it depends on how you define quality of care. Let's put the question the other way. Many Australian patients are dissatisfied with foods provided to them while they receive hospital services. This may not necessarily mean medical services are also of poor quality. In many countries, people don't care much about what foods they eat in hospitals. As a matter of fact, many hospitals don't supply foods at all. Satisfaction is a subject measure, reflecting a gap between expectation and reality.

This is a known public health dilemma. Perceived quality by patients is completely different from technical quality. Technical quality can be divided at least in purely medical terms and in cost-effectiveness. An injection for instance in most African countries is regarded by patients as very good quality care, independently from the product administered. An injection can be medically correct but unacceptable when regarding the costs. Other products might be as effective and less costly and therefore more indicated. And to make things even more complex: if you think the patient might not comply with oral drugs because he prefers or demands an injection, the latter might be more cost-effective hence indicated anyway.

By making the distinction between perceived quality and technical quality the discussion gets usually clearer.

I agree with Chaojie, how do you define quality? Timeliness? Safety? Efficacy? Equability? Definition will decide a lot.

It gets even worse...how do you feel confident that patients responding as 'satisfied' in a survey are actually 'satisfied' in the common garden variety sense of the term? In the mid-1990's, several key publications reviewed the major methodological challenges of patient satisfaction surveys:

Carr-Hill, R. A. (1992). The measurement of patient satisfaction. Journal of Public Health, 14(3), 236-249.

Williams, B. (1994). Patient satisfaction: a valid concept? Social Science & Medicine, 38(4), 509-516.

Sitzia, J., & Wood, N. (1997). Patient satisfaction: a review of issues and concepts. Social Science & Medicine, 45(12), 1829-1843.

When you look at the problems with measuring patient satisfaction, it is no wonder we get 'puzzling' results, never mind the truth that others have pointed out between technical definitions of 'quality care' and patient understandings.

In the USA patients react much more to whether they are treated courteously by the staff and are often not able to make an informed judgment of the technical quality of the care. In Ghana I would imagine strong cultural sentiments about technological health care.

This depends on the utility function at which some choice variables are chosen to maximize his satisfaction of health care received. In this case the optimum level of satisfaction of health care client can best be estimated at a point where his marginal utility of health care consumed equals the cost of health care.

I would suggest looking at some of Fred Lee's work. He questions the use of satisfaction as a valid measure on several levels. For one thing, the bounds of satisfaction lie on a continuum that starts at "absolutely horrendous" and ends at "the best thing ever". Why focus on such a narrow range from that continuum? A patient could have a terrible experience and be left with the nearest feedback option of "not satisfied", which hardly cuts it.

Lee, F. (2003). Stop measuring patient satisfaction. To build loyalty, hospitals need to exceed customers' expectations. Marketing Health Services, 2003, 23(2), 32-7.

There is also evidence that satisfaction surveys are subject to bias that inflates satisfaction for the least satisfied patients, and that an unwillingness to express dissatisfaction is especially prominent with more vulnerable groups.

Mazor, K M; Clauser, B E; Feild, T; Yood, R A; Gurwitz, J H (2002). A Demonstration of the Impact of Response Bias on the Results of Patient Satisfaction Surveys. Health Services Research, 37(5), 1403-1417.

Kahan, B; Goodstadt, M (1999). Continuous quality improvement and health promotion: can CQI lead to better outcomes? Health Promotion International. 1999, 14(1), 83-91.

Arnold Eiser makes a very valid point--patients respond to courtesy versus receiving appropriate care. You may consider looking at the The Donabedian Model of health services. This conceptual framework delineates quality of care into process, structure, and outcomes. Structure refers to the context of care (e.g. hospital building, financing, staff, etc); Process refers to interactions between clinicians/staff and patients (e.g. actual care delivered, satisfaction ,etc); and Outcomes refers to the effects of health care delivery on patient/population health status.

While there are other models such as WHO quality of care framework, Donabedian's model is widely used.

It depends on the context . How quality of care is defined and how it is assessed. A lot depends on the client's knowledge, awareness and demand for the quality. Also linked with the base line services they have been receiving from years. For example in developing countries of south Asia , in rural areas where people had seen Public health facilities without doctors and medicines for a long time, once the doctors and paramedics were appointed, retained and medicines were made available in the facility , majority of clients and communities were satisfied with the service no matter whether technical standards for QoC were met or not. Clients are also happy and satisfied with the apparently clean facility irrespective of its infection prevention practices or waste disposal mechanisms. Considering Prescription standards, management protocols and technical skills of health providers for the satisfactory  services,  are beyond the perceptions and capacity of clients in these countries even among educated ones. So it is very true that client satisfaction does not always mean that QoC is being observed and delivered. especially in poor setting with illiterate populations.

Underlying much of the discussion is the problematic nature of 'satisfaction' eluded to above (linked of course to problems in defining 'quality'). I think this is why the discussion (in the UK anyway) has more recently moved to a consideration of 'experiences' of patients. Patient experience is but one element of quality, but it becomes much clearer that if we are going to focus on this we need to determine what aspects of experience matter most to them. It will be culturally specific and, in some cases, may not be straightforwardly compatible with other elements of quality (e.g. effectiveness, safety, efficiency).  

The challenge for a 'quality' health service / provider is to recognize the challenge and achieve the best balance between these different aspects of quality. it does not translate into 'patient want injection ->give injection' but nor does it translate into simply ignoring those expectations because the care is not 'effective'.

Our colleagues suggested good scientific articles, but I would like to suggest a book that deals with this concept very well: "If Disney Ran Your Hospital", by Fred Lee. I think you'll find your answer there.

I agree with many of the statements above.  Not only can "satisfied patients" have received bad quality of care (in various dimensions) and "dissatisfied patients" have received good quality of care (in various dimensions), but satisfaction ratings are notoriously insensitive to the range of patient experiences.  Fred Lee's book and the various references above are worth reading.  So is a paper entitled, "Mortality among Patients with Acute Myocardial Infarction: The Influences of Patient-Centered Care and

Evidence-Based Medicine" by  Mark Meterko, Steven Wright, Hai Lin, Elliott Lowy, and

Paul D. Cleary.  It can be found in:   HSR: Health Services Research 45:5, Part I (October 2010).

Very interesting that I am now seeing this question. I would recommend that you look at quality from the 3 dimensions of Structure of the program, the Process of giving and

receiving care under the national health insurance, and the outcomes of care, the latter includes satisfaction .

This is the Donabedian Model for assessing health care quality and he recommends that for a holistic picture of health care or system, aspects of all 3, ie structure, process, and outcomes are to be included in every assessment of quality.

I would recommend further that since there are multiple stakeholders involved, ie policy makers, development partners, healthcare providers, enrollees in the system and the general public, all these people would need to be sampled and interviewed as part of the data collection efforts. Please also remember that we have different types of healthcare providers engaging with the system and therefore each category of providers need to be covered. Let's discuss this further if still interested