Examining the Business Case for Patient Experience: A Systematic Review

EXECUTIVE SUMMARY

Hospitals, physician groups, and other healthcare providers are investing in improved patient care experiences. Prior reviews have concluded that better patient care experiences are associated with less healthcare utilization and better adherence to recommended prevention and treatment, clinical outcomes, and patient safety within hospitals. No comprehensive review has examined the business case for investing in patient experiences. This article reviews the literature on associations between patient experience—measured from the perspective of patients and families—and business outcomes, including patient allegiance and retention, complaints, lawsuits, provider job satisfaction, and profitability We searched U.S. English-language peer-reviewed articles from January 1990 to July 2019. We followed the preferred reporting items for systematic reviews and meta-analyses guidelines and undertook a full-text review of 564 articles, yielding the inclusion of 40 articles. Our review found that patients with positive care experiences are more likely to return to the same hospital and ambulatory settings for future healthcare needs, retain their health plan, and voice fewer complaints. Associations between patient experiences and profitability or provider job satisfaction were limited/mixed. This suggests that providers can pursue better patient care experiences for the intrinsic value to patients, while also recognizing it is good for intermediate business outcomes: specifically increased recommendations, better patient retention, and fewer complaints. Nursing and physician care, broadly defined, are the only specific aspects of patient experience consistently associated with retention, with evidence pointing to communication and trust as parts of care linked to the intent to return. These aspects of patient experience are also the largest contributors to the overall ratings of a provider or facility.

INTRODUCTION

Patient experience is a core element of high-quality healthcare (Institute of Medicine & Committee on Quality of Health Care in America, 2001). Healthcare providers and facilities are prioritizing patient experience and seeking to improve patient and family experiences of care. A growing proportion of U.S. healthcare providers report having well-established efforts to improve the patient experience and have assigned senior leaders responsibility for addressing that (Wolf, 2017). Quality measures assessing patient and family care experiences play a prominent role in federal and state public reporting and pay-for-performance initiatives, drawing attention to and incentives for better performance. Consumers have access to information about care experiences from a variety of sources, including websites and social media, which can affect a provider’s reputation. As health systems market themselves, patient care experiences are a key differentiator affecting patients’ choices (Carrus et al., 2015).

Prior reviews have concluded that better patient care experiences are associated with less care utilization and more adherence to recommended prevention and treatment, clinical outcomes, and patient safety within hospitals (Anhang Price et al., 2014; Doyle et al., 2013; Lee, 2017). No comprehensive review has examined the “business case” for investing in patient experience—that is, the degree to which patient experience is associated with healthcare providers’ business outcomes beyond the incentives of value-based payment programs. In our review, we examined evidence of the link between patient experience and business outcomes.

To guide our work, we developed a conceptual model of the relationship between patient experience and business outcomes (Figure 1).

FIGURE 1.

Conceptual Framework of Associations Between Patient Experience and Business Outcomes

Patient experience is commonly assessed using surveys of patients or their family caregivers to report on care experiences—the processes of care that are observable to them (e.g., waiting time, provider explanations). We derived measures of the patient experience from these surveys to assess both overall ratings of care and domains of care experience that are important to patients and families (Elliott et al., 2009; Paddison et al., 2015). Patient experience measures are key components of healthcare quality assessment in the United States, as many policy initiatives for the improvement of quality and the facilitation of patient choice include public reporting of providers’ performances on patient experience measures (Elliott et al., 2009; Johnson & Abraham, 2012; Paddison et al., 2015; Rickert, 2012).

Building upon findings from other industries that suggest customer satisfaction boosts profits (Zeithaml, 2000), we examined the relationship between business outcomes and patient experiences. Patient experience may affect intermediate business outcomes such as the acquisition of new patients, patient loyalty and retention, optimized frequency and intensity of patient visits, staff morale and retention, and provider reputation, as well as the number of complaints, grievances, and lawsuits (Lied et al., 2003; Nelson et al., 1992; Robert Wood Johnson Foundation, 2010). Intermediate business outcomes and financial incentives for providing high-quality patient experiences (offset by the costs of administering patient experience surveys to assess patient experience) determine profitability. Our review focused on both intermediate business outcomes and profitability. Our model presents the idea that business outcomes can coexist with the primary goals of the patient-provider relationship.

We propose three causal pathways by which better patient experiences may affect intermediate business outcomes. First, better care experiences may make patients more likely to return to their provider (Safran et al., 2001) and less likely to file a complaint or lawsuit (Beckman et al., 1994; Bilimoria et al., 2017; Fullam et al., 2009). Second, better experiences may also make patients more likely to recommend their provider to friends and family. Third, healthcare staff may experience higher job satisfaction when working in environments more focused on patient and family needs and preferences (Charmel & Frampton, 2008).

METHODS

We identified articles for this review that considered the relationship between patient experience and business outcomes in the United States. We adhered to the preferred reporting items for systematic reviews and meta-analyses guidelines (Liberati et al., 2009; Moher et al., 2009). Our checklist is provided as an appendix to this article, published as Supplemental Digital Content at http://links.lww.com/JITM/A53.

Search

We applied a structured search strategy to PubMed, Business Source Complete, and EconTit to identify peer-reviewed studies, limited to U.S. English-language articles from January 1990 to July 2019. For EconLit and Business Source Complete databases, we identified articles using keywords and Boolean operators with at least one patient experience keyword (“patient experience” or “patient-centered care” or “patient satisfaction”) and at least one business outcome keyword (“health outcome” or “loyalty” or “retention” or “new patient” or “new patients” or reputation or grievance* or “medical malpractice” or “customer satisfaction” or “employee satisfaction” or “provider satisfaction” or “pay for performance” or revenue* or profit* OR “consumer satisfaction”). For the PubMed search, we excluded commentaries, editorials, and interviews, and using Medical subject headings (MeSH), keywords and Boolean operators, we required phrases “patient experience” or “patient-centered care” or MeSH Major Topic “patient satisfaction” designation. For PubMed articles not indexed using MeSH topics, we required the term “patient satisfaction.” We also required articles to have at least one business outcome keyword phrase or term: “health outcome” or loyalty or retention[title/abstract] or “new patient” or “new patients” or reputation or grievance* or “medical malpractice” or “customer satisfaction” or “employee satisfaction” or “pay for performance” or revenue* or profit* or “consumer satisfaction.” or searches identified 2,179 unique articles, and experts identified 13 additional articles.

Screening

We (DQ, RAP, KR, SD) reviewed titles and abstracts of identified articles. After initial double-coding to establish consistency across reviewers, individual reviewers screened abstracts for inclusion. All articles were double-reviewed (either DQ/RAP or KR/SD). If initial assessments differed, reviewers discussed discrepancies during regular four-person team meetings and resolved disagreements to reach a consensus on inclusion.

As shown in Figure 2, articles were excluded during title and abstract screening if the research did not include measures of patient experience or business outcomes; did not address the relationship between patient experience and business outcomes; were based in healthcare settings outside the United States; were not empirical; and did not focus on humans.

FIGURE 2. PRISMA Diagram.

Note. PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Abstraction

We undertook a full review of 574 articles. At the onset of abstraction, a small number of articles were selected for double-coding and discussion to ensure that all four coders employed a similar approach. Once this preparation was complete, articles were assigned to individual coders for abstraction. After abstraction, each article was reviewed by a second reviewer to ensure accuracy of abstracted content and discussed, if needed, to gain consensus achieving 100% interrater agreement. Researchers abstracted specific information into a form: Author (year), study aim, study type, study design, statistical approach, methods, setting, sample size, sample description, patient experience measures, business outcome measures, and relationship and findings between patient experience and business outcome measures. After abstraction, each article was reviewed by the other reviewer to ensure accuracy of abstracted content and discussed, if needed, to gain consensus achieving 100% interrater agreement.

We excluded 124 articles on non-U.S. healthcare systems and another 410 studies that did not include a measure of patient experience (n = 84), did not include a measure of business outcome (n = 143), and did not test the relationship between them (n = 177) (see Figure 2).

Risk of Bias-Within-Studies and Quality Assessment

After full-text review, researchers independently scored each of the 46 articles at the study-level and discussed the study quality ratings to gain consensus. Regarding study quality, 24 articles were rated as “adequate” and 16 rated as “good” (quality rating is notated in Table 1). Six articles were excluded for “poor” study quality (see Figure 2). Their limitations included not controlling for factors that may affect the association between predictors and the outcome (n = 6) (Abraham et al., 2011; Burkle & Keegan, 2015; Hill & Joonas, 2005; Lonial & Raju, 2015; MacStravic, 1994; Spake & Bishop, 2009), use of survey measures with unknown psychometric properties (n = 6), and nonrandom convenience sampling (n = 1) (Hill & Joonas, 2005). Altogether, 40 studies were included.” Table 1 describes each reviewed study; Supplemental Table 1, provided as an appendix to this article, published as Supplemental Digital Content at http://links.lww.com/JHM/A54, reviews the methods, measures, and relevant findings of each included study.

TABLE 1.

Summary of Reviewed Studies by Included Status in Alphabetical Order by Authors’ Last Names (N = 40)

Author(s) and Year	Design* and Statistical Approach	Setting (Patient Experience Survey Used)	Patient Experience Measures	Business Outcome Measures
40 Included Studies
Abrahamson et al. (2017)	Cross-sectional, decision tree analysis	Nursing home (Press Ganey)	Nursing care, admission/registration, place/environment, other	Willingness to recommend
Baker & Taylor (1998)	Cross-sectional, correlations	Hospital	Overall rating	Retention
Bilimoria et al. (2017)	Cross-sectional, hierarchical linear models	Hospital (HCAHPS)	Communication, timeliness of care/access including wait time, place/environment, other	Malpractice
Boss & Thompson (2012)	Cross-sectional, correlations	Ambulatory	Nursing care, staff care, physician care, communication, respect/trust, timeliness of care/access including wait time, place/environment, other	Willingness to recommend
Chen et al. (2018)	Cross-sectional, correlations	Hospital/ambulatory (Press Ganey)	Timeliness of care/access including wait time, staff care, physician care, other	Willingness to recommend
Chong et al. (2012)	Cross-sectional, correlations	Health plan	Staff care, communication, timeliness of care/access including wait time	Willingness to recommend
Clark et al. (2006)	Cross-sectional, correlations	Hospital (Press Ganey)	Overall rating	Willingness to recommend provider satisfaction
Crutchfield & Morgan (2010)	Cross-sectional, structural equation modeling	Ambulatory	Respect/trust	Retention
Dang et al. (2016)	Longitudinal, logistic regression	Ambulatory (CAHPS)	Overall rating, physician care	Retention
DuGoff & Chou (2019)	Retrospective cross-sectional, logistic regression	Health plan (CAHPS)	Overall rating, timeliness of care/access including wait time, other	Retention
Dyer et al. (2012)	Cross-sectional, correlations	Ambulatory	Overall rating, staff care, communication, respect/trust, timeliness of care/access including wait time	Willingness to recommend
Flickinger et al. (2013)	Longitudinal, regression	Ambulatory (CAHPS)	Communication, respect/trust	Retention
Ford et al. (2013)	Cross-sectional, linear regression	Hospital (HCAHPS)	Overall rating	Willingness to recommend
Garman et al. (2004)	Longitudinal, correlations	Hospital	Overall rating, physician care, nursing care, admission/registration, discharge, place/environment, other	Retention
Hays et al. (1990)	Cross-sectional, correlations	Hospital	Physician care, nursing care, communication, admission/registration, discharge, place/environment, other	Willingness to recommend, retention
Hays et al. (1991)	Cross-sectional, correlations	Hospital	Physician care, nursing care, staff care, communication, admission/registration, discharge, place/environment, other	Willingness to recommend, retention
Hays et al. (1998)	Cross-sectional, mean scores	Ambulatory	Overall rating, timeliness of care/access including wait time	Retention
Hays et al. (1999)	Cross-sectional, correlations	Health plan	Overall rating	Willingness to recommend
Hays et al. (2003)	Cross-sectional, correlations	Health plan (CAHPS survey and DoctorGuide survey)	Communication, timeliness of care/access including wait time	Willingness to recommend, retention
Kang et al. (2019)	Cross-sectional, correlations	Hospital/ambulatory (inpatient SHEP, clinician, and group CAHPS)	Overall rating	Provider satisfaction
Kelly et al. (2010)	Longitudinal, logistic regression	Ambulatory (inpatient SHEP, clinician, and group CAHPS)	Overall rating	Retention
Kerr et al. (1998)	Cross-sectional, logistic regression	Health plan (Group Health Association of America Survey)	Overall rating, timeliness of care/access including wait time	Retention
Kessler & Mylod (2011)	Cross-sectional, regression	Hospital (Press Ganey)	Overall rating, place/environment	Retention
Lis et al. (2011)	Cross-sectional, correlations, logistic regression	Ambulatory	Communication, respect/trust, admission/registration, timeliness of care/access including wait time	Willingness to recommend
Maiga & Jacobs (2009)	Cross-sectional, structural equation modeling	Hospital	Overall rating	Profitability
Morales et al. (2003)	Cross-sectional, correlations	Health plan	Overall rating, staff care, communication, timeliness of care/access including wait time	Willingness to recommend
Nelson et al. (1992)	Cross-sectional, inear regression	Hospital	Nursing care, communication, admission/registration, discharge, other	Profitability
O’Connor et al. (1992)	Cross-sectional, LISREL	Hospital/ambulatory	Overall rating	Retention
Otani et al. (2010)	Cross-sectional, regression	Hospital	Physician care, nursing care, staff care, admission/registration place/environment	Retention, willingness to recommend
Peltier et al. (1999)	Cross-sectional, linear regression	Hospital	Physician care, nursing care	Retention
Platonova et al. (2008)	Cross-sectional, structural equation modeling	Ambulatory	Overall rating	Retention, willingness to recommend
Rangnekar et al. (2015)	Retrospective, logistic regression	Hospital/ambulatory (HCAHPS, CAHPS)	Overall rating	Profitability
Richter et al. (2017)	Cross-sectional, generalized estimating equations	Hospital (HCAHPS)	Overall rating, communication, discharge, place/environment, other	Profitability
Rodriguez et al. (2008)	Cross-sectional patient data and retrospective lawsuit data, ANOVA	Ambulatory (Ambulatory Care Experience Survey)	Staff care, communication, timeliness of care/access including wait time, other	Complaints
Rothman et al. (2008)	Cross-sectional, correlations	Hospital	Nursing care, communication, respect/trust, discharge, place/environment	Willingness to recommend
Solomon et al. (2005)	Cross-sectional, correlations	Health Plan	Overall rating, communication, timeliness of care/access including wait time	Retention
Stelfox et al. (2005)	Cross-sectional regression	Hospital	Overall rating, nursing care, place/environment	Complaints
Suess & Mody (2018)	Cross-sectional, structural equation modeling	Ambulatory	Overall rating	Retention
Weidmer et al. (2012)	Cross-sectional, correlations	Hospital	Communication	Willingness to recommend
Ye et al. (2017)	Cross-sectional, generalized method of moments	Hospital/ambulatory	Overall rating	Profitability

Note.

^*Study quality of “good” is bold font, “adequate” is roman font. ANOVA = analysis of variance, CAHPS = Consumer Assessment of Healthcare Providers and Systems Survey, LISREL = linear structural relations, SHEP = Veterans Affairs Medical Centers’ Inpatient Survey of Healthcare Experiences of Patients, which uses the same items as the hospital CAHPS survey.

RESULTS

Of the 40 studies, 16 were conducted in a hospital, 5 were in both hospital and ambulatory settings, 7 were within a health plan, 1 was in a nursing home, and the remaining 11 were solely in ambulatory care settings. All but two studies focused on adults receiving healthcare services; the other two included both adults and children. Thirty-three studies were cross-sectional, four were longitudinal, two were retrospective (i.e., referred back to a point in time), and one had both cross-sectional and retrospective components. Table 1 describes each reviewed study and Supplemental Table 1, provided as an appendix to this article, reviews the methods, measures, and relevant findings of each included study.

The most common measure of patient experience was an overall rating or summary score (23 studies). Patient experience surveys also frequently included specific domains or aspects of care. The most common specific patient experience domains assessed were provider communication (16 studies) and access to care (12 studies). Table 2 summarizes the studies by their patient experience measures and business outcomes.

TABLE 2.

Evidence for Associations Between Patient-Reported Experiences and Healthcare Business Outcomes

	Pathways		Intermediate Business Outcome		Business Outcome
Patient Experience Domain	Willingness to Recommend (N = 17)	Provider Job Satisfaction (N = 2)	Retention (N = 18)	Complaints* (N = 2) and Malpractice* (N = 1)	Profitability (N = 5)
Overall rating/summary score (N = 23)	Clark et al. (2006) Ford et al. (2013) Platonova et al. (2008) Dyer et al. (2012) Hays et al. (1999) Morales et al. (2003)	Clark et al. (2006) Kang et al. (2019) **	Baker & Taylor (1998) Garman et al. (2004) Kessler & Mylod (2011) O’Connor et al. (1992)** Hays et al. (1998) Platonova et al. (2008) Kelly et al. (2010) Dang et al. (2016) Suess & (Mody (2018) Kerr et al. (1998) Solomon et al. (2005) DuGoff & Chao (2019)	Stelfox et al. (2005)	Maiga & Jacobs (2009) Richter et al. (2017) Rangnekar et al. (2015)** Ye et al. (2017)**
Communication (N = 16)	Hays et al. (1990)++ Hays et al. (1991)++ Rothman et al. (2008) Weidmer et al. (2012) Lis et al. (2011) Boss & Thompson (2012) Dyer et al. (2012) Morales et al. (2003) Hays et al. (2003) Chong et al. (2012)		Hays et al. (1990)++ Hays et al. (1991)++ Flickinger et al. (2013) Solomon et al. (2005)	Bilimoria et al. (2017) Rodriguez et al. (2008)	Nelson et al. (1992) Richter et al. (2017)
Timeliness of care/access/wait time (N = 12)	Chen et al. (2018) ** Lis et al. (2011) Boss & Thompson (2012) Dyer et al. (2012) Morales et al. (2003) Hays et al. (2003) Chong et al. (2012)	Kerr et al. (1998) Solomon et al. (2005) DuGoff & Chou (2019)	Bilimoria et al. (2017) Rodriguez et al. (2008)
Place/environment (N = 11)	Hays et al. (1990)++ Hays et al. (1991)++ Rothman et al. (2008) Otani et al. (2010) Boss & Thompson (2012) Abrahamson et al. (2017)+	Hays et al. (1990)++ Hays et al. (1991)++ Garman et al. (2004) Otani et al. (2010) Kessler & Mylod (2011)	Stelfox et al. (2005) Bilimoria et al. (2017)	Richter et al. (2017)
Nursing care/rating (N = 10)	Hays et al. (1990)++ Hays et al. (1991)++ Rothman et al. (2008) Otani et al. (2010) Boss & Thompson (2012) Abrahamson et al. (2017)+	Hays et al. (1990)++ Hays et al. (1991)++ Peltier et al. (1999) Garman et al. (2004) Otani et al. (2010)	Stelfox et al. (2005)	Nelson et al. (1992)
Staff care/rating (N = 9)	Hays et al. (1991) ++ Otani et al. (2010) Chen et al. (2018) ** Boss & Thompson (2012) Dyer et al, (2012) Morales et al. (2003) Hays et al. (2003) Chong et al. (2012)		Hays (1991) ++ Otani (2010)	Rodriguez et al. (2008)
Respect/trust (N = 7)	Rothman et al. (2008) Lis et al. (2011) Boss & Thompson (2012) Dyer et al. (2012)		Platonova et al. (2008) Crutchfield & Morgan (2010) Flickinger et al. (2013)
Physician care/rating (N = 7)	Hays et al. (1990) ++ Hays et al. (1991) ++ Otani et al. (2010) Chen et al. (2018) **		Hays et al. (1990)++ Hays et al. (1991)++ Peltier et al. (1999) Garman et al. (2004) Otani et al. (2010) Dang et al. (2016)
Admission/registration (N = 7)	Hays et al. (1990) ++ Hays et al. (1991) ++ Otani (2010) Lis et al. (2011) Abrahamson et al. (2017) ++	Hays et al. (1990)++ Hays et al. (1991)++ Garman et al. (2004) Otani et al. (2010)		Nelson et al. (1992)
Discharge (N = 6)	Hays et al. (1990) ++ Hays et al. (1991) ++ Rothman (2008)		Hays et al. (1990)++ Hays et al. (1991)++ Garman et al. (2004)		Nelson et al. (1992) Richter et al. (2017)
Other aspects of patient experience (N = 11)	Hays et al. (1990) ++ Hays et al. (1991) ++ Chen et al. (2018) ** Boss & Thompson (2012) Abrahamson et al. (2017) ++		Hays et al. (1990)++ Hays et al. (1991)++ Garman et al. (2004) DuGoff &Chao (2019)	Bilimoria et al. (2017) Rodriguez et al. (2008)	Nelson et al. (1992) Richter et al. (2017)

Note. Associations: Italic font indicates positive association, roman font no or mixed association, and parentheses a (negative association) between the indicator of patient experience and other aspects of healthcare quality.

^*We have reversed the coding for the association of a business outcome of complaints (or malpractice) and patient experience. Thus, a positive association represents a positive patient experience associated with a decrease in complaints (or malpractice), whereas a negative association represents a negative patient experience associated with an increase in complaints (or malpractice).

Settings: Bold font indicates hospital setting of care, roman font an ambulatory setting, and underlined font a health plan setting;

^**includes both hospital and health system ambulatory data;

⁺includes nursing home setting.

Outcome measures: ++ includes a combined measure of intent-to-return and willingness to recommend as a business outcome.

The most common intermediate business outcome assessed was patient retention (i.e., ability of the provider or facility to retain the loyalty of the patient so that the patient remains under the care of the provider or facility) (18 studies), particularly intent-to-return (i.e., in the event of another episode that requires care the patient intends to select the same facility/provider and return for care) (12 studies). The second-most commonly assessed intermediate outcome was the willingness to recommend (i.e., willingness of the patient to recommend the provider or facility to their family or friends) (17 studies). Two studies measured the association between better patient experience and provider job satisfaction. Another two studies assessed the association between patient experience and complaints, and one assessed the association between patient experience and malpractice. There was limited evidence for the ultimate business outcome of profitability.

Intermediate Business Outcomes

Retention

Out of the 18 studies focused on retention, 12 studies, using a variety of statistical methods, found a significant positive association between overall ratings of patient experience and the patient returning or intending to return for a future healthcare visit. Eight of these studies controlled for patient characteristics and other factors, while three relied on bivariate analysis at the patient or health plan level and one on structural equation modeling.

Nine of these 12 studies examined the intent-to-return while the remaining 3 analyzed the actual return of a patient for treatment. Two articles analyzed disenrollment rates of health plans. The three articles that analyzed actual return found that patient experience is significantly associated with the patient’s actual return. For example, Dang and colleagues (2016), controlling for socioeconomic, health, and other variables related to HIV diagnosis and treatment, found that the overall patient experience with an HIV provider and overall experience with the HIV clinic at the initial visit were positively and significantly associated with subsequent return to the clinic at 6 months but not at 12 months. Two articles found that patient experience—measured by overall ratings of care, access to specialty care, access to hospital care, convenience of care, and overall rating of doctor quality—was statistically associated with the desire to disenroll or actual disenrollment from a health plan.

Out of the 18 studies focused on retention, 13 studies assessed the association between specific aspects of patient experience and patient retention. Of these, five studies demonstrated a significant relationship between positive ratings of care provided by physicians or nurses and retention. All five found significant and positive associations between ratings of nursing care and willingness or intent to return to a provider, four found significant and positive associations between ratings of physician care and retention in the hospital, and one did not differentiate between nursing and physician care but found a nonsignificant relationship between ratings of all providers (i.e., aggregating ratings of physician and nursing care) and retention.

The literature also examined the relationship of several specific aspects of patient experience and retention. Four studies found positive bivariate correlations between communication and retention. Specific patient experience and retention variables in these studies were patient-reported physicians listening or treating patients with respect and the proportion of appointments kept by HIV patients (controlling for patient demographics and substance use), intent to switch (controlling for age, education, self-reported health status), and patient-reported trust in the provider among new mothers.

Three studies found significant positive associations between patient-reported access and retention. Specific access variables in these studies included patient reports regarding getting care quickly, getting needed care, dissatisfaction with access to specialty care and hospital care, and convenience of care.

Two studies of hospital patients found that experiences of staff care, nursing care, physician care, admission, discharge, and hospital room environment were significantly and positively associated with a combined measure of recommendation and intention to return. Another study found that experiences of staff care, nursing care, physician care, admission experience, and hospital room environment were significantly associated with willingness to return to the hospital. Two other studies, however, found that aspects of patient experience were unrelated to willingness to return.

In summary, after controlling for patient demographics, studies assessing the associations of patient experience with retention provided mixed findings. Most found that patients’ overall ratings of their experience with a provider or a clinic are positively associated with intent or actual return to a provider, but four found no significant relationship between these outcomes.

Complaints and Malpractice

Two studies reported a positive association between patient experience and fewer complaints, while one study reported mixed associations between patient experience and measures of malpractice. One study on complaints (Rodriguez et al., 2008) found that better patient experiences with communication and care coordination were significantly and negatively associated with patient complaints. Another also found that the patient experience was significantly and negatively associated with a physician’s rate of complaints, but patient experiences with nursing care and the environment (e.g., meals) were not associated with complaints. Finally, one study on malpractice found a mixed relationship between patient experience and malpractice lawsuits.

Pathways Linking Patient Experience and Intermediate Business Outcomes

Willingness to Recommend

Willingness to recommend is an indicator of patient commitment or allegiance. Six studies found a positive association between the overall rating of patient experience and willingness to recommend a hospital, a provider, or a health plan. These studies based their findings on correlations of the overall rating and the likelihood of recommending the hospital, with a hospital rating of 9 or 10 of 10 correlated to patients “definitely” recommending the hospital (r = 0.91, p < .001). For example, Ford and colleagues (2013) found that an overall rating of patient experience of 9 or 10 out of 10 was positively and significantly correlated with willingness to recommend.

Eleven unique studies assessed the association of specific aspects of patient experience and overall willingness to recommend: communication (10 studies), access to care (7), staff care (7), nursing care (6), admission process (5), environment (5), physician care (4), respect/trust (4), and discharge (3). These studies found significant correlations between overall willingness to recommend and the specific aspect of the patient experience: doctor communication, nurse communication, access to care, staff care, respect/trust, nursing care, environment, confidence in physician care, discharge, admission, and overall rating of doctor. Most studies analyzed correlations. The strongest correlates of willingness to recommend were confidence in provider, doctor communication, and overall rating of doctor. One study found specific patient experiences were not predictive of being “extremely likely” to recommend the facility to friends (Lis et al., 2011), while another found a positive association between physician care and likelihood to recommend, but had mixed results on other patient experience variables (Chen et al., 2018).

Provider Job Satisfaction

Two articles studied the association of patient-reported experiences and provider job satisfaction and found mixed results. Overall patient experience was significantly positively associated with healthcare providers’ satisfaction with their work in both studies. However, one study had mixed results, finding positive associations between provider satisfaction with the organization and ratings for hospitals, primary care, and specialty care, but found no association between providers’ satisfaction with their specific jobs (rather than satisfaction with the organization for which they work) and patient ratings of these three.

Ultimate Business Outcome

Profitabiiity

All five articles that assessed profitability focused on hospital settings (one article included both hospital and ambulatory settings) and demonstrated mixed results. One found that better patient experience is positively associated with hospital profitability (measured by a hospital’s operating profit, return on assets, and return on investment). Another found that the overall rating of care, both current and past, for 25 hospital and ambulatory clinical units was associated with improved profitability (measured as a hospitals total revenue less the total cost to evaluate the effect of service attributes on the ultimate financial bottom line). A third, however, found no relationship between patient experience and hospital bond ratings. A fourth found the percentage of patients who rated the hospital a 9 or 10 on the HCAHPS overall rating scale was positively associated with the hospital’s net income and net patient revenue, but that hospital patient experience ratings are not associated with operating margin. A fifth found that patient-reported experiences of the discharge process were significantly and positively associated with net revenue and return on assets but not with hospital earnings, and that the delivery of other services was significantly and positively associated with net revenue and return on assets but not to hospital earnings, while admission, nursing care, and communication were not associated with these outcomes.

DISCUSSION

This review systematically assesses associations of patient experience and business outcomes. It appears that positive patient experiences, in addition to being good for patients, can be good for business. We found the strongest evidence for the claim that better patient experiences are associated directly with patient retention and indirectly through the likelihood of patients recommending a provider, facility, or health plan. We found more limited positive evidence associating better patient experiences with fewer patient complaints. Evidence for a direct relationship between patient experiences and profitability or an indirect relationship of provider job satisfaction linking patient experiences to improved business outcomes is continuing to emerge, but suggests there may be positive effects of patient experience on these outcomes. We also found no studies on the relationship between patient experiences and the intermediate business outcomes of new patient acquisition, the types of patient visits (i.e., frequency and/or intensity of visits) or direct improvements in provider reputation. We also found no studies that assessed whether better patient experiences resulted in overuse of care. Thus, additional work would be beneficial for a more complete understanding of the relationship between patient experience and business outcomes.

Surveys of patient experience almost always ask patients to provide an overall rating of their provider, clinic, hospital, or health plan. We found that such overall ratings are positively associated with patient retention. The limited evidence regarding the association between overall ratings of patient care experiences and patient complaints suggests an inverse relationship between the two. We also found that overall ratings of patient experiences were associated with a higher likelihood of recommending the provider/facility/health plan to friends or family (although this finding is unsurprising, given that patients typically provided their overall ratings and an indication of willingness to recommend in response to the same survey).

Many of the studies assessed the relationship between specific aspects of patient experience and business outcomes; these findings are important for identifying potential areas for quality improvement that may drive both better patient experiences and better business outcomes. The studies in our review indicated a consistent association between positive patient ratings of doctor and nurse communication, access to care (such as timeliness of care and getting needed care), and respect/trust of providers and staff with the willingness to recommend the provider. They also indicated that positive patient ratings of nursing and physician care are associated with fewer complaints and the intent-to-return. These findings are not surprising, given strong and consistent prior evidence that nurse communication is the most important driver of overall patient experience ratings of hospital care (Elliott et al., 2009; Martsolf et al., 2016) and that doctor communication is the strongest predictor of patient ratings of doctors (Hays et al., 1990, 1991; Rothman et al., 2008). While the most important dimension of communication varies by specialty of the doctor, showing respect is the most important aspect of communication for most physicians (Quigley et al., 2014).

Several aspects of patient experience not directly related to physician or nursing care, such as discharge and admission/registration processes, had more limited or mixed evidence supporting relationships with business outcomes. Aspects of patient experience even more distal to patient interactions with healthcare providers, such as amenities and technician care, had inconsistent associations with patient retention.

Limited evidence concerning specific aspects of patient experience and patient complaints indicates that communication and care coordination are negatively associated with such complaints (i.e., better patient experiences are related to fewer complaints). Other aspects of patient experience such as timeliness of care, staff care, nursing care, and the environment were not consistently studied and showed mixed associations with patient retention and complaints. No studies reviewed other aspects of patient experience or amenities such as meals, rooms, and visitor policies and profitability. We found a lack of support that amenities are a key driver of patient experience and that they improve market share and/or the bottom line (Torpie, 2014).

Study Limitations

Our work has limitations. Most notably, the number of studies for several business outcomes (provider job satisfaction, complaints, malpractice, profitability) is small, which limits the strength of our conclusions. Second, the variables used to measure business outcomes are process-related organizational-level measures of operations, not specifically a business outcome of profit or loss. We found the emergence of a body of research suggesting that improvements in patient experience are good for business—specifically in patient retention and willingness to recommend—in addition to being good for patients, but we did not find conclusive evidence or a comprehensive body of knowledge. Out of 40 articles, most had positive or mixed associations between patient experience and business outcomes, and very few identified negative or null associations. This could point to publication bias, whereby studies that found negative or null findings were less likely to be published. At the same time, it is also possible that publication bias might be less pronounced, given that negative or null findings might have been of particular interest to healthcare providers, healthcare systems, and peer-reviewed journals. Another challenge for understanding the underlying associations of patient experience and business outcomes is that both concepts are complex and multi-dimensional. As a result, different studies may focus on different components of each construct.

PRACTICE IMPLICATIONS

The literature suggests linkages between patient experiences and the bottom line, though the evidence is more complete and stronger for intermediate outcomes such as patient retention and complaints. Patients’ willingness to recommend a clinic, facility, or health plan is positively associated with overall patient experience and aspects of the patient experience. Nevertheless, there are some areas that are unstudied as well as limited evidence for other mechanisms (e.g., provider job satisfaction). Moreover, there is limited evidence related specifically to measures of profitability, with only five studies on varying metrics of hospital profitability, and two studies of profitability including the hospital and ambulatory settings. Nursing and physician care broadly defined are the only aspects of patient experience consistently associated with retention, with evidence pointing to communication and respect/trust being linked to the intent to return. Healthcare providers aiming to improve retention, reduce complaints, and increase the likelihood of patient recommendations might consider focusing on provider communication, notably explaining and listening, and showing respect. These aspects of patient experience are the largest contributors to a positive overall rating of a provider or a facility. For other aspects of patient experience, there is mixed evidence of the association between patient experience and business outcomes.

CONCLUSION

Healthcare providers can pursue better patient experiences of care for the intrinsic value to the patient, while also recognizing that it is good for intermediate business outcomes—specifically increased recommendations, better patient retention, and lower complaints. Evidence indicates a consistent positive association of nursing care and physician care with the intent to return, the likelihood of recommending, and patient complaints. Further research should focus on whether and how patient experiences are associated with profitability.