Background: To assess hospital performance, quality perceptions of various stakeholders are increasingly taken into account. However, because of substantial background differences, various stakeholder groups might have different and even contrasting quality perceptions.
Purpose: We test the hypothesis that an overall perception gap exists between employees and patients with respect to perceived hospital quality. We additionally elaborate on how various employee groups differ from each other and from patients.
Methodology: We use primary survey data on perceived hospital quality from 9,979 patients and 4,306 employees from 11 German hospitals. With a multilevel regression and variance analysis, we test the impact of respondent type (employee or patient) on quality perception scores and test the interaction with hospital size. We additionally contrast different employee groups and test differences for various quality dimensions.
Results and Conclusion: Hospital employees score hospital quality consistently lower than patients and are also more heterogeneous in their assessments. This makes it from a managerial point of view relevant to subdivide employees in more homogeneous subgroups. Hospital size has no clear effect on the perception gap. Doctors compared to patients and other employee groups have substantially different perceptions on hospital quality.
Practice Implications: Our findings fuel the practical and ethical debate on the extent that perception gaps could and should be allowed in the context of high-quality and transparent hospital performance. Furthermore, we recommend that the quality perception gap is a substantial part of the overall hospital evaluation for ethical reasons but also to enable managers to better understand the (mis)match between employees’ priorities and patients’ preferences. However, we do warn practitioners that perceptions are only to a limited extent related to the organizational level (in contrast to the individual level), and only minimal improvements can thus be reached by differentiating from other hospitals.
The growing pressure to quantify and report hospital performance (Hibbard, Stockard, & Tusler, 2003, 2005; Lindenauer et al., 2007) has led to the increased use of proxy-output variables, such as mortality rate, patients treated, or the number of infections and medical injuries during hospitalization (Higgins, 2007; Zhan & Miller, 2003). In addition, it has also led to the increased use of more subjective assessments by the stakeholders involved in the service delivery processes (e.g., Arnetz, 1999; Fottler, Dickson, Ford, Bradley, & Johnson, 2006; Ginsburg, 2003). Despite their subjectivity, such stakeholder assessments, for example, from hospital employees and patients, are argued to have substantial value as they focus directly on those stakeholders that are involved in the service delivery processes (Kim, Kim, Kim, Kim, & Kang, 2008; Kvist, Voutilainen, Mantynen, & Vehvilainen-Julkunen, 2014; Zhou, Bundorf, Le Chang, Huang, & Di Xue, 2011).
Combining the opinions of patients and employees is a particularly interesting source of information given their high in-depth involvement in the core processes of hospitals (Nembhard, Yuan, Shabanova, & Cleary, 2015; Schiffinger, Latzke, & Steyrer, 2016). However, because of the specific context and the nature of the services delivered in hospitals, substantial subjectivity might exist, partially resulting from different expectations among various stakeholders (Arnetz, 1999; Stepanikova & Cook, 2008) and partially from different abilities to evaluate all quality elements of a service (Ginsburg, Norton, Casebeer, & Lewis, 2005; Gurses, Carayon, & Wall, 2009; Hansen, Williams, & Singer, 2011; Wallace, Lemaire, & Ghali, 2009). Furthermore, little is known about how patients and employees differ in their opinions of the same processes that they experience from different points of view (Abuosi, 2015; Fottler et al., 2006; Kvist et al., 2014). However, from a practitioner perspective, it is important to better clarify whether potential differences exist between hospital employees and patients and whether they can be explained based on manageable variables. Such analysis can help managers to understand the divergent priorities of patients and employees and how both stakeholder groups each attribute different importance to the various elements that constitute quality. For example, when employees have a different idea about how waiting times create potentially frustration for patients, they might not sufficiently be urged to deal with this issue (Abuosi, 2015). In contrast, employees might have the perception that the quality of a particular service element is (too) low (e.g., the amount of information given to patients), whereas it might not be considered problematic to the same extent by patients (Zhao, Akkadechanunt, & Xue, 2009). Having an insight in such a perception gap could avoid effortful investments by hospitals that in the end have not the desired effects with respect to improving hospital service quality (Fottler et al., 2006).
In addition, hospital quality contains several dimensions, and quality perceptions can thus be built on different elements from the overall service experience (Arnetz, 1999; Hibbard et al., 2003; Oppel, Winter, & Schreyögg, 2016). Consequently, a quality perception gap might be consistently present for several quality dimensions (Zhao et al., 2009). In addition, an insight in the quality elements that in particular are susceptible for perception gaps can help practitioners for the identification of areas that need their attention. In addition, it can also help scientists in better pinpointing further research opportunities on the various causes of perception gaps.
Against this background, the aim of this study is to analyze the overall quality perception gap between hospital employees and patients and explore whether this gap is different for distinct quality dimensions. Building on the principal–agent paradigm (see Theory section), we hypothesize and test whether for the data used in this study a significant perception gap exists between patients (principles) and hospital employees (agents) and whether both groups differ in heterogeneity of perceptions. Analyzing the heterogeneity of perceptions helps in better understanding the extent that patients and employees answer uniformly on particular quality dimensions and whether it is useful to make additional subdivisions within these stakeholder groups. Moreover, we look at hospital size as a potential factor that explains perception gaps.