Patient
satisfaction regarding the quality of the medical services received is one of
the indicators that reflect the true performance of a hospital (Observatorul
Român de Sănătate, 2018).

According to the
report developed by the Romanian Health Observatory, the Clinical Hospital of
Rehabilitation is on the second place in terms of patient satisfaction
(Observatorul Român de Sănătate, 2018).

 

The healthcare
service is confronted with many challenges
and competition in the development
of the private medical providers. The patients have become more informed of the
various options of treatment through online platforms. This results in high expectations of patients towards
physicians to being able to provide the necessary information on their
condition, politeness, empathy and attention from their doctors, which brings
them very close to the traditional meaning of consumer profile ADDIN CSL_CITATION {
"citationItems" : [ { "id" : "ITEM-1",
"itemData" : { "DOI" :
"10.1007/978-3-319-52875-5_62", "author" : [ {
"dropping-particle" : "", "family" :
"Co\u021biu", "given" : "M.A.",
"non-dropping-particle" : "", "parse-names" :
false, "suffix" : "" }, { "dropping-particle" :
"", "family" : "Sabou", "given" :
"A.", "non-dropping-particle" : "",
"parse-names" : false, "suffix" : "" } ],
"id" : "ITEM-1", "issued" : {
"date-parts" : [ [ "2017" ] ] }, "page" :
"297-302", "publisher" : "Springer, Cham",
"title" : "Patient Satisfaction with Diabetes Care in Romania
\u2013 An Importance-performance Analysis", "type" :
"chapter" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=eae94d3e-fc5b-30ec-a0e4-9575a9c85fd1"
] } ], "mendeley" : { "formattedCitation" :
"(Co\u021biu and Sabou, 2017)",
"plainTextFormattedCitation" : "(Co\u021biu and Sabou, 2017)",
"previouslyFormattedCitation" : "(Co\u021biu and Sabou,
2017)" }, "properties" : { 
}, "schema" :
"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"
}(Coțiu and Sabou, 2017).

 

Gradually, the
healthcare system undergoes pressures (financial,
demographic and technological) in order to deliver good quality services to the patients. As a consequence, the
protection of patients’ rights has evolved within the key aspect in the agenda
of the new global health ADDIN CSL_CITATION {
"citationItems" : [ { "id" : "ITEM-1",
"itemData" : { "author" : [ { "dropping-particle"
: "", "family" : "Ahoobim", "given" :
"Oren", "non-dropping-particle" : "",
"parse-names" : false, "suffix" : "" }, {
"dropping-particle" : "", "family" :
"Altman", "given" : "Dan",
"non-dropping-particle" : "", "parse-names" :
false, "suffix" : "" }, { "dropping-particle" :
"", "family" : "Garrett", "given" :
"Laurie", "non-dropping-particle" : "",
"parse-names" : false, "suffix" : "" }, {
"dropping-particle" : "", "family" :
"Hausman", "given" : "Vicky", "non-dropping-particle"
: "", "parse-names" : false, "suffix" :
"" }, { "dropping-particle" : "",
"family" : "Huang", "given" :
"Yanzhong", "non-dropping-particle" : "",
"parse-names" : false, "suffix" : "" } ],
"id" : "ITEM-1", "issued" : {
"date-parts" : [ [ "2012" ] ] }, "title" :
"Council on Foreign Relations The New Global Health Agenda",
"type" : "article-journal" }, "uris" : [
"http://www.mendeley.com/documents/?uuid=fd716717-58c7-31f5-b238-4fff2cf78b67"
] } ], "mendeley" : { "formattedCitation" : "(Ahoobim
<i>et al.</i>, 2012)", "plainTextFormattedCitation"
: "(Ahoobim et al., 2012)", "previouslyFormattedCitation" :
"(Ahoobim <i>et al.</i>, 2012)" }, "properties"
: {  }, "schema" :
"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"
}(Ahoobim et al., 2012). The
national public health organizations, health promotion agencies, health service
providers, scientific research institutions and consumers association have put
significant efforts to promote and
support the patients’ rights protection
around the world. In the last decades, researchers have conducted analysis on
the rights of patients, their protection and its direct/indirect link with the
healthcare quality and its improvement ADDIN
CSL_CITATION { "citationItems" : [ { "id" :
"ITEM-1", "itemData" : { "DOI" :
"10.1093/intqhc/mzs049", "ISBN" : "1353-4505",
"ISSN" : "13534505", "PMID" :
"22941366", "abstract" : "This editorial discusses
quality improvement (QI), patient satisfaction and better health outcomes for
specific service users. QI methodologies have their roots in industry but have
been applied in healthcare settings now for 20 years or more with some success.
Although widespread evidence of a consistent association between cost reduction
and improved outcomes across all healthcare settings is patchy, there is some
evidence that the use of QI methodologies can lead to cost reduction. We
believe that these same methods can be used to improve the health of a whole
population. Most healthcare services, whether primary or secondary, have a
specific catchment population. Clear identification of the population or
community is therefore of paramount importance to those planning services,
regardless of the healthcare system in which they are operating. Secondly, it
is important to identify levels of need within the defined population so that
services can be targeted to those people or areas where they have the greatest
potential for meeting needs. This approach ought perhaps to be standard
practice, but in reality there is often a piecemeal approach to needs assessment,
with much commissioning being done on the basis of what has gone before.
Reconciling high-quality outcomes for individual patients with the health and
healthcare needs of whole populations requires a new approach. Those involved
in the QI work, alongside clinicians, researchers, healthcare managers and
commissioners, public health professionals and of course patients all share a
common interest-to improve patients’ experience of health care, to ensure
high-quality services and to achieve the best possible health outcomes-but
approach it from very different perspectives. (PsycINFO Database Record (c)
2013 APA, all rights reserved)", "author" : [ {
"dropping-particle" : "", "family" :
"Green", "given" : "Stuart",
"non-dropping-particle" : "", "parse-names" :
false, "suffix" : "" }, { "dropping-particle" :
"", "family" : "Sullivan", "given" :
"Paul", "non-dropping-particle" : "",
"parse-names" : false, "suffix" : "" }, {
"dropping-particle" : "", "family" :
"Bell", "given" : "Derek", "non-dropping-particle"
: "", "parse-names" : false, "suffix" :
"" }, { "dropping-particle" : "",
"family" : "Barnes", "given" : "Ruth",
"non-dropping-particle" : "", "parse-names" :
false, "suffix" : "" } ], "container-title" :
"International Journal for Quality in Health Care", "id" :
"ITEM-1", "issue" : "5", "issued" : {
"date-parts" : [ [ "2012" ] ] }, "page" :
"441-442", "title" : "Aligning quality improvement to
population health", "type" : "article-journal",
"volume" : "24" }, "uris" : [
"http://www.mendeley.com/documents/?uuid=c9bc1def-5277-4442-94ee-69feb31031c2"
] } ], "mendeley" : { "formattedCitation" : "(Green
<i>et al.</i>, 2012)", "plainTextFormattedCitation"
: "(Green et al., 2012)", "previouslyFormattedCitation" :
"(Green <i>et al.</i>, 2012)" }, "properties" :
{  }, "schema" :
"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"
}(Green et al., 2012).

 

There are studies
that indicate the importance of customer
expectations from the healthcare system. This is described as a means of
desires to seek for the assistance from the doctor, demands or wants and
preferences. Patients’ expectations are important because it implies their
involvement and creates the possibilities to better access health services.
These expectations from the Romanian healthcare providers are based on the model on active passivity, which
describes the physician-patient
relationship in Romania. Within years of passivity, the Romanian system has
moved to a more democratic approach.
This is a new approach that focuses on the call for more client-centred orientation in the healthcare services. Therefore,
the knowledge and awareness are expected to meet the needs of the patients ADDIN
CSL_CITATION { "citationItems" : [ { "id" :
"ITEM-1", "itemData" : { "author" : [ {
"dropping-particle" : "", "family" :
"Ionil\u00e3, Ana-Claudia, A C Bara, WJA van den Heuvel",
"given" : "JAM Maarse", "non-dropping-particle" :
"", "parse-names" : false, "suffix" :
"" } ], "container-title" : "Ionil\u00e3,
Ana-Claudia", "id" : "ITEM-1", "issued" : {
"date-parts" : [ [ "200" ] ] }, "title" :
"The Romanian health care system in transition from the users’
perspective", "type" : "article-journal" }, "uris"
: [
"http://www.mendeley.com/documents/?uuid=9aac3887-178f-384a-a0be-b0c92e145b01"
] } ], "mendeley" : { "formattedCitation" :
"(Ionil\u00e3, Ana-Claudia, A C Bara, WJA van den Heuvel, 200AD)",
"plainTextFormattedCitation" : "(Ionil\u00e3, Ana-Claudia, A C
Bara, WJA van den Heuvel, 200AD)", "previouslyFormattedCitation"
: "(Ionil\u00e3, Ana-Claudia, A C Bara, WJA van den Heuvel, 200AD)"
}, "properties" : {  },
"schema" :
"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"
}(Ionilã, Ana-Claudia, A C Bara, WJA
van den Heuvel, 200AD).

 

Secondly, patients
measure their expectations based on their level
of satisfaction with the healthcare services. This is mostly used as an
indicator of the medical care outcome ADDIN
CSL_CITATION { "citationItems" : [ { "id" :
"ITEM-1", "itemData" : { "author" : [ {
"dropping-particle" : "", "family" :
"Ionil\u00e3, Ana-Claudia, A C Bara, WJA van den Heuvel",
"given" : "JAM Maarse", "non-dropping-particle" :
"", "parse-names" : false, "suffix" :
"" } ], "container-title" : "Ionil\u00e3,
Ana-Claudia", "id" : "ITEM-1", "issued" : {
"date-parts" : [ [ "200" ] ] }, "title" :
"The Romanian health care system in transition from the users’
perspective", "type" : "article-journal" },
"uris" : [ "http://www.mendeley.com/documents/?uuid=9aac3887-178f-384a-a0be-b0c92e145b01"
] } ], "mendeley" : { "formattedCitation" :
"(Ionil\u00e3, Ana-Claudia, A C Bara, WJA van den Heuvel, 200AD)",
"plainTextFormattedCitation" : "(Ionil\u00e3, Ana-Claudia, A C
Bara, WJA van den Heuvel, 200AD)", "previouslyFormattedCitation"
: "(Ionil\u00e3, Ana-Claudia, A C Bara, WJA van den Heuvel, 200AD)"
}, "properties" : {  },
"schema" :
"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"
}(Ionilã, Ana-Claudia, A C Bara, WJA
van den Heuvel, 200AD).

 

Thirdly, the first
step to prevent dissatisfied patients is through the knowledge of the patients’ needs, because this may result to
discontinuity of care and cost ineffectiveness of the healthcare ADDIN
CSL_CITATION { "citationItems" : [ { "id" :
"ITEM-1", "itemData" : { "author" : [ {
"dropping-particle" : "", "family" :
"Ionil\u00e3, Ana-Claudia, A C Bara, WJA van den Heuvel",
"given" : "JAM Maarse", "non-dropping-particle" :
"", "parse-names" : false, "suffix" :
"" } ], "container-title" : "Ionil\u00e3,
Ana-Claudia", "id" : "ITEM-1", "issued" : {
"date-parts" : [ [ "200" ] ] }, "title" :
"The Romanian health care system in transition from the users’
perspective", "type" : "article-journal" },
"uris" : [ "http://www.mendeley.com/documents/?uuid=9aac3887-178f-384a-a0be-b0c92e145b01"
] } ], "mendeley" : { "formattedCitation" :
"(Ionil\u00e3, Ana-Claudia, A C Bara, WJA van den Heuvel, 200AD)",
"plainTextFormattedCitation" : "(Ionil\u00e3, Ana-Claudia, A C
Bara, WJA van den Heuvel, 200AD)", "previouslyFormattedCitation"
: "(Ionil\u00e3, Ana-Claudia, A C Bara, WJA van den Heuvel, 200AD)"
}, "properties" : {  },
"schema" :
"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"
}(Ionilã, Ana-Claudia, A C Bara, WJA
van den Heuvel, 200AD).

 

Patients’
satisfaction is an important part of quality assessment of the healthcare
system ADDIN CSL_CITATION {
"citationItems" : [ { "id" : "ITEM-1",
"itemData" : { "DOI" : "10.1093/fampra/12.2.193",
"ISSN" : "0263-2136", "author" : [ {
"dropping-particle" : "", "family" :
"Williams", "given" : "Susan",
"non-dropping-particle" : "", "parse-names" :
false, "suffix" : "" }, { "dropping-particle" :
"", "family" : "Weinman", "given" :
"John", "non-dropping-particle" : "",
"parse-names" : false, "suffix" : "" }, {
"dropping-particle" : "", "family" :
"Dale", "given" : "Jeremy",
"non-dropping-particle" : "", "parse-names" :
false, "suffix" : "" }, { "dropping-particle" :
"", "family" : "Newman", "given" :
"Stanton", "non-dropping-particle" : "",
"parse-names" : false, "suffix" : "" } ],
"container-title" : "Family Practice", "id" :
"ITEM-1", "issue" : "2", "issued" : {
"date-parts" : [ [ "1995", "6", "1" ] ]
}, "page" : "193-201", "publisher" : "Oxford
University Press", "title" : "Patient expectations: What do
primary care patients want from the GP and how far does meeting expectations
affect patient satisfaction?", "type" :
"article-journal", "volume" : "12" },
"uris" : [
"http://www.mendeley.com/documents/?uuid=3f4f0ea7-0e7f-33a6-b1b3-ba5e42260daa"
] } ], "mendeley" : { "formattedCitation" : "(Williams
<i>et al.</i>, 1995)", "plainTextFormattedCitation"
: "(Williams et al., 1995)", "previouslyFormattedCitation"
: "(Williams <i>et al.</i>, 1995)" },
"properties" : {  },
"schema" :
"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"
}(Williams et al., 1995).
There are two dimensions used to improve the patient satisfaction:

·        
The procedural dimension of the
quality of the provided services (such as the time spent at the waiting reception before
getting the required medical attention), the condition of the accommodation
provided according to the needs of the patient, and the doctor or physicians
anticipated with the patient’s needs 

·        
The personal dimension of the
provided service quality-that is, the physical aspect of cleanness, maintenance of the facility,
the attitude of the practitioner towards the patients, the demonstration of the
body language between the physician and the patient and the voice tone used to
address the patients ADDIN
CSL_CITATION { "citationItems" : [ { "id" :
"ITEM-1", "itemData" : { "DOI" :
"10.1016/j.sbspro.2013.06.283", "ISSN" :
"1877-0428", "abstract" : "Assessment of patient
satisfaction in the context of hospitals accreditation becomes a major concern
to pass the test to obtain an accreditation certificate, but how hospitals are
evaluating it is a matter of responsibility and ethics of institution
management towards their principal stakeholders. The aim of our study is to
reveal the degree of satisfaction of Romanian patients and the real concerns
and tools of hospitals management in evaluating it. To reach the aim of the
research we make a broad overview of several studies, researches and reports.
Also, we highlight the results of our own qualitative research made on the
websites of the first three categories of the national classified Romanian
hospitals.", "author" : [ { "dropping-particle" :
"", "family" : "Agheorghiesei", "given"
: "Daniela-Tatiana", "non-dropping-particle" :
"", "parse-names" : false, "suffix" :
"" }, { "dropping-particle" : "",
"family" : "Copoeru", "given" : "Ion",
"non-dropping-particle" : "", "parse-names" :
false, "suffix" : "" } ], "container-title" :
"Procedia -Social and Behavioral Sciences World Conference on Psychology
and Sociology", "id" : "ITEM-1", "issued" :
{ "date-parts" : [ [ "2013" ] ] }, "page" :
"404-410", "title" : "Evaluating Patient Satisfaction
\u2013 A Matter of Ethics in the Context of the Accreditation Process of the Romanian
Hospitals", "type" : "article-journal",
"volume" : "82" }, "uris" : [
"http://www.mendeley.com/documents/?uuid=685a2fce-d536-3899-9b7b-465ff4af32e8"
] } ], "mendeley" : { "formattedCitation" :
"(Agheorghiesei and Copoeru, 2013)", "plainTextFormattedCitation"
: "(Agheorghiesei and Copoeru, 2013)",
"previouslyFormattedCitation" : "(Agheorghiesei and Copoeru,
2013)" }, "properties" : { 
}, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json"
}(Agheorghiesei
and Copoeru, 2013).

 

The most used instrument in measuring patient
satisfaction is a questionnaire ADDIN
CSL_CITATION { "citationItems" : [ { "id" :
"ITEM-1", "itemData" : { "DOI" :
"10.1186/s12913-017-2412-z", "ISSN" : "14726963",
"abstract" : "\u00a9 2017 The Author(s). Background: The main
objective of this cross sectional study was to assess the psychometric
properties of a new research instrument. The secondary aim was to analyze
patients’ levels of dissatisfaction with the professionalism of medical staff.
Methods: A social survey questionnaire was created and administered online. The
instrument consisted of two scales: the 30-item patient dissatisfaction scale
and the 10 items institutional scale. In this article, we assessed only the
patient dissatisfaction scale. The research population includes 1838 subjects.
The statistical procedures used were descriptive statistics, Pearson’s
correlation, and factorial analyses with the SPSS.19 software. The internal
consistency of the instrument was determined using the Cronbach’s alpha
coefficient. We used a principal component analysis to investigate the
factorial validity of the scale. Results: The patients’ scale of
dissatisfaction obtained an alpha Cronbach score of 0.81. Three latent factors
corresponding to three dimensions of dissatisfaction emerged from the data:
medical staff’s ability to communicate, medical staff’s hygiene, as well as
sanitary and privacy conditions within the hospital. The first factor explained
43.47% of the variance in patient dissatisfaction, the second factor explained
10.24%, and the third factor explained 7.59%; overall, the three factors
explained 61.30% of the total variance. Conclusion: The Romanian healthcare
system has an organization and management structure which has shown few changes
since the communist period. Our study indicates that although more than 25
years have passed since the political regime changed in Romania and the
introduction of a different system of social care, there have been no
corresponding changes in the medical staff’s mentality or in the way that
patients are approached. The present assessment of patient dissatisfaction is
not a strictly theoretical exercise; it also represents a valuable instrument
for healthcare system management.", "author" : [ { "dropping-particle"
: "", "family" : "Popa", "given" :
"Daniela", "non-dropping-particle" : "",
"parse-names" : false, "suffix" : "" }, {
"dropping-particle" : "", "family" :
"Drugu\u015f", "given" : "Daniela",
"non-dropping-particle" : "", "parse-names" : false,
"suffix" : "" }, { "dropping-particle" :
"", "family" : "Lea\u015fu", "given" :
"Florin", "non-dropping-particle" : "",
"parse-names" : false, "suffix" : "" }, {
"dropping-particle" : "", "family" :
"Azoic\u01cei", "given" : "Doina",
"non-dropping-particle" : "", "parse-names" :
false, "suffix" : "" }, { "dropping-particle" :
"", "family" : "Repanovici", "given" :
"Angela", "non-dropping-particle" : "",
"parse-names" : false, "suffix" : "" }, {
"dropping-particle" : "", "family" :
"Rogozea", "given" : "Liliana Marcela",
"non-dropping-particle" : "", "parse-names" :
false, "suffix" : "" } ], "container-title" :
"BMC Health Services Research", "id" : "ITEM-1", "issue"
: "1", "issued" : { "date-parts" : [ [
"2017" ] ] }, "title" : "Patients’ perceptions of healthcare
professionalism – A Romanian experience", "type" :
"article-journal", "volume" : "17" },
"uris" : [
"http://www.mendeley.com/documents/?uuid=b1da6ec2-9d8a-4867-b0c2-436c195b2eb2"
] } ], "mendeley" : { "formattedCitation" : "(Popa
<i>et al.</i>, 2017)", "plainTextFormattedCitation"
: "(Popa et al., 2017)", "previouslyFormattedCitation" :
"(Popa <i>et al.</i>, 2017)" }, "properties" :
{  }, "schema" :
"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"
}(Popa et al., 2017). This
is most of the time implemented during or after the patients are being
discharged from the sanitary units. 
Studies have shown that the method of assessing the patient satisfaction
uses broad and vague terms that
result in short term, superficial, and positive answers without any true
meaning ADDIN CSL_CITATION {
"citationItems" : [ { "id" : "ITEM-1",
"itemData" : { "DOI" :
"10.1186/s12913-017-2412-z", "ISSN" : "14726963",
"abstract" : "\u00a9 2017 The Author(s). Background: The main
objective of this cross sectional study was to assess the psychometric
properties of a new research instrument. The secondary aim was to analyze
patients’ levels of dissatisfaction with the professionalism of medical staff.
Methods: A social survey questionnaire was created and administered online. The
instrument consisted of two scales: the 30-item patient dissatisfaction scale
and the 10 items institutional scale. In this article, we assessed only the
patient dissatisfaction scale. The research population includes 1838 subjects.
The statistical procedures used were descriptive statistics, Pearson’s
correlation, and factorial analyses with the SPSS.19 software. The internal
consistency of the instrument was determined using the Cronbach’s alpha coefficient.
We used a principal component analysis to investigate the factorial validity of
the scale. Results: The patients’ scale of dissatisfaction obtained an alpha
Cronbach score of 0.81. Three latent factors corresponding to three dimensions
of dissatisfaction emerged from the data: medical staff’s ability to
communicate, medical staff’s hygiene, as well as sanitary and privacy
conditions within the hospital. The first factor explained 43.47% of the
variance in patient dissatisfaction, the second factor explained 10.24%, and
the third factor explained 7.59%; overall, the three factors explained 61.30%
of the total variance. Conclusion: The Romanian healthcare system has an
organization and management structure which has shown few changes since the communist
period. Our study indicates that although more than 25 years have passed since
the political regime changed in Romania and the introduction of a different
system of social care, there have been no corresponding changes in the medical
staff’s mentality or in the way that patients are approached. The present
assessment of patient dissatisfaction is not a strictly theoretical exercise;
it also represents a valuable instrument for healthcare system
management.", "author" : [ { "dropping-particle" :
"", "family" : "Popa", "given" :
"Daniela", "non-dropping-particle" : "",
"parse-names" : false, "suffix" : "" }, {
"dropping-particle" : "", "family" :
"Drugu\u015f", "given" : "Daniela",
"non-dropping-particle" : "", "parse-names" :
false, "suffix" : "" }, { "dropping-particle" :
"", "family" : "Lea\u015fu", "given" :
"Florin", "non-dropping-particle" : "",
"parse-names" : false, "suffix" : "" }, { "dropping-particle"
: "", "family" : "Azoic\u01cei",
"given" : "Doina", "non-dropping-particle" :
"", "parse-names" : false, "suffix" :
"" }, { "dropping-particle" : "",
"family" : "Repanovici", "given" :
"Angela", "non-dropping-particle" : "",
"parse-names" : false, "suffix" : "" }, {
"dropping-particle" : "", "family" :
"Rogozea", "given" : "Liliana Marcela",
"non-dropping-particle" : "", "parse-names" :
false, "suffix" : "" } ], "container-title" :
"BMC Health Services Research", "id" : "ITEM-1",
"issue" : "1", "issued" : {
"date-parts" : [ [ "2017" ] ] }, "title" :
"Patients’ perceptions of healthcare professionalism – A Romanian
experience", "type" : "article-journal",
"volume" : "17" }, "uris" : [
"http://www.mendeley.com/documents/?uuid=b1da6ec2-9d8a-4867-b0c2-436c195b2eb2"
] } ], "mendeley" : { "formattedCitation" : "(Popa
<i>et al.</i>, 2017)", "plainTextFormattedCitation"
: "(Popa et al., 2017)", "previouslyFormattedCitation" :
"(Popa <i>et al.</i>, 2017)" }, "properties" :
{  }, "schema" :
"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"
}(Popa et al., 2017).

 

There are numerous
researchers that have brought to attention the term of “patient satisfaction”.
Although this term is commonly used in evaluating and guiding the delivery of
healthcare services, it is likely to be related to the quality of services rather than the quality of care provided. According to Pomerantz, several changes
have occurred within the recent years in
the way healthcare service users perceive the quality of care. He
suggested that “an increased focus on the patients’ needs and preferences may help better orient medical care, compared to the
focus on the adherence to care standards” ADDIN
CSL_CITATION { "citationItems" : [ { "id" :
"ITEM-1", "itemData" : { "DOI" :
"10.1186/s12913-017-2412-z", "ISSN" : "14726963",
"abstract" : "\u00a9 2017 The Author(s). Background: The main
objective of this cross sectional study was to assess the psychometric
properties of a new research instrument. The secondary aim was to analyze
patients’ levels of dissatisfaction with the professionalism of medical staff.
Methods: A social survey questionnaire was created and administered online. The
instrument consisted of two scales: the 30-item patient dissatisfaction scale
and the 10 items institutional scale. In this article, we assessed only the
patient dissatisfaction scale. The research population includes 1838 subjects.
The statistical procedures used were descriptive statistics, Pearson’s
correlation, and factorial analyses with the SPSS.19 software. The internal
consistency of the instrument was determined using the Cronbach’s alpha
coefficient. We used a principal component analysis to investigate the
factorial validity of the scale. Results: The patients’ scale of
dissatisfaction obtained an alpha Cronbach score of 0.81. Three latent factors
corresponding to three dimensions of dissatisfaction emerged from the data:
medical staff’s ability to communicate, medical staff’s hygiene, as well as
sanitary and privacy conditions within the hospital. The first factor explained
43.47% of the variance in patient dissatisfaction, the second factor explained
10.24%, and the third factor explained 7.59%; overall, the three factors
explained 61.30% of the total variance. Conclusion: The Romanian healthcare
system has an organization and management structure which has shown few changes
since the communist period. Our study indicates that although more than 25
years have passed since the political regime changed in Romania and the
introduction of a different system of social care, there have been no
corresponding changes in the medical staff’s mentality or in the way that
patients are approached. The present assessment of patient dissatisfaction is
not a strictly theoretical exercise; it also represents a valuable instrument
for healthcare system management.", "author" : [ {
"dropping-particle" : "", "family" :
"Popa", "given" : "Daniela",
"non-dropping-particle" : "", "parse-names" :
false, "suffix" : "" }, { "dropping-particle" :
"", "family" : "Drugu\u015f", "given" :
"Daniela", "non-dropping-particle" : "",
"parse-names" : false, "suffix" : "" }, {
"dropping-particle" : "", "family" :
"Lea\u015fu", "given" : "Florin",
"non-dropping-particle" : "", "parse-names" :
false, "suffix" : "" }, { "dropping-particle" :
"", "family" : "Azoic\u01cei", "given"
: "Doina", "non-dropping-particle" : "", "parse-names"
: false, "suffix" : "" }, { "dropping-particle" :
"", "family" : "Repanovici", "given" :
"Angela", "non-dropping-particle" : "", "parse-names"
: false, "suffix" : "" }, { "dropping-particle" :
"", "family" : "Rogozea", "given" :
"Liliana Marcela", "non-dropping-particle" : "",
"parse-names" : false, "suffix" : "" } ],
"container-title" : "BMC Health Services Research",
"id" : "ITEM-1", "issue" : "1",
"issued" : { "date-parts" : [ [ "2017" ] ] },
"title" : "Patients’ perceptions of healthcare professionalism –
A Romanian experience", "type" : "article-journal",
"volume" : "17" }, "uris" : [
"http://www.mendeley.com/documents/?uuid=b1da6ec2-9d8a-4867-b0c2-436c195b2eb2"
] } ], "mendeley" : { "formattedCitation" : "(Popa
<i>et al.</i>, 2017)", "plainTextFormattedCitation"
: "(Popa et al., 2017)", "previouslyFormattedCitation" :
"(Popa <i>et al.</i>, 2017)" }, "properties" :
{  }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json"
}(Popa et al., 2017).

 

The most frequent
aspect of satisfaction and dissatisfaction in the healthcare services is professionalism among the providers.
Professionalism is an area that includes various subcategories such as:

·        
advancement
in medical knowledge,

·        
improved
level of development in clinical competence,

·        
strong
ethical morals and standards,

·        
sharing
of honesty and respect as values,

·        
showing
empathy, courtesy and kind attitude towards the patients.

In economically
developed countries such as the Western European countries and USA, the medical
orientation act changed from a “predominantly doctor-oriented approach to a
patient centred culture”. This cannot be expressed in Eastern Europe, which is influenced by corruption, informal payments and in-need of a new reform. Since the 1970s, Eastern European
countries are slagging behind Western European countries in terms of healthcare
quality because of its communist policy
throughout the region. Romanian has the lowest
level of patient satisfaction in Europe. Romania is faced with other
challenges that is related to the lack of access to health services among the
less privileged communities.  The general
dissatisfaction and cynicism in Romania is owed by the country’s poor economic performance, which limits
the freedom of individual to explain a greater degree in behavioural and
environmental factors ADDIN CSL_CITATION {
"citationItems" : [ { "id" : "ITEM-1",
"itemData" : { "DOI" :
"10.1186/s12913-017-2412-z", "ISSN" : "14726963",
"abstract" : "\u00a9 2017 The Author(s). Background: The main
objective of this cross sectional study was to assess the psychometric
properties of a new research instrument. The secondary aim was to analyze
patients’ levels of dissatisfaction with the professionalism of medical staff.
Methods: A social survey questionnaire was created and administered online. The
instrument consisted of two scales: the 30-item patient dissatisfaction scale
and the 10 items institutional scale. In this article, we assessed only the
patient dissatisfaction scale. The research population includes 1838 subjects.
The statistical procedures used were descriptive statistics, Pearson’s correlation,
and factorial analyses with the SPSS.19 software. The internal consistency of
the instrument was determined using the Cronbach’s alpha coefficient. We used a
principal component analysis to investigate the factorial validity of the
scale. Results: The patients’ scale of dissatisfaction obtained an alpha
Cronbach score of 0.81. Three latent factors corresponding to three dimensions
of dissatisfaction emerged from the data: medical staff’s ability to
communicate, medical staff’s hygiene, as well as sanitary and privacy
conditions within the hospital. The first factor explained 43.47% of the
variance in patient dissatisfaction, the second factor explained 10.24%, and
the third factor explained 7.59%; overall, the three factors explained 61.30%
of the total variance. Conclusion: The Romanian healthcare system has an
organization and management structure which has shown few changes since the
communist period. Our study indicates that although more than 25 years have
passed since the political regime changed in Romania and the introduction of a
different system of social care, there have been no corresponding changes in
the medical staff’s mentality or in the way that patients are approached. The
present assessment of patient dissatisfaction is not a strictly theoretical
exercise; it also represents a valuable instrument for healthcare system
management.", "author" : [ { "dropping-particle" :
"", "family" : "Popa", "given" :
"Daniela", "non-dropping-particle" : "",
"parse-names" : false, "suffix" : "" }, {
"dropping-particle" : "", "family" :
"Drugu\u015f", "given" : "Daniela",
"non-dropping-particle" : "", "parse-names" :
false, "suffix" : "" }, { "dropping-particle" :
"", "family" : "Lea\u015fu", "given" :
"Florin", "non-dropping-particle" : "",
"parse-names" : false, "suffix" : "" }, {
"dropping-particle" : "", "family" :
"Azoic\u01cei", "given" : "Doina",
"non-dropping-particle" : "", "parse-names" :
false, "suffix" : "" }, { "dropping-particle" :
"", "family" : "Repanovici", "given" :
"Angela", "non-dropping-particle" : "",
"parse-names" : false, "suffix" : "" }, {
"dropping-particle" : "", "family" :
"Rogozea", "given" : "Liliana Marcela",
"non-dropping-particle" : "", "parse-names" :
false, "suffix" : "" } ], "container-title" :
"BMC Health Services Research", "id" : "ITEM-1",
"issue" : "1", "issued" : {
"date-parts" : [ [ "2017" ] ] }, "title" :
"Patients’ perceptions of healthcare professionalism – A Romanian experience",
"type" : "article-journal", "volume" :
"17" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=b1da6ec2-9d8a-4867-b0c2-436c195b2eb2"
] } ], "mendeley" : { "formattedCitation" : "(Popa
<i>et al.</i>, 2017)", "plainTextFormattedCitation"
: "(Popa et al., 2017)", "previouslyFormattedCitation" :
"(Popa <i>et al.</i>, 2017)" }, "properties" :
{  }, "schema" :
"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"
}(Popa et al., 2017).

 

The Romanian healthcare system is functioning based on the same principles in
the last 30 years. It is built around the central
administration and subsidiary, the medical
staff, while the patients or their representatives do not have any control
over the decision-making process in order to influence the system which they
finance and access  CITATION Cri08 \l 1048 (Comisia Prezidențială pentru analiza și elaborarea politicilor din
domeniul sănătății publice din România, 2008).

 

The only major modification in the system was the introduction of the healthcare insurance system, with the scope of strengthening
the responsibility role of the main customer of healthcare services – the
National Health Insurance House, through direct election of the leading
structures at a local level  CITATION Cri08 \l 1048 (Comisia Prezidențială pentru analiza și elaborarea politicilor din
domeniul sănătății publice din România, 2008)

 

This brought a larger level of autonomy
for the local structures in terms of collecting
and managing the insurance funds,
which means that the structure gained more legitimacy
and direct responsibility in
front of the citizens. Although it could have been a significant change, the
initiative was not politically accepted and after being approved in the
Parliament. The law was significantly
modified, leading to the centralization of the National Insurance House,
politically controlled by the Ministry of Health and the Ministry of Finances,
with a low degree of autonomy and
difficulties of separating roles from other institutions.

 

Inside the healthcare system, the central authority, the Ministry of Health
is keeping an organizational structure,
central and local, which does not have a
real overview over the healthcare needs of the population. Essential areas
for an effective functioning of a
modern healthcare system are not
developed at all in none of the Ministry of Health structures. Systems of
quality assurance, patient safety and the risk management are areas which do not have any type of representativity
at the level of decision-making structures, although the quality of the medical
services provided and patient safety are the areas that sanitary authorities  should constantly monitor  CITATION Cri08 \l 1048 (Comisia Prezidențială pentru analiza și elaborarea politicilor din
domeniul sănătății publice din România, 2008).

 

Another important responsibility area is the resource allocation, which practically functions based on the same
methods that are not changed for decades. The decisions in these areas are
taken without having accepted criteria, both at a national and international
level. The allocation of the public resources in the healthcare system must
take into consideration the available evidence
on statistical data (qualitative and quantitative), prevalence studies and different pathology trends etc, nationally and internationally  CITATION Cri08 \l
1048 (Comisia Prezidențială pentru analiza și elaborarea
politicilor din domeniul sănătății publice din România, 2008).

 

An informational system would be
required in order to make appropriate decisions. This would allow the
identification of the healthcare priorities and would evaluate the method of
way resources are used in different levels of the system, in a way that would
allow the effective feedback of the decision-making factors  CITATION Cri08 \l 1048 (Comisia Prezidențială pentru analiza și elaborarea politicilor din
domeniul sănătății publice din România, 2008).

 

For that, healthcare information systems
are required. These would offer the appropriate information in a decent
amount of time about various domains such as:

the utilization of the healthcare
resources, work productivity, the social
and economical impact of the determinants of health and different types of
interventions, the coverage rate and
accessibility to different
healthcare services, etc.  At the current
time, Romania does not have a coherent policy in terms  of healthcare information. Because of that,
all of the attempts to build an effective informational system in healthcare,
based on informational technologies and and modern communication methods did not
succeed, even though high amounts of money were invested  CITATION Cri08 \l 1048 (Comisia Prezidențială pentru analiza și elaborarea politicilor din
domeniul sănătății publice din România, 2008).

 

Another area of improvement is the incomplete
or even confusing legislative and
normative framework, in which the roles and responsibilities are not
clearly defined or they present similar attributions with other institutions or
organizational structures. This problem exists due to the continuous changes of
direction as far as the structure and the role of the healthcare system is
concerned, but also due to the lack of qualified resources on different
decision-making levels  CITATION Cri08 \l 1048 (Comisia Prezidențială pentru analiza și elaborarea politicilor din
domeniul sănătății publice din România, 2008).

 

Moreover, an appropriate inter-sectorial
approach would be required in order to ensure and maintain good quality of life for the general
population. This is because of the fact that numerous of the major
determinants of health can not be influence only by the healthcare sector. From
this point of view, the capacity of the Ministry of Health to get involved in
influencing other sectors to respect the insurance of a healthy living
environment is low. There is no official written document to state this role of
the Ministry of Health in this direction, matching the recommendations of the
European Union which mentions the fact that policy and program evaluation or
any other intervention is mandatory.

 

RECOMMENDATIONS

One of  the recommendations to the
stated problems would be to develop a quality
assurance mechanism in the Romanian healthcare system. The system highly
requires a program of upgrading the quality of the healthcare services, which
would provide information related to the quality of the delivered services and
would follow the constant progress of the quality of the services. The system
will evaluate and improve the quality of the medical services, it will maintain
and raise the level of patient
satisfaction and will demonstrate the effectiveness of the financial
resources invested in the healthcare system CITATION Cri08 \l 1048 (Comisia Prezidențială pentru analiza și elaborarea politicilor din
domeniul sănătății publice din România, 2008).

 

In terms of patient satisfaction and patient experience, measuring the level of satisfaction is
necessary, due to the fact that it presents a realistic overview on the patient’s experience and it represents a starting point in improving the services provided,
meeting the patients’ expectations or observe the performance of the medical
staff  CITATION She14 \l 1033 (Sherri L. LaVela, 2014).

Patient satisfaction represents the analysis made by the patient alone,
persuaded by external and internal factors, based on their opinion on how the
services provided made them feel  CITATION She14 \l 1033 (Sherri L. LaVela, 2014).

In a pilot study realized in an interdisciplinary feeding team clinic, a
survey was developed for the patients and their families in order to explore the areas that require improvement
and analyze the level of satisfaction as far as the care coordination is
concerned. The hospital from the study (Cincinnati Children’s Hospital Medical
Center – CCHMC) has its own system for analyzing the patient satisfaction,
developed for the individual services provided. The method used by the hospital
consisted in applying telephone
interviews on a weekly basis, by two
marketing research organizations which are oriented in the healthcare
domain. The questions that were asked were:

·        
Were
you able to get an appointment as soon as you wanted?

·        
Did
the health care provider give you a chance to explain the reasons for your
child’s visit? Did they listen to what you had to say about your child?

·        
Were
you involved in decisions about your child’s care as much as you wanted?

·        
When
you asked questions, did you get answers you could understand?

  CITATION Cla16 \l 1033 (Claire K. Miller, 2016).

The survey used in the pilot study added three questions to the existing
one, using a five-point Likert scale to measure the level of satisfaction
between the patient and the healthcare provider. The questions concerned the scheduling appointment, if the
healthcare providers understood the concerns and the usefulness of the advices received from the medical staff, rating
them from strongly agree to strongly disagree. Moreover, the pilot study
included two more open-ended questions related to what could have been better regarding the services received and to
detail the positive aspects of patients’ experience.

 

The surveys were completed at the end of the staying, introduced in an Excel
database and further analyzed using descriptive summary statistical methods  CITATION Cla16 \l
1033 (Claire K. Miller, 2016).

Even though the setting is different, in order to collect as much
relevant data as possible, the telephone
interview can be a relevant method of analyzing patient satisfaction, if
the necessary resources would be invested (the contract with a marketing
company focused on healthcare that would do the interviews).

In order to be applicable at the Rehabilitation Hospital in Cluj Napoca
the data with the information of the patients should be introduced in online
registers.

 

In 2015, The Ministry of health introduced the feedback mechanism for
the patient satisfaction in the public sanitary units from the Romanian
healthcare system  CITATION Min15 \l 1048 (Ministerul Sănătății, 2015).

 “The feedback mechanism of the
patient represents all of the measures and procedures which have as objective raising the trust level of the patients in
the medical services offered by the public hospitals, through feedback analysis regarding the quality
of the services received, the degree of respecting the rights and obligations
both by the patients and the medical staff. The mechanism also includes a
component of managing the ethical
complaints that happened in the sanitary unit, through the Ethics Committee”
 CITATION Min15 \l 1048 (Ministerul Sănătății, 2015).

 

The mechanism offers the patient the opportunity to fill in a questionnaire at the moment of the
discharge by receiving a text message on the mobile phone with a link to fill it
online, and all of the public sanitary units must apply the methodology of the
feedback mechanism of the patient  CITATION Min15 \l 1048 (Ministerul Sănătății, 2015).

 

We have observed that there is an internal questionnaire about patient
satisfaction on the website of the Rehabilitation Hospital. After reading the
law regarding the patient satisfaction mechanism developed by the Ministry of
Health, the standard questionnaire of patient satisfaction must be implemented
by all public hospitals.

 

Even though the Rehabilitation Hospital was ranked on the second place
at patient satisfaction level, according to the Romanian Health Observatory,
the response rate was low (5,9%), meaning that there were 630 responses out of
11983 discharges. The low response rate means that the conditions might not be
as satisfying as they were presented.

 

Improvements for the
Rehabilitation Hospital:

·        
Promoting
and insisting on the feedback mechanism developed by the Ministry of Health, so
that the rate of responses will increase. Having two questionnaires might lead
to having biased results (due to the fact that some patients might complete it
twice, they might even give different answers/opinions, etc);

·        
In
the case of keeping the current questionnaire, we suggest some modifications on
the response options: we noticed the fact that, at some questions there is one
negative option and two positive. This might influence the patients in choosing
a positive answer, even though it would not necessarily reflect the
reality.  One alternative way for having
the options can be ”Highly unsatisfied”, ”Unsatisfied”, ”Neither unsatisfied or
satisfied”, ”Satisfied”, ”Very satisfied”;

·        
As
there might be the risk that some of the patients do not complete the online
surveys because they are not internet users (for example the elderly or people
with a low educational background), a survey in a physical format could be
necessary. This would be filled in by the patients at the moment of the
discharge, being introduced afterwards in the Ministry’s online database by the
person in charge to introduce patient’s data from the hospital;

·        
Awareness
through word-of-mouth promotion of the survey could also increase the response
rates, if it would be done by the hospital staff, or only at the reception of
the hospital, both in the moment of admission and the moment of discharge.

 

Implementing Staff
Training:

Most hospital
staff such as the physician or the healthcare organizers have expressed their concern to ask patients personal questions that includes their race, ethnicity and language. They
believe that it may offend the patient. In addition, most physicians may be time-sensitive towards the modern
nature of clinical practice and want to ensure the effectiveness of asking
questions. For data to be accurate and consistent, healthcare organizations are
required to invest in clinical training
among all staff levels (health professionals, administrative staff, hospitals
and health plan leadership), which includes integrating the significance of the
data for detecting and addressing health care needs. For instance, those
assigned to the task of asking questions directly to the patients, enrollers
can receive a front-line training on the importance of collecting the
information, how to use the information and the means of collecting the data,
and how to address the concerns of the patients and other members ADDIN CSL_CITATION {
"citationItems" : [ { "id" : "ITEM-1",
"itemData" : { "URL" :
"https://www.ahrq.gov/research/findings/final-reports/iomracereport/reldata5.html",
"accessed" : { "date-parts" : [ [ "2018",
"4", "27" ] ] }, "author" : [ {
"dropping-particle" : "", "family" : "Agency
for Healthcare Research and Quality", "given" : "",
"non-dropping-particle" : "", "parse-names" :
false, "suffix" : "" } ], "container-title" :
"U.S Department of Health and Human Services", "id" :
"ITEM-1", "issued" : { "date-parts" : [ [
"2014" ] ] }, "title" : "Improving Data Collection
across the Health Care System | Agency for Healthcare Research &amp;
Quality", "type" : "webpage" }, "uris" : [
"http://www.mendeley.com/documents/?uuid=aff794ba-8f5e-341c-8258-33f2c8849d70"
] } ], "mendeley" : { "formattedCitation" : "(Agency
for Healthcare Research and Quality, 2014)",
"plainTextFormattedCitation" : "(Agency for Healthcare Research
and Quality, 2014)", "previouslyFormattedCitation" :
"(Agency for Healthcare Research and Quality, 2014)" },
"properties" : {  },
"schema" :
"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"
}(Agency for Healthcare Research and
Quality, 2014).

 

The training exercise
should be based on the context and the methods of collecting and utilizing the data. For example, health plan staff
who do not have face-to-face communication with the enrollers can obtain the
demographic information through telephone encounters. Therefore, there should
be a training for “telephone means of collecting data” because pre-registration
by telephone can occur before hospital admission or ambulatory care
appointments.  Before establishing a
formal training session with the medical staff, an assessment should be conducted
based on the practices and determine what is currently happening and identify
the necessary changes. These changes will be clearly communicated among the
staff members during the training session ADDIN CSL_CITATION {
"citationItems" : [ { "id" : "ITEM-1",
"itemData" : { "URL" : "https://www.ahrq.gov/research/findings/final-reports/iomracereport/reldata5.html",
"accessed" : { "date-parts" : [ [ "2018",
"4", "27" ] ] }, "author" : [ {
"dropping-particle" : "", "family" : "Agency
for Healthcare Research and Quality", "given" : "",
"non-dropping-particle" : "", "parse-names" :
false, "suffix" : "" } ], "container-title" :
"U.S Department of Health and Human Services", "id" :
"ITEM-1", "issued" : { "date-parts" : [ [
"2014" ] ] }, "title" : "Improving Data Collection
across the Health Care System | Agency for Healthcare Research &amp;
Quality", "type" : "webpage" }, "uris" : [
"http://www.mendeley.com/documents/?uuid=aff794ba-8f5e-341c-8258-33f2c8849d70"
] } ], "mendeley" : { "formattedCitation" : "(Agency
for Healthcare Research and Quality, 2014)",
"plainTextFormattedCitation" : "(Agency for Healthcare Research
and Quality, 2014)", "previouslyFormattedCitation" :
"(Agency for Healthcare Research and Quality, 2014)" },
"properties" : {  },
"schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json"
}(Agency for Healthcare Research and
Quality, 2014).

 

Sharing and Collecting of
Data Across the Healthcare System:

The health system
is a diverse set of public and private entity that contribute to the collection
of data including health surveys, administrative enrolment, billing records and
medical records used by different medical department such as the hospitals,
CHCs, physicians and health plan management. The data collected on the
patient’s race, language and ethnicity are extended to these entities
suggesting that each can collaborate to obtain and sustain the patient’s
medical record.  No one of the entities
can individually gather the necessary information regarding the population of
patients, neither can they collect the health data on an individual
patient.  Therefore, it is important to
increase the integration of data from other sources within and across the
healthcare system ADDIN CSL_CITATION { "citationItems" : [ { "id"
: "ITEM-1", "itemData" : { "URL" :
"https://www.ahrq.gov/research/findings/final-reports/iomracereport/reldata5.html",
"accessed" : { "date-parts" : [ [ "2018",
"4", "27" ] ] }, "author" : [ {
"dropping-particle" : "", "family" : "Agency
for Healthcare Research and Quality", "given" : "", "non-dropping-particle"
: "", "parse-names" : false, "suffix" :
"" } ], "container-title" : "U.S Department of Health
and Human Services", "id" : "ITEM-1", "issued"
: { "date-parts" : [ [ "2014" ] ] }, "title" :
"Improving Data Collection across the Health Care System | Agency for
Healthcare Research &amp; Quality", "type" :
"webpage" }, "uris" : [
"http://www.mendeley.com/documents/?uuid=aff794ba-8f5e-341c-8258-33f2c8849d70"
] } ], "mendeley" : { "formattedCitation" : "(Agency
for Healthcare Research and Quality, 2014)",
"plainTextFormattedCitation" : "(Agency for Healthcare Research
and Quality, 2014)", "previouslyFormattedCitation" :
"(Agency for Healthcare Research and Quality, 2014)" },
"properties" : {  },
"schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json"
}(Agency for Healthcare Research and
Quality, 2014).

 

CONCLUSION

All
in all, the information stated above presents how the functioning of the
healthcare system in Romania affects the sanitary system at a hospital level,
directly influencing patient satisfaction. In this sense, measures have been
taken, but there is still a lot to pursue in order to have clear and accurate
data on the patient satisfaction level and how it can be improved. The
suggestions presented are a small step that can be taken to develop the process
of collecting data, based on a realistic national approach.

 

REFERENCES:

 BIBLIOGRAPHY Comisia Prezidențială pentru
analiza și elaborarea politicilor din domeniul sănătății publice din România,
2008. Un sistem sanitar centrat pe nevoile cetățeanului, București:
s.n.

Sherri L. LaVela, A. S. G., 2014. Evaluation and measurement of patient
experience. Patient Experience Journal , 4.Volume 1.

Claire K. Miller, S. P., 2016. Exploring patient satisfaction with
interdisciplinary care of complex feeding problems. Patient Experience
Journal, Volume 3.

Ministerul Sănătății, 2015. [Online]
Available at: http://sanatoriulbrad.ro/documente/20150427154315.pdf
[Accessed 9 5 2018].

World Health Organization, 2014. Strengthening people-centred health
services delivery in the WHO European Region, s.l.: s.n.

Observatorul Român de Sănătate, 2018. Cât de mulțumiți au fost
pacienții români de spitalele publice în 2017, s.l.: s.n.

ADDIN Mendeley Bibliography CSL_BIBLIOGRAPHY Agency for Healthcare Research
and Quality (2014) Improving Data Collection across the Health Care System
| Agency for Healthcare Research &amp; Quality, U.S Department of
Health and Human Services. Available at:
https://www.ahrq.gov/research/findings/final-reports/iomracereport/reldata5.html
(Accessed: 27 April 2018).

Agheorghiesei,
D.-T. and Copoeru, I. (2013) ‘Evaluating Patient Satisfaction – A Matter of
Ethics in the Context of the Accreditation Process of the Romanian Hospitals’,
Procedia -Social and Behavioral Sciences World Conference on Psychology and
Sociology, 82, pp. 404–410. doi: 10.1016/j.sbspro.2013.06.283.

Ahoobim,
O. et al. (2012) ‘Council on Foreign Relations The New Global Health
Agenda’. Available at: www.cfr.org (Accessed: 20 April 2018).

Azevedo,
M. J. and Johnson, B. H. (2011) ‘The Impact of Globalization Determinants and
the Health of the World’s Population’, INTECH. Available at:
https://pdfs.semanticscholar.org/ae18/3b3f24372b20b0c286ba2b563561a8567086.pdf
(Accessed: 20 April 2018).

Burcea,
M., Toma, S.-G. and Papuc, R.-M. (2014) ‘PATIENTS’ SATISFACTION WITH THE
HEALTH CARE SYSTEM IN THE AGE OF GLOBALIZATION: THE CASE OF ROMANIA* Marin
BURCEA Sorin-George TOMA Răzvan-Mihail PAPUC’, Transylvanian Review of
Administrative Sciences, Special Issue, pp. 5–20. Available at:
http://rtsa.ro/tras/index.php/tras/article/viewFile/410/400 (Accessed: 18
April 2018).

Coțiu,
M. A. and Sabou, A. (2017) ‘Patient Satisfaction with Diabetes Care in Romania
– An Importance-performance Analysis’, in. Springer, Cham, pp. 297–302. doi:
10.1007/978-3-319-52875-5_62.

Green,
S. et al. (2012) ‘Aligning quality improvement to population health’, International
Journal for Quality in Health Care, 24(5), pp. 441–442. doi:
10.1093/intqhc/mzs049.

Ionilã,
Ana-Claudia, A C Bara, WJA van den Heuvel, J. M. (200AD) ‘The Romanian health
care system in transition from the users’ perspective’, Ionilã, Ana-Claudia.
Available at: https://www.rug.nl/research/portal/files/2994141/c6.pdf
(Accessed: 27 April 2018).

Williams,
S. et al. (1995) ‘Patient expectations: What do primary care patients
want from the GP and how far does meeting expectations affect patient
satisfaction?’, Family Practice. Oxford University Press, 12(2), pp.
193–201. doi: 10.1093/fampra/12.2.193.

Popa,
D. et al. (2017) ‘Patients’ perceptions of healthcare professionalism –
A Romanian experience’, BMC Health Services Research, 17(1). doi:
10.1186/s12913-017-2412-z.