Study 1: Focus Groups
The insights collected during the focus groups can be grouped in the following topics:
- Staff;
- Information;
- Brand;
- Atmosphere and Comfort;
- Institutional communication (offline and online);
- Usage of online tools.
Staff: the hospital’s staff is meant to be the key driver of the experience. When having to define it, adjectives such as "enviable, always available and sunny” are used.
- Women emphasize the role of midwifes as fundamental for the entire pregnancy (“the key figure in the maternity path”).
- The ultrasound scan is also considered a delicate moment in which women clearly express the willing to “constantly see the monitor” because “it is reassuring”.
- People working in a hospital need to be “full of humanity”.
- Patients want someone who answers to all their questions/doubts/fears; “even when I realize that I am really asking too much”.
- An interesting topic was the easy recognition of the role of health staff members. Some women appreciate when "staff members introduce themselves". The alternative option of “reading the badge " is not perceived in a positive way.
Information: the topic of obtaining information emerged while talking about the characteristics needed in the personnel, but was also further discussed thoroughly.
- In fact, the general need is of “receiving complete information”.
- Furthermore, the terminology used is described as a "guarantee of technical professionalism", but also as a cause of a difficulty in understanding.
- The best for the staff to express themselves would be in a “clear, concise and simple manner”.
Brand: during the focus group several informants have declared their reasons for choosing Burlo Garofolo Hospital, mentioning its value as a brand.
- In order to evaluate the excellence of a maternal and child health hospital women look at its specializations.
- The water birth is considered a plus by some new mothers, but in general everyone agrees about the importance of having intensive care first.
- “Trust" is often mentioned as one of the main needs and is perceived as strictly linked to “quality”.
- The attention provided to children is considered obvious but the support to the mother is considered an underestimated need.
- The value of a hospital is high when it is “reassuring”.
Atmosphere and Comfort: the ambience is perceived highly important in order to complete the experience.
- No specific architectural solution is mentioned in order to improve the stay at the hospital.
- Cleanliness is often emphasized.
- Visiting hours are described as noisy, overcrowded, and not very serene. Women suggest they should be regularized in such a way as to avoid the overcrowding of spaces and excessive confusion.
Institutional Communication (Offline and Online): while no specific suggestions emerged about the design of spaces, details about how services provision and administrative procedures could be managed were discussed.
- Bureaucracy is perceived as the main obstacle in any health procedure/issue.
- The need of a good link and communication between medical and administrative staff and among departments is stressed possibly “using digitized tools that can overcome the existing limits of the administrative procedures".
- Online institutional communication channels are considered fundamental in order to obtain correct and accurate information (the main needs are registered on the hospital’s facilities, the offered therapies and practices, pre-birth courses, check-in times, waiting lists and medical exemptions).
- The hospital’s official website is seen as the online touch point and should be “very intuitive and easy to be understood".
Usage of Online Tools: the discussion emphasized the role of the web and of social media tools.
- The Internet was not perceived as the main information source on pregnancy and childbirth. What hampers its use is mainly "the danger of self-diagnosis".
- There was broad agreement on social networks’ help to promote a sharing of ideas among mothers. Despite this, only a couple of participants used forums and communities. Even Facebook as a means of discussing pregnancy is used in a limited manner, while all participants confirm to be part of a Whatsapp group of expectant women/new mothers, and to find it extremely useful “to receive an answer to any doubt, anxiety, problem or need by obtaining immediate support at any time of the day”. Some women also underline the importance of Youtube channels.
Study 2: Explorative Qualitative Analysis Text Mining for Maternity Patients Content Analysis
The most relevant or active online communities found using the Scrapebox software were those reported in table 1.
Table 1 Features of the communities selected for the study
Type of community
|
Community Name
|
N° of unique
URLs related to Burlo Garofolo
|
Online Forum
|
“Periodo Fertile”
|
400
|
Online Forum
|
“Forum Al Femminile”
|
115
|
Online Forum
|
“Mammole del Burlo Garofolo”
|
28
|
Online Forum
|
“Cerco un bimbo”
|
17*
|
Online Forum
|
“Sopravvissute al Burlo Garofolo”
|
1*
|
Facebook group
|
“Le Supermamme di Trieste”
|
55
|
Facebook page
|
“Mamme alla pari di Trieste”
|
367
|
Facebook page
|
“Mammole del reparto Burlo Garofolo”
|
958
|
*despite of low number of discussions, these forums were chosen because of the importance and the length of the dialogues
A similar research in other social media platforms with no relevant results was also performed.
Thanks to the analysis obtained through QDA Miner 5.0 software it was possible to code textual data from Facebook forums which were organized using relative frequency in order to analyze consumer sentiments towards brands (Table 2).
Table 2 Frequencies and consumer sentiment
WORDS
|
FREQUENCY
|
% SHOWN
|
% PROCESSED
|
%TOTAL
|
To experience
|
39
|
11.71%
|
3.28%
|
1.22%
|
Midwife/midwives
|
20
|
6%
|
1.68%
|
0.62%
|
Delivery
|
18
|
5.41%
|
1.51%
|
0.56%
|
Very pleasant
|
16
|
4.8%
|
1.33%
|
0.51%
|
Hospital unit
|
12
|
3.6%
|
1.01%
|
0.37%
|
Hospital staff
|
12
|
3.6%
|
1.01%
|
0.37%
|
Super
|
12
|
3.6%
|
1.01%
|
0.37%
|
Hospital
|
9
|
2.7%
|
0.76%
|
0.28%
|
Breastfeeding
|
9
|
2.7%
|
0.76%
|
0.28%
|
Very competent
|
9
|
2.7%
|
0.76%
|
0.28%
|
Nursery
|
7
|
2.1%
|
0.59%
|
0.22%
|
Delivery room
|
6
|
1.8%
|
0.5%
|
0.19%
|
Available
|
5
|
1.5%
|
0.42%
|
0.16%
|
Care about me
|
5
|
1.5%
|
0.42%
|
0.16%
|
Pregnancy
|
5
|
1.5%
|
0.42%
|
0.16%
|
Physician
|
5
|
1.5%
|
0.42%
|
0.16%
|
Medical examination
|
5
|
1.5%
|
0.42%
|
0.16%
|
Shift change
|
5
|
1.5%
|
0.42%
|
0.16%
|
These words or phrases might provide insights on a certain topic, in particular, it is possible to recognize specific places, professional figures or pregnancy moments that had some relevance for the users participating to the debate about Burlo Garofolo. The correlations of different categories can help inidentifying pairs of brand-related topics that are associated with each other by users on social media (figure 1).
Observing the overall sentiment expressed on social media platforms, the authors found that positive comments represent the majority of all comments with a 55.9% while negative comments represented the 44.1% (figure 2).
In this paper a traditional method for user experience assessment with a qualitative social science approach were combined, to process a large amount of text data obtained from forums and Facebook pages. In these contexts, mothers express their feelings and a judgment about their experience of health care. The outcome of online conversations analysis reinforces the results from satisfaction and patients experiences surveys. And this is in keeping with previous work (59, 60).
With the text analysis, hot topics of interest and sentiment expression were identified. In particular, some places (delivery room, hospital unit, nursery), people (midwives versus physicians or interns), and pregnancy phases (breastfeeding, delivery, recovery), frequently equipped with the expression of sentiments and opinion were identified.
The overall experience is positive, even during a painful moment as delivery. Midwives are largely responsible for this opinion since they are described as “fantastic”, “available” and “very pleasant”. The most frequent words associated with positive feelings are adjectives referred to midwives or the overall personal experience in the Burlo Garofolo hospital context. Otherwise, the negative words are referred to actions and they are represented by verbs. Actions considered negative are those associated with a poor assistance, with rude manners or lack of dialogue. When an adjective is used to express a negative feeling, it refers to the management of medical exams or hospital units spatial or operative organization. The tagcloud shown in figure 3 provides a visual representation of the most frequently used words based on the results of text analysis.
This first study demonstrates that it is possible to evaluate patients experience and satisfaction online. Online platforms represent a possibility to understand health care system performance. It is clear that the experience at Burlo Garofolo is widley discussed and mentioned online even if the online institutional presence is limited. Moreover, a positive sentiment related to the experience is enlightened. Specifically, the most positive statements are connected to the personnel of the hospital, revealing their massive importance. Instead, the highest negative sentiment is about breastfeeding, due to the scarse information given at parents during mothers’ in-hospital stay.
Study 3: Quantitative Analysis
The insights collected through the first two qualitative studies allowed to focus on variables which seemed to be relevant in the overall experience and therefore inspired a deeper quantitative analysis aimed to assess their impacts on patients’ satisfaction.
Literature
Online patient experience. Consumer expectations for healthcare have no difference than in the retail context. It is then critical for healthcare organizations to deliver a digital experience that meets consumer standards.
This means thinking at the online experience of users in order to understand the perceived quality of the web contents and the journey, through the accessed pages, with the objective of reaching high-quality advice (61), allowing to share experiences and to find support as well as information.
The Internet is a primary source for health information and advice (62) but several authors present their findings showing that health information quality online is a problem (63, 64). Some argue that trust reflects the perceived competence, integrity, predictability and/or benevolence of a site (65). A few authors also highlight the importance of personalization in the formation of trust judgments (66) or the notion of good relationship management with the need to improve accessibility and usability of portals (67) in other cases, the link between patient experiences and the characteristics of various generational cohorts, which affect perceived ease of use and usefulness of healthcare online portals and services, is studied (68).
The reality is that today patients have changed: they are better informed and empowered than ever before plus medicine has become technological. Patients, who in past times might have relied blindly on doctors, now attend an appointment having already lived an experience as patients on online platforms. The healthcare marketer’s role is to meet patients’ needs by providing useful information, and by using new tools to improve both the access and the quality of healthcare.
Given this reality of new patients’ behaviours, physicians and healthcare units have made many improvements in their use of ICT changing the experiences patients can live online by fully computerizing processes and applying technology in all phases of patient care.
Perceived clinical quality. Clinical quality of care relates to the interaction between health-care providers and patients and the ways in which inputs from the health system are transformed into health outcomes (69, 70). Clinical quality is important for patient outcomes but perceptions of the quality of care may not correlate with actual quality (71, 72) since perceptions of the quality of care are based on a mix of individual experience, processed information and rumour. Perceptions of the quality of care may relate entirely to non-clinical factors. Although quality is a construct largely based on individual subjective perceptions, such perceptions are shaped by collective and traditional beliefs and peer influences. In fact, the patients’ inability to evaluate technical aspects of care means that most of them base their evaluation of medical care processes on the manner in which the healthcare service is delivered to them (73).
Arguments that question the validity of consumer information on quality of care all presume that the information reflects something other than attributes of medical care (74). They argue that data from consumers:(1) reveal more about the consumer than about the quality of care; (2) reflect how much was done, not how well it was done; (3) disagree with physicians’ judgment regarding quality; and (4) simply reflect whether the provider was nice to them.
While improving or, at least, maintaining the actual quality of the provided care, health should address the gap between perceived and actual quality (69).
Hospital atmosphere. A key component of customer experience is related to aesthetic sensory and physical aspects of the offer (75). Research has highlighted how physical environmental elements directly affect customers (76, 77), evoking internal responses (78), and indirectly influencing their behaviors (79, 80) and satisfaction (81). Literature (see table 3) suggests that environmental aspects of the experience can include variables such as ambience/atmosphere, color (82, 83), shape, sound, cleanliness, waiting time, comfort & services, food quality, lighting and smell (76, 80, 84-88).
Table 3 Atmosphere and comfort elements
Color & shape
|
(Conti A., 2006, Lupi G., 1999, Bellizzi J. A. and Hite R. E., 1992, Gorn G. J. et al., 1997, Zhang Y. et al., 2006, Ugolini M. et al., 2014).
|
Cleanliness
|
(Finzi G. et al., 2009, Bitner M. J. et al., 2000, Gardner M. P. and Siomkos G. J., 1986).
|
Smell
|
(Webb K., 2007, Bitner M. J. et al., 2000, Bitner M. J., 1992, Chebat J. C. and Michon R., 2003, Joy A. and Sherry J. F., 2003, Baker J. et al., 1992, Baraban R. S. and Durocher J. F., 2001, Donovan R. J. and Rossiter J. R., 1982, Ugolini M. et al., 2014).
|
Lighting
|
(Philips Luminaires, 2007, Bitner M. J. et al., 2000, Bitner M. J., 1992, Chebat J. C. and Michon R., 2003, Joy A. and Sherry J. F., 2003, Baker J. et al., 1992, Baraban R. S. and Durocher J. F., 2001, Donovan R. J. and Rossiter J. R., 1982).
|
Sound
|
(Burt, May/June 2006, Lichtle M. C. et al., 2002, Yalch R and Spangenberg E., 1990, Dube´ L. et al., 1995, Ugolini M. et al., 2014).
|
Waiting times
|
(Burt T., 2006).
|
Services
|
(Reese S., 2009, Meyers S., 2009, Beccari S., 2010).
|
Food quality
|
(Lichtle M. C. et al., 2002, Yalch R and Spangenberg E., 1990, Dube´ L. et al., 1995).\
|
Although some of the above described elements are recurring in patient experience research, they have been analyzed separately so far. Hence, it appears difficult to find studies that jointly examine those items and provide a unique classification of the key experience components related to the environment.
Relationship with clinical staff and patient empowerment. Web channels are reshaping a wide range of relationships in the healthcare industry (89), where, traditionally, information exchanges between patients and providers used to be significantly “asymmetric” and “formal” as for their nature. This resulted in increased opportunities of empowerment (90-98), which may refer to:
- Patients who take an active role in healthcare choices (99): “Patients are empowered when they have the knowledge, skills, attitudes and self-awareness necessary to influence their own behaviour and that of others (…) to improve the quality of their lives” (100);
- Caregivers and family members who become involved in care processes (101);
- Medical staff who gains control on both the content and context of their practice (102) and extend their role along the patient journey (103).
A number of studies suggest that empowered people are healthier than non-empowered ones; lack of empowerment is therefore a disease risk factor (104, 105). It may be argued (106) that the final objective of patient empowerment is the achievement of better compliance in patient’s behaviour: “Patient empowerment is therefore most often defined as a process of behaviour change, with a focus on how to help patients become more knowledgeable and take control over their bodies, disease and treatment. In this definition, empowerment is viewed as a process of “activating” patients, who as a result of “rejecting the passivity of sick role behaviour and assuming responsibility for their care (...) are more knowledgeable about, satisfied with, and committed to their treatment regimen” (107).
A recurring issue is the new balance of roles and responsibilities between the patient and the health provider. Despite this evidence, a thoroughgoing critical analysis of patient empowerment challenge has not been extensively developed so far (108).
The World Health Organization (109) introduced the definition of “patients’ respect”, articulating it in three dimensions: respect for the patients’ dignity; privacy with regards to medical information; autonomy of the patient in deciding about his own healthcare.
Patients’ respect is mainly related to how the hospital staff interacts with patients, specifically with regards to the level of empathy, relationship skills, listening skills and the interest toward the patient as a person (34, 110-113). Other important elements are represented by spiritual care, staff’s willingness to listen to patients’ fears (114), the focus on pain management (115) and the privacy that a patient experiences through the different phases of his medical treatments (27, 112, 116-118). The concept of empowerment means inclusion of patients in the decision-making process, as well as the degree of such participation (119, 120) by considering it a bricolage of tactical interactions with social environments rather than as the consequence of an external strategic process (121). Contradicting the traditional paternalistic approach, today it is important to give patients the ability to get information about their disease, understand and rationally analyze all of their data, apply their well developed personal beliefs to this input and make a medical decision for themselves (122). As a result, patients are nowadays more involved in the healthcare decision making process while having to decide which medical treatments to undergo (123, 124).
Communication between clinical staff members and patients is one of the most complex relationships among inter-personal ones, and is thus attracting more attention within health care studies (125). A traditional approach with regards to this relationship usually involved high physician control compared to patients’ one, and can thus be described as a model where the doctor is the one who decides the care process on patients’ behalf. However, nowadays medical consultations are becoming increasingly based on mutuality, meaning that patients are gaining a greater control over that relationship with a clear link between physician relationship and patient involvement determining satisfying patient empowerment (126). In the context of the above mentioned trends of patient empowerment, patient loyalty to a medical doctor does not seem to be guaranteed and it is thus becoming more important to change the traditional agency relationship into a more collaborative one (127, 128). In that direction moves the consumerist approach, based on the active role of the patient and on a more passive beheaviour of the doctor (129).
Doctor-patient communication seems to be linked to patients' behavior and well-being and even state of health (130-132). The need of more detailed information is arising (133), patients are becoming less reliant on doctors as Internet acts as an alternative source of information (134-136).
The quality of the relationship can be improved by perceiving the staff team as a harmonious group (137) where the professional role of each member can be easily identified by the patient. This is normally obtained by the use of different colours in employees uniforms. Courtesy, attention, empathy capabilities, professionalism of staff members and their ability to establish and maintain a positive relation with their patients affect patients’ satisfaction (111, 113).
Hospital brand. The new profile of the empowered patient and the increasing competition in the industry require healthcare organizations to develop strong and distinctive brand identities aimed to build trust, loyalty and satisfaction (138-140).
A brand is a promise to consumers that the hospital will deliver the kind of care needed. (141). This promise is necessary in order to create an emotional connection and relationship between the patient and the provider during the health care service experience.
Kemp et al (141) indicate that trust, referent influence and corporate social responsibility are key variables in establishing an affective commitment which favours advocacy and positive word of mouth.
As Keller (23) suggests, it has become a necessity to have a brand identity in order to find a position in the market and consumer’s mind, for products and services. As it is now recognised, the healthcare sector is facing unique challenges in creating brand identity among customers (40). Brand identity strategies provide a way to create it; representing how a hospital seeks to identify itself. A well-built brand identity will effectively communicate a hospital personality and its value to potential customers, and will help in building brand recognition, association and loyalty.
Brand Identity deals with:
- Hospital internal perceptions;
- Expected quality or a promise defined within the hospital;
- Functional and emotional relationship with patient.
Brand identity is the promise that a hospital makes to people along with the mission, personality and competitive advantages. It includes the thinking, belief and expectations of the target customers. It is a means of identifying and distinguishing an association from another. A brand image is a way for hopital to reinforce its market position by being able to influence the patient decision-making process (34, 38).
The Model in Study 3
Starting from the above mentioned literature and considering the main insights from the qualitative analysis, an exploratory factor analysis was conducted setting the number of latent factors equal to 6. Later, a confirmatory factor analyses (CFAs) was performed in order to get evidence of convergent and discriminant validity of the measurement scales. Consequently, as suggested from the exploratory and confirmatory factor analysis, the following model in figure 4 seems to be the best way to proceed with the analysis.
The following hypotheses where formulates:
H1: Online experience perceived quality is positively related to the overall patients’ satisfaction.
H2: Perceived clinical quality, is positively related to the overall patients’ satisfaction.
H3: Cleanliness’ perception is positively related to the overall patients’ satisfaction.
H4: Atmosphere’s perception is positively related to the overall patients’ satisfaction.
H5: Perceived relationship & empowerment quality is positively related to the overall patients’ satisfaction.
H6: Perceived relationship & empowerment quality is positively related to the perceived brand value.
H7: The perceived brand value is positively related to the overall patients’ satisfaction.
In this analysis we choose to test as mediator brand value in the relationship between the variables relationship & empowerment quality and patients’ satisfaction:
H8: Perceived brand value is a mediator between perceived relationship & empowerment quality and patients’ satisfaction.
Measurements of Variables in Study 3
The measures employed in the empirical analysis are summarized in table 4 and are described below.
Online Experience: Kelly, Ziebland and Jenkinson (142) through their paper, document the development of a tool to compare the potential consequences and experiences a person may encounter when using health-related websites. Five themes were identified and labelled: (1) Information, (2) Feeling supported, (3) Relationships with others (4) Experiencing Health Services and; (5) Affecting behavior. In their work the e-Health Impact Questionnaire is validated. This questionnaire is used as our main source in order to evaluate the experiential perceptions of those who have used Burlo Garofolo’s official web site. Through this variable we are interested in understanding the sources of information used online for supporting pregnancy and the personal perceptions about Burlo Garofolo’s website.
Clinical Quality: it must be noticed that when considering this variable, the objective is not to judge the clinical level of the hospital but to understand the perception according to the experience lived hypothesizing that it can have an impact on the overall satisfaction. The clinical quality is measured starting from the scales used in the Patient Satisfaction Questionnaire - PSQ (143) and in the Neonatal Instrument of Patients Satisfaction - NIPS (144, 145) placing specific attention to diagnose procedures and integration among departments which appeared disappointing during the qualitative phase of the analysis.
Cleanliness: concern over perceived inadequacies in-hospital cleaning has always been a relevant topic due to the huge negative impacts it can bring. In fact, a lot of literature focuses on proposals for the assessment of hygiene in medical contexts. Cleanliness - especially of the hospital rooms and bathrooms - is one of the most noted items for quality of hospital in several findings (146). We assess this variable adapting the Total Quality Service Indicator in healthcare - TQS (147).
Atmosphere: this variable refers to the ambience and comfort offered by the hospital. It is evaluated starting from the Total Quality Service Indicator in healthcare - TQS (147) adapting the assessed items to the Burlo Garofolo’s structure. Some questions are common to all the respondents while others are addressed only to in-hospital patients.
Relationship & Empowerment: communication between doctors and patients is one of the most complex relationships among inter-personal ones. The quality of the relationship can be improved by perceiving the staff team as a harmonious group (137) where the professional role of each member can be easily identified by the patient. Courtesy, attention, empathy capabilities, professionalism of staff members and their ability to establish and maintain a positive relation with their patients are expected to affect patients’ satisfaction always keeping in mind their need of involvement in the care process and the perceived importance of receiving complete and clear information (111, 113). In order to measure this variable Total Quality Service Indicator in healthcare - TQS (147), Patient Satisfaction Questionnaire - PSQ (143) and Neonatal Instrument of Patients Satisfaction - NIPS (144, 145) are used.
Brand Value: the objective was to measure the perceived value of Burlo Garofolo Hospital as a brand. The main source of measurement was the optimization of the items proposed by Aaker (148). It was in fact possible to assess the perception about the brand as a whole but also by combining the hospital with specific adjectives such as trustworthy, reassuring, cheerful, professional. We used the adjectives which came to light during the two previous studies.
Patients’ Satisfaction: in order to test patient overall satisfaction of pregnant women treated at Burlo Garofolo Hospital, two main scale sources were used: Patient Satisfaction Questionnaire - PSQ (143) and Neonatal Instrument of Patients Satisfaction - NIPS (144) which was developed to distinguish between parents who are satisfied and parents who are dissatisfied specifically within the medical neonatal intensive care (144, 145). Furthermore, for the overall satisfaction also Aaker’s variables were considered (148) and the Total Quality Service Indicator in healthcare - TQS (147).
Table 4 Adopted measuring scales
VARIABLES
|
ADOPTED SCALES: SOURCES
|
Online Experience:
|
(Kelly, Ziebland et al. 2015)
|
Clinical Quality:
|
(Ware 1976, Mitchell-Dicenso, Guyatt et al. 1996, Conner and Nelson 1999)
|
Atmosphere:
|
(Duggirala, Rajendran et al. 2008)
|
Cleanliness:
|
(Sofaer, Crofton et al. 2005, Duggirala, Rajendran et al. 2008)
|
Relationship & Empowerment:
|
(Ware 1976, Mitchell-Dicenso, Guyatt et al. 1996, Duggirala, Rajendran et al. 2008)
|
Brand Value:
|
(Aaker 1996)
|
Patients’ Satisfaction:
|
(Ware 1976, Aaker 1996, Mitchell-Dicenso, Guyatt et al. 1996, Conner and Nelson 1999, Duggirala, Rajendran et al. 2008)
|
SEM Hypotheses Testing in Study 3
As previously stated, a Structural Equation Model was applied to the research. According to McDonald and Ho (149), absolute fit indices were calculated in order to determine how well an a priori model fits the sample data and to demonstrate that the proposed model has a good fit. These measures provide the most fundamental indication of how well the proposed theory fits the data. Unlike incremental fit indices, their calculation does not rely on comparison with a baseline model but is instead a measure of how well the model fits in comparison to no model at all (150). Included in this category are the Chi-Squared test, RMSEA, GFI, AGFI, the RMR and the SRMR (151). Thus, according to Hu and Bentler (152), first it was necessary to assess the properties of the measurement model. The principal model fit measures are shown in table 5 and they result adequate.
Table 5 Model fit measures
|
Chi square (df)
|
CFI
|
RMSEA
|
PCLOSE
|
Model Fit measures
|
4.3 (5)
|
1.000
|
0.000
|
0.782
|
At this stage, factor scores were computed for the constructs that are error free and can be used for further analyses.