indicator
Greek 74 92.5 85 95.5 between several other significant ones. These results
can be logically explained, as citizens in megacities
Other 6 7.5 4 4.5 (ED1) are aware of the excess demand for health care
Health insurance services,61 so they tend to have relatively low expecta-
Yes 62 77.5 73 82.0
tions regarding the functional and technical aspects of
the provided services, while they pay more attention in
No 18 22.5 16 18.0 waiting times. In contrast, in provincial EDs (ED2), both
Department quality dimensions (“PTFQ,” “waiting time”) have a
statistically significant impact on “PQ.” In a relevant
Pathology 17 21.3 44 49.4
study, McFarland et al64 found that patient satisfaction
Cardiology 8 10.0 6 6.7 indexes are usually lower in large city hospitals, be-
Orthopedic 3 3.8 1 1.1 cause of patients’ perceptions about hospital cleanli-
ness, receiving help on time, doctor communication,
Surgical 13 16.3 20 22.5
and so forth.
Pediatric 3 3.8 5 5.6
Urological 1 1.3 2 2.2
CONCLUSIONS
Ophthalmology 16 20.0 1 1.1
Patient satisfaction is important to the overall ED perfor-
Other 19 23.8 10 11.2 mance, since it strongly affects financial remuneration
Severity of health condition and patient compliance.65 In this article, patient satis-
faction is measured as a function of perception and
Nonurgent 1 1.3 3 3.4
expectation. This approach allows the consideration of
Standard 23 28.7 11 12.4 the psychological processes that may explain why 2 pa-
Urgent 35 43.8 43 48.3 tients experiencing similar care in 2 different EDs can
express very different levels of satisfaction and behav-
Very urgent 14 17.5 27 30.3 ioral intentions.
Extremely urgent 7 8.8 5 5.6 The empirical findings of this study revealed that, irre-
Hour of arrival
spective of the size of the ED, patient perceptions about
the provided service quality are important antecedents
8:00 AM-11:00 AM 31 38.8 44 49.4 of their satisfaction which, in turn, leads to a higher
11:01 AM-2:00 PM 30 37.5 33 37.1 willingness to recommend and seek future treatment
in the same hospital. Moreover, PWT, in both EDs, was
2:01 PM-5:00 PM 12 15.0 11 12.4
found to be the most important determinant of service
5:01 PM-8:00 PM 7 8.7 1 1.1 quality, while the technical/functional characteristics of
Waiting time for examination the provided services were taken into consideration
only by visitors of the small-sized ED. Under this con-
0-30 min 37 46.3
text, various interventions can be proposed to change
31-60 min 23 28.7 80 89.9 the patients’ way of thinking and, hence, improve their
(continues) OS.

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206 October–December 2019 r Volume 28 r Number 4 www.qmhcjournal.com

Table 4. Respondents’ Demographic Characteristics

Emergency Department 1 Emergency Department 2
Options Meana SD Meana SD
Causes of waiting time–related problems
Bureaucracy 2.9375 1.60177 2.2584 1.35284
Personnel 2.2500 1.24778 2.8045 1.41195
Shortcomings in staff 3.5875 1.46429 3.3708 1.36000
Shortcomings in technical equipment 3.3250 1.58134 3.1910 1.41322
The management of the ED 2.9375 1.40833 2.4382 1.46904
Causes of technical and functional quality–related problems
Bureaucracy 2.8625 1.40292 2.3258 1.30363
Personnel 2.5000 1.43112 2.9978 1.50136
Shortcomings in staff 3.2000 1.44433 3.2247 1.31212
Shortcomings in technical equipment 3.3125 1.45475 3.3034 1.31775
The management of the ED 3.2875 1.18208 2.5506 1.43028
Abbreviation: ED, emergency department.
a
Items were rated using a 5-point Likert scale (1 = “Strongly disagree,” 5 = “Strongly agree”).

Managerial implications Moreover, in order to increase patient satisfaction,

This study offers suggestions to health care managers.
Empirical findings revealed that in order to increase
the perceived level of quality and enhance patient
satisfaction, quality improvements and research-based
interventions are needed. Previous studies66-69 identi-
fied that most causes for patients’ excessive ED stay
were related to the hospital operations outside the ED.
Therefore, interventions in order to improve hospital
occupancy (eg, better discharge process, expansion
of beds) and/or improve laboratory response time
are more likely to result in positive outcomes, in
comparison with adopting other initiatives, such as
expanding the ED or increasing its staff.
hospitals need to develop strategies that empower
their employees. This would mean making employees
more customer-focused and responsive in an effort
to improve the overall compassion and self-image of
the staff.44 Furthermore, as stated throughout this
article, patients must be made aware and reassured
that the hospital is taking very special care of them.70
The medical staff should take into consideration the
fact that patients expect kindness, empathy, com-
passion, confidence, respect, interest, and a sense
of responsibility.71,72 These traits can make patients
satisfied with the provided services and in turn improve
their willingness to recommend the hospital services

Figure 2. Research model—Structural Equation Modeling results (both emergency departments).

Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
October–December 2019 r Volume 28 r Number 4
to others.1 Furthermore, hospital management should
also be engaged in improving the health care services
quality. Locating additional funding resources and
implementing drastic changes for better utilizing the
existing resources are considered optimal for the
further enhancement of service quality.
Finally, the most significant implication of this study
is that both hospital managers and medical staff should
bear in mind that each case (hospital/ED) is unique in
its nature. Hence, the successful implementation of
any change initiative largely depends upon the general
characteristics and the specific problems of each ED. As
stated earlier, what patients consider important in one
ED might be different in another. Health professionals
should consider the demographic of their patients and
the socioeconomic context they operate in. Generally,
in big cities patients care more about the waiting time,
while in smaller cities patient satisfaction is based on a
collection of different factors.
Limitations and future research
First, the personal and subjective nature of evaluations
means that views about given standards of care can
vary. Second, the study was conducted during a period
of economic crisis for the Greek economy. The lack of
financial resources hinders hospital progress and re-
duces the quality of provided services. Therefore, it
is possible for someone to assume that if the same
study was conducted at a different time, results would
be different. Third, sampling was not conducted dur-
ing evening hours, while the sample size could have
been higher. Moreover, patients with serious health
problems were disproportionally represented in the fi-
nal sample. Finally, empirical data were gathered from
all ED subdepartments, but results were not examined
accordingly.
Future studies conducted in other countries may pro-
vide additional knowledge about the main research
question and offer the ground for comparisons. As
stated previously, this study found that each ED is a
unique case with different needs and characteristics;
therefore, a single generalized course of action does
not exist. All the alternative practices that may improve
the perceived patient quality should be extensively ex-
amined in the future. Until now, the literature has failed
to examine “waiting time” as a significant quality indi-
cator; therefore, there is need for further investigation.
Although the results of empirical research conducted
in a country facing financial difficulties cannot be gen-
eralized, this study could provide additional knowledge
and offer the ground for comparison with other studies
conducted in countries with similar financial character-
istics, or with EDs displaying the same functional and
technical challenges.
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