Table 6. Sources of variation in patient satisfaction ratings and considerations for value-based purchasing policies, Odisha, India, 2020.

Source of variation	Descriptiona	Policy considerations for value-based purchasing
Values	Ideal expectations are similar to aspirations, desires or preferred outcomes; what a person ultimately values, that is, in a situation without limitation	Values can, and likely do, vary between patients and contexts; expectations represent an anticipated source of variation, allowing satisfaction ratings to reflect a diverse range of patient values
Expectations	Predicted expectations are realistic, practical or anticipated outcomes that result from personal experiences, reported experiences of others and sources of knowledge such as the media	Addressing variation that results from differences in predicted expectations may include the following: - Collecting basic demographic information about patients that are potentially associated with historical marginalization, for example, religious identity, caste and educational attainment. These data can be used to better understand hospitals’ baseline population as well as augment clinically-focused risk adjustment, which is often used within value-based purchasing programmes and focuses on case mix, i.e. morbidity type and severity
	Normative expectations are based on what should or ought to happen, often based on a mutually agreed upon threshold for what constitutes patient-centred care (similar to human rights standards)	Addressing variation that results from differences in normative expectations may include the following: - Pair subjective satisfaction ratings with more objective assessments of what a patient is experiencing during a given clinical interaction (that align with normative guidance) and look for discordance in patient ratings, that is, when patients give positive ratings to potentially inadequate careb - Due to low and variable thresholds for reporting dissatisfaction when exposed to low quality care, do not use a satisfaction rating to trigger sub-items, which are sometimes only posed to dissatisfied patients
Expression	Expression is how patients convey or report their satisfaction with care to others, which may differ for patients regardless of ideal, predicted, or normative expectations of care and inform reporting bias,c that is, how satisfaction is expressed may differ among patients with a similar level of true satisfaction	Addressing variation that results from differences in expression may include the following: - Consider the addition of variables within surveys used for value-based purchasing that may inform reporting bias. For example, interview privacy and interviewer ID. Consider these factors when analysing data to address underreporting, which may be more prevalent for marginalized patients. - If resources allow, follow up with a random subset of interviewed patients to assess if there is a variation in responses once they left the hospital

^a Adapted from Thomson & Sunol, 1995.³⁴

^b For example, being yelled at by a provider is generally seen as unacceptable by both national and international standards. It is important to understand if patients consistently give positive feedback to such care, as this helps ensure that these forms of poor-quality care are challenged, particularly among marginalized patients.

^c Thomson & Sunol³⁴ include a related concept, which they call “unformed expectations,” which is when individuals are unable to articulate their expectations because they do not have expectations, have difficulty expressing their expectations or do not wish to reveal their expectations due to fear, anxiety or conforming to social norms.